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
Medial Epicondylalgia: Physiotherapy as a First-Line Treatment for Sustainable Results
Overview Medial epicondylalgia, or golfer’s elbow, is a less common but equally disabling condition compared to lateral epicondylalgia. It involves degenerative changes at the common flexor tendon origin, especially in the flexor carpi radialis and pronator teres. Evidence increasingly supports physiotherapy—including eccentric loading, manual therapy, and neuromuscular retraining—as a first-line intervention that can reduce pain, restore function, and lower recurrence rates without the need for corticosteroids or surgery. Pathophysiology Unlike inflammatory tendinitis, medial epicondylalgia is a tendinosis involving collagen disorganization, neovascularization, and microtearing from overuse. This leads to impaired load tolerance and grip strength deficits. Evidence-Based Physiotherapy Interventions 1. Eccentric Loading Protocols Tyler et al. (2014) conducted an RCT demonstrating that eccentric loading for the wrist flexors improved function and pain scores in medial epicondylalgia patients more than rest or conventional care. Eccentric exercise promotes collagen synthesis and tendon remodeling, essential for long-term healing. 2. Manual Therapy + Exercise Combination Seo et al. (2013) found that combining exercise therapy with manual techniques such as cross-friction massage and mobilizations provided superior outcomes over exercise alone in both medial and lateral epicondylalgia patients. 3. Neuromuscular and Postural Control Although data is more robust for lateral elbow conditions, several case series and comparative trials suggest addressing proximal deficits (e.g., scapular dyskinesis or weak shoulder girdle muscles) may improve outcomes in chronic medial elbow pain. Our Physiotherapy Approach Includes Progressive eccentric/concentric loading for wrist flexors Isometrics for early-stage pain relief Scapular and shoulder strengthening to improve proximal control Manual therapy, including soft tissue mobilization and neural gliding if needed Grip strength training and return-to-function drills Ergonomic assessment and activity modification We use standardized outcome tools such as the Patient-Rated Elbow Evaluation (PREE) and pain-free grip strength as measurable indicators of progress. When to Refer to Physiotherapy Persistent medial elbow pain (>2–3 weeks) Recurrence of symptoms despite rest or medication Functional limitations in gripping, lifting, or sport Previous failed corticosteroid injection Pre- or post-injection rehabilitation Conclusion Medial epicondylalgia is often under-treated or mismanaged as an inflammatory condition. Evidence from RCTs strongly supports eccentric-based physiotherapy and manual therapy for effective and sustained recovery. Early referral can optimize outcomes and help patients avoid unnecessary medications or surgical interventions. References: Tyler, T. F., Thomas, G. C., Nicholas, S. J., & McHugh, M. P. (2014). Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial. Journal of Shoulder and Elbow Surgery, 19(6), 917–922. https://doi.org/10.1016/j.jse.2009.05.031 Seo, J. B., Kang, J. H., Lee, J. H., Lee, S. Y., & Kim, H. S. (2013). Effects of exercise therapy and manual therapy on pain and function in patients with medial or lateral epicondylitis: A randomized controlled trial. Journal of Physical Therapy Science, 25(5), 551–554. https://doi.org/10.1589/jpts.25.551