Overview
Lateral Epicondylalgia (LE) is a degenerative tendinopathy affecting the extensor carpi radialis brevis tendon, presenting as lateral elbow pain during resisted wrist extension or gripping. It affects approximately 1–3% of the population, especially middle-aged adults and individuals engaged in repetitive forearm activity.
While corticosteroid injections offer short-term relief, mounting RCT evidence supports physiotherapy as a superior long-term intervention, particularly when involving targeted exercise and patient education.
Pathophysiology
LE is primarily a tendinosis, not an inflammatory condition—characterized by disorganized collagen, neovascularization, and impaired tendon healing. This has shifted management focus from anti-inflammatories to mechanotherapy—loading the tendon to stimulate remodeling.
RCT-Based Evidence Supporting Physiotherapy
1. Exercise Therapy
Coombes et al. (2013) conducted a comprehensive RCT evaluating corticosteroid injections vs. physiotherapy in LE.
Findings: Corticosteroids provided initial pain relief but had significantly higher recurrence rates (72%) than exercise-based physiotherapy (10%) at 1 year.
Physiotherapy, particularly isometric and eccentric loading, led to long-term symptom resolution.
2. Eccentric Training Superiority
Stasinopoulos & Johnson (2005) demonstrated in an RCT that eccentric and static stretching protocols led to significantly better pain relief and functional improvement compared to standard care.
3. Manual Therapy and Mobilization with Movement (MWM)
Vicenzino et al. (1996) reported that adding MWM to an exercise protocol accelerated early symptom resolution, likely via neurophysiological mechanisms and pain modulation.
Physiotherapy Approach
Our conservative management strategy includes:
- Progressive eccentric-concentric loading of the wrist extensors
- Isometric loading for pain modulation
- Shoulder and scapular stabilization
- Ergonomic re-education
- Manual therapy, including MWM and radial head mobilizations
- Adjuncts: taping, dry needling, or ultrasound as indicated
Outcome measures used include the Patient-Rated Tennis Elbow Evaluation (PRTEE) and Grip Strength Dynamometry.
When to Refer to Physiotherapy
- Persistent pain >2 weeks unresponsive to self-management
- Recurrence after corticosteroid injection
- Functional limitations (gripping, lifting, typing, tool use)
- Interest in avoiding surgery or repeated injections
- Post-injection rehabilitation or flare-up management
Conclusion
Evidence-based physiotherapy is the gold standard for long-term recovery in lateral epicondylalgia. It not only resolves pain but also addresses biomechanical deficits and recurrence risk. Collaborating early with physiotherapists improves patient satisfaction, reduces healthcare costs, and prevents chronicity.
References:
Coombes, B. K., Bisset, L., & Vicenzino, B. (2013). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomized controlled trials. The Lancet, 376(9754), 1751–1767. https://doi.org/10.1016/S0140-6736(10)61160-9
Stasinopoulos, D., & Johnson, M. I. (2005). Effectiveness of extracorporeal shock wave therapy, supervised exercise program and combination of both on lateral epicondylitis: A randomized controlled trial. British Journal of Sports Medicine, 39(9), 561–565. https://doi.org/10.1136/bjsm.2004.015362
Vicenzino, B., Collins, D., Wright, A. (1996). The initial effects of a MWM technique on grip strength in subjects with lateral epicondylalgia. Physiotherapy Theory and Practice, 12(3), 129–138. https://doi.org/10.3109/09593989609036478
