Clinical Pearls & Morning Reports
Published June 21, 2023
Lateral epicondylitis is primarily a clinical diagnosis. The most common findings on physical examination are tenderness at the lateral epicondyle of the distal humerus and weakness or pain with resisted wrist extension (the Thomsen test). Read the NEJM Clinical Practice Article here.
Q: What causes lateral epicondylitis?
A: Lateral epicondylitis, more properly termed a tendinopathy and commonly known as tennis elbow, is a condition that is characterized by the insidious onset of lateral elbow pain, usually in the absence of trauma. Although the cause is not well understood, lateral epicondylitis is thought to be caused by chronic degenerative change at the origin of the elbow extensor tendons.
Q: Does lateral epicondylitis resolve without intervention?
A: The natural history of lateral epicondylitis is not well characterized, but available evidence suggests that it typically resolves without intervention. A critical component of management is education. A meta-analysis of the existing literature showed no superiority of nonoperative treatment over no treatment. Patients should be informed about the favorable natural history of lateral epicondylitis, that choosing no intervention is a reasonable decision, and that use of the affected arm (including lifting and exercise) does not negatively affect the course of the condition—recommendations that are supported by analysis of the current literature.
A: A meta-analysis (including 16 trials involving physical therapy and 27 involving electrophysiotherapy) showed that physiotherapy conferred considerable reduction in pain and improvement in function (but not grip strength) as compared with no physiotherapy; electrophysiotherapy reduced pain and improved function but with a greater occurrence of adverse events than was seen with physiotherapy. A more recent, smaller meta-analysis (including five trials) showed no benefit of physiotherapy. Other randomized trials as well as a large systematic review and meta-analysis of randomized, controlled trials that assessed physiotherapy as compared with bracing concluded that physiotherapy resulted in greater reduction in pain than bracing in the long term (12 to 52 weeks). Approximately 2 to 4% of patients have persistent pain regardless of treatment and undergo surgery. Many experts recommend a minimum of 6 to 12 months of persistent symptoms before surgical procedures are considered, since pain and dysfunction resolve in the majority of persons over this time period regardless of treatment. Given the favorable natural history of lateral epicondylitis and the observational nature of data to support the benefits of surgery, questions remain about its role in management.
A: Glucocorticoid injections have long been used for the treatment of lateral epicondylitis. Although studies have shown short-term pain relief with this treatment, evidence suggests that long-term outcomes are worse with regard to pain and function as compared with a wait-and-see approach. For example, a randomized, controlled trial (involving 185 participants) that assessed glucocorticoid injections, physiotherapy, and a wait-and-see approach in primary care noted success (defined as complete recovery or much improvement) at 6 weeks in 92%, 47%, and 32% of the participants, respectively, but substantially worse outcomes after glucocorticoid injection at 52 weeks (success in 69%, 91%, and 83%, respectively), with no significant differences between physiotherapy and the wait-and-see approach. Histologic studies that showed decreased collagen production and fibroblast viability in tendon tissue after glucocorticoid injection suggest a potential mechanism for adverse outcomes. In addition, repeated injections pose a risk of skin thinning and atrophy.