lateral elbow tendinopathy report #042

#042 – 6 Articles on Lateral Elbow Tendinopathy in 2021

Estimated reading time: 5 minutes, 19 seconds

This report include:

  • Extracorporeal shock wave therapy (ESWT) should be considered before surgery.
  • Extracorporeal shock wave therapy (ESWT) is better than ultrasound and laser.
  • Adding scapular muscle strengthening with local therapy is as effective as local therapy alone.
  • Exercise is effective compared with passive interventions with or without invasive treatment.
  • Upper limb position affects pain‐free grip strength.
  • Cozen’s test and grip strength measurement present high accuracy in the diagnosis of lateral elbow tendinopathy.

1 – Lateral elbow tendinopathy: surgery versus extracorporeal shock wave therapy

(Restricted Access)


  • 16 participants in the surgery group.
  • 16 paticipants in the extracorporeal shock wave therapy (ESWT) group.
    • ESWT 1 session/week for 3 weeks.
    • 1000 impulses at a frequency of 4 Hz and an energy flow density of 0.2 mJ/mm²
    • After treatment, ice application was advised and analgesics if necessary. A re-education program with muscle strengthening and stretching exercises was provided.


  • None of the differences were significant,
  • Surgical treatment was somewhat better in terms of patient satisfaction and the percentage of subjective improvement, with a p = 0.07 indicating a statistical tendency.
  • In combination with the other findings, surgical treatment seemed to be somewhat more favorable. However, the statistical power in this study is too low to draw solid conclusions.
  • Almost all patients scored good or excellent according to the Verhaar criteria at 12 months.
  • The percentage of improvement was 57% for ESWT and 76% for surgery (not significant, Student’s t test).


  • The clinical results of ESWT were somewhat inferior to those of surgical treatment, but this was not statistically significant.
  • ESWT may, as a non-invasive procedure, be considered in a conservative treatment regimen prior to potential LET surgery.

2 – Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy

Systematic review and meta-analysis (Restricted Access)


  • Randomized controlled trials assessing the effectiveness of extracorporeal shockwave therapy alone or as an additive intervention compared with sham or other interventions. Pain intensity, grip strength and elbow disability were used as primary outcome measures.


  • 72 studies including 1871 patient.
  • Extracorporeal shockwave therapy reduced pain intensity at mid-term follow-up,
  • Improved grip strength at very short and short-term follow-up compared with sham treatment.
  • No clinically significant results were found between comparators in all outcomes and follow-up times.
  • Extracorporeal shockwave therapy presented clinically better compared to Laser in grip strength at short-term and ultrasound in pain intensity at very short-term follow-up.


  • Low to moderate certainty of evidence suggests that there are no clinical benefits of extracorporeal shockwave therapy compared to sham interventions or corticosteroid injections.
  • Based on very-low and moderate certainty of evidence, extracorporeal shockwave therapy outperforms against Laser and ultrasound.

3 – The Effect of Scapular Muscle Strengthening on Functional Recovery in Patients With Lateral Elbow Tendinopathy

A Pilot Randomized Controlled Trial. (Restricted Access)


  • The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET.


  • 32 participant were randomized to LT or LT + SMS groups.
  • Interventions: Both groups received education, a non-articulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises.


  • No statistical between-group differences were found for any of the outcome measures.
  • There were significant within-group improvements in all outcome measures from baseline to all follow-up points.


  • The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge, as well as the 6- and 12-month follow-ups.
  • Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

4 – Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small

A systematic review and meta-analysis of 2123 subjects in 30 trials. (Restricted Access)

Included articles

RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET.


  • 30 RCTs including 2123 participants
  • Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points, except short-term pain reduction.
  • Clinically significant differences were found in pain-free grip strength at short-term mid-term and long-term follow-up.
  • Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up.


  • Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small.

5 – Upper limb position affects pain‐free grip strength in individuals with lateral elbow tendinopathy

A cohort study (Restricted Access)


  • Pain‐free grip (PFG) force is commonly used to monitor treatment outcomes in lateral elbow tendinopathy (LET); however, it is unclear whether changes in forearm and elbow position affect PFG force values.
  • This study aims to examine the effect of elbow/shoulder and forearm position on non‐normalized and normalized PFG force in individuals with unilateral LET.


  • 21 subjects with clinically diagnosed unilateral LET performed PFG force (symptomatic arm) and maximal grip (asymptomatic arm) tasks using four upper limb positions: (1) shoulder neutral, elbow flexed (90°), forearm pronated; (2) shoulder neutral, elbow flexed (90°), forearm neutral; (3) shoulder flexed (90°), elbow extended, forearm pronated; and (4) shoulder flexed (90°), elbow extended, forearm neutral.
  • PFG force was normalized to the maximal grip of the asymptomatic side.


  • This study shows that PFG force was higher when performed with forearm neutral supination/pronation, elbow flexion, and shoulder neutral than other tested positions, and irrespective of whether PFG force was normalized to the maximal grip force of the contralateral limb.
  • This indicates that arm position should be standardized for comparison.

6 – Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET)

A systematic review (Restricted Access)


  • 24 studies with 1370 participants were identified reporting the diagnostic performance of Ultrasound Imaging (USI) (18 studies), physical examination tests (2 studies) and Magnetic Resonance Imaging (MRI) (4 studies).
  • Sonoelastography showed the highest sensitivity (75- 100%) and specificity (85- 96%).
  • Grayscale with or without Doppler USI presented poor to excellent values (sensitivity: 53%-100%, specificity: 42%-90%).
  • MRI performed better in the diagnosis of tendon thickening and enthesopathy (sensitivity and specificity: 81%-100%).
  • The Cozen’s test reported high sensitivity (91%) while a grip strength difference of 5%-10% between elbow flexion and extension showed high sensitivity (78%-83%) and specificity (80%-90%).


  • Cozen’s test and grip strength measurement present high accuracy in the diagnosis of LET but are poorly investigated.
  • USI and MRI provide variable diagnostic accuracy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary.
  • Substantial heterogeneity was found in inclusion criteria, operator/ examiner, mode of application, type of equipment, and reference standards across the studies.

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