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Clinical Practice Guidelines

ANN M. LUCADO, PT, PhD, CHT • JOSEPH M. DAY, PT, PhD, OCS • JOSHUA I. VINCENT, PT, PhD

JOY C. MACDERMID, PT, PhD, CHT • JANE FEDORCZYK, PT, PhD, CHT

RUBY GREWAL, MD • ROBROY L. MARTIN, PT, PhD

Lateral Elbow Pain and Muscle

Function Impairments

Clinical Practice Guidelines Linked to the International Classiﬁcation

of Functioning, Disability and Health from the Academy of Hand and

Upper Extremity Physical Therapy and the Academy of Orthopaedic

Physical Therapy of the American Physical Therapy Association

J Orthop Sports Phys Ther. 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302

Physical Therapy, American Physical Therapy Association (APTA), Inc, and JOSPT

, Inc. The Academy of Orthopaedic Physical Therapy, Academy of Hand and Upper

Extremity Physical Therapy, APTA, Inc, and JOSPT

, Inc consent to reproducing and distributing this guideline for educational purposes. Address correspondence to Clinical

Practice Guidelines Managing Editor, Academy of Orthopaedic Physical Therapy, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: [email protected]

SUMMARY OF RECOMMENDATIONS ................................CPG2

INTRODUCTION .................................................................CPG4

METHODS ..........................................................................CPG5

CLINICAL PRACTICE GUIDELINES:

Impairment/Function-Based Diagnosis ............................ CPG8

Pathoanatomical Features .................................................. CPG8

Risk Factors ......................................................................... CPG9

Clinical Course ................................................................... CPG10

Prognosis ............................................................................ CPG11

Diagnosis/Classiﬁcation .................................................... CPG12

Examination ........................................................................ CPG15

Interventions ...................................................................... CPG25

DECISION TREE ...............................................................CPG43

AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS ... CPG45

REFERENCES ...................................................................CPG46

APPENDICES ................................................................... CPG53

REVIEWERS: John DeWitt, PT, DPT, AT • Steve Paulseth, PT, DPT, SCS, ATC • James A. Dauber, DPT, DSc

Mike Szekeres, PhD, OT Reg (Ontario), CHT • Paul F. Beattie, PhD, PT, OCS, FAPTA, NREMT

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

Summary of Recommendations*

OUTCOME, ACTIVITY LIMITATIONS,

SELF-REPORT MEASURES

Clinicians should use the diagnosis-speciﬁc Patient-Rated

Tennis Elbow Evaluation (PRTEE) to assess pain/irritability

and function and/or the region-speciﬁc Disabilities of the Arm,

Shoulder and Hand (DASH) to assess upper extremity function at

baseline and at least one other follow-up point that includes dis-

charge for individuals with lateral elbow tendinopathy (LET).

Clinicians should use the Patient-Speciﬁc Functional Scale

(PSFS) for patients with high-demand activities and/or should

administer a scale that assesses activity-speciﬁc disability (eg, DASH

work or sports/performing arts module) at baseline and at least one

other follow-up point that includes discharge for individuals with LET.

PHYSICAL IMPAIRMENT MEASURES

Clinicians should include the physical impairment mea-

sures of elbow and wrist range of motion, pressure pain

threshold, pain-free grip strength, and maximum grip strength at

baseline and at least one other follow-up point that includes dis-

charge for individuals with LET.

INTERVENTIONS: THERAPEUTIC EXERCISE

Clinicians should use isometric, concentric, and/or eccen-

tric therapeutic resisted exercises of the wrist extensors in

the treatment of individuals with subacute or chronic LET.

Clinicians may use a phased approach to reintroduce stress,

increase strength, improve endurance, and restore optimal

motor control in individuals who have LET symptoms with high-de-

mand occupations, hobbies, performing arts, or athletic interests.

MULTIMODAL INTERVENTIONS: INCLUDING

THERAPEUTIC EXERCISE

Clinicians should use therapeutic resisted wrist extension

strengthening exercises in combination with other thera-

peutic interventions, including manual therapy, in the treatment

of patients with subacute or chronic LET.

Clinicians may include shoulder and scapular stabilizer

muscle training exercises, when impairments are identi-

ﬁed, in conjunction with other forms of wrist extensor strengthen-

ing exercise in individuals with LET.

INTERVENTIONS: MANUAL THERAPY JOINT

MOBILIZATIONS/MANIPULATIONS

Clinicians should use local elbow joint manipulation or

mobilization techniques to reduce pain and increase pain-

free grip strength in individuals with LET, as a stand-alone or ad-

junctive treatment in improving short-term outcomes for those

who can tolerate the speciﬁc technique.

Clinicians may use manipulation or mobilization techniques

directed at the cervical spine, thoracic spine, and/or wrist as

an adjunct to local treatment for short-term pain relief in individuals

with LET when impairments in those regions are identiﬁed.

INTERVENTIONS: MANUAL THERAPY

SOFT TISSUE MOBILIZATION

Clinicians may use soft tissue mobilizations, including

manual release therapy, to improve pain and function in

individuals with chronic LET.

Clinicians may use instrument-assisted soft tissue mobili-

zation combined with exercise to improve pain and func-

tion in those with chronic LET.

Based on conﬂicting evidence, a recommendation cannot be

made regarding the use of deep transverse tendon cross-fric-

tion massage to alleviate symptoms in individuals with LET.

INTERVENTIONS: DRY NEEDLING

Clinicians should use either tendon or trigger point dry

needling for the treatment of pain and functional deﬁcits

associated with LET.

INTERVENTIONS: ORTHOSES

Based on conﬂicting evidence, a recommendation cannot

be made regarding the use of a forearm counterforce or

wrist support orthosis to alleviate intermediate or long-term

symptoms in individuals with LET.

Clinicians may use a forearm counterforce or wrist sup-

port orthosis to be worn during activity for immediate im-

provement of pain and strength in those with LET whose

symptoms are aggravated with activity.

INTERVENTIONS: TAPING

Clinicians should use rigid taping techniques for immedi-

ate/short-term pain relief and improvement in pain-free

muscle function in those with irritable LET.

Clinicians may use kinesiology tape application as part of

a multimodal treatment program for immediate and

short-term management of pain and muscle function in individu-

als with LET.

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journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg3

Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

INTERVENTIONS: CRYOTHERAPY

Clinicians may use cryotherapy combined with burst

transcutaneous electrical nerve stimulation (TENS) to re-

duce pain in the short term in individuals with symptoms of LET

for greater than 30 days.

Clinicians may use cryotherapy to reduce pain in individu-

als with irritable symptoms of LET.

INTERVENTIONS: THERAPEUTIC ULTRASOUND

Based on conﬂicting evidence, a recommendation cannot

be made for the use of ultrasound as a stand-alone

treatment.

INTERVENTIONS: PHONOPHORESIS

Clinicians should not use phonophoresis with 10% hydro-

cortisone gel, topical prednisolone (2 mg/d), or 1% di-

clofenac sodium gel for the treatment of LET.

INTERVENTIONS: IONTOPHORESIS

Clinicians may use iontophoresis with an anti-inﬂamma-

tory drug, early in the rehabilitation phase (no later than

2-4 weeks from onset or aggravation of symptoms), in individuals

presenting with highly irritable symptoms of LET.

INTERVENTIONS: TENS

Clinicians may use burst TENS applied to the painful re-

gion or high- or low-frequency TENS applied to acupunc-

ture points, for short-term pain relief in individuals with LET.

INTERVENTIONS: LASER

Clinicians may use laser therapy for improvements in pain

and grip strength, seen in follow-up periods >4 weeks to

6 months, for individuals with LET.

INTEREVENTIONS: ERGONOMICS

Clinicians may use ergonomic interventions in the man-

agement of symptoms in individuals with LET; the imple-

mentation of education, behavioral modiﬁcation, ergonomic

equipment, and workstation adjustments is moderately support-

ed by best practice/standard of care.

*These recommendations and clinical practice guidelines are based on the scien-

tiﬁc literature published prior to November 2021.

List of Abbreviations

AHUEPT: Academy of Hand and Upper Extremity

Physical Therapy

APTA: American Physical Therapy Association

ANOVA: analysis of variance

AOPT: Academy of Orthopaedic Physical Therapy

CI: conﬁdence interval

CPG: clinical practice guideline

DASH: Disabilities of the Arm, Shoulder and Hand

DFM: deep friction massage

ECRB: extensor carpi radialis brevis

ES: eect size

GCS: Global Change Scale

GROC: Global Rating of Change

HADS: Hospital Anxiety & Depression Scale

HILT: high-intensity laser therapy

ICC: intraclass correlation coecient

ICD: International Classiﬁcation of Diseases

ICF: International Classiﬁcation of Functioning, Disability

and Health

JOSPT: Journal of Orthopaedic & Sports Physical Therapy

LET: lateral elbow tendinopathy

LILT: low-intensity laser therapy

MCID: minimal clinically important dierence

MD: mean dierence

MDC: minimal detectable change

MEPI: Mayo Elbow Performance Index

MRI: magnetic resonance imaging

MRT: manual release therapy

MVIC: maximum voluntary isometric contraction

MWM: mobilization with movement

NPRS: numeric pain-rating scale

OR: odds ratio

PE: percutaneous electrolysis

PFGS: pain-free grip strength

PPT: pressure pain threshold

PRFEQ: Patient-Rated Forearm Evaluation Questionnaire

PROM: patient-reported outcome measure

PRTEE: Patient-Rated Tennis Elbow Evaluation

PRWE: Patient-Rated Wrist Evaluation

PSFS: Patient Speciﬁc Functional Scale

RCT: randomized clinical trial

RM: Score: Roles and Maudsley Score

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

ROM: range of motion

RR: relative risk

SD: standard deviation

SEM: standard error of measurement

SMD: standardized mean dierence

SRM: standardized response mean

TDN: trigger point dry needling

TENS: transcutaneous electrical nerve stimulation

UE: upper extremity

US: ultrasound

VAS: visual analog scale

WMD: weighted mean dierence

W/cm

: Watts per centimeter squared

Introduction

AIM OF THE GUIDELINES

The Academy of Hand and Upper Extremity Physical Thera-

py (AHUEPT) and Academy of Orthopaedic Physical Ther-

apy (AOPT) of the American Physical Therapy Association

(APTA) have an ongoing eort to create evidence-based

practice guidelines for management of patients with mus-

culoskeletal impairments described in the World Health

Organization’s International Classiﬁcation of Functioning,

Disability and Health (ICF).

204

The purposes of these clinical guidelines are to:

• Describe evidence-based practice including diagnosis,

prognosis, intervention, and assessment of outcomes of

musculoskeletal disorders commonly managed by ortho-

paedic, sports, and hand physical therapists

• Classify and deﬁne common musculoskeletal conditions

using the World Health Organization’s terminology relat-

ed to impairments of body function and body structure,

activity limitations, and participation restrictions

• Identify interventions supported by current best evidence

to address impairments of body function and structure, ac-

tivity limitations, and participation restrictions associated

with common musculoskeletal conditions

• Identify appropriate outcome measures to assess changes

resulting from physical therapy interventions in body func-

tion and structure as well as in activity and participation of

the individual

• Provide a description to policy makers, using internation-

ally accepted terminology, of the practice of orthopaedic,

sports, and hand physical therapists

• Provide information for payers and claims reviewers re-

garding the practice of orthopaedic, sports, and hand ther-

apy for common musculoskeletal conditions

• Create a reference publication for clinicians, academic

instructors, clinical instructors, students, interns, res-

idents, and fellows regarding the best current practice

of orthopaedic and sports physical therapy and hand

rehabilitation

STATEMENT OF INTENT

These guidelines are not intended to be construed or to serve

as a standard of medical care. Standards of care are deter-

mined on the basis of all clinical data available for an individ-

ual patient and are subject to change as scientiﬁc knowledge

and technology advance and patterns of care evolve. These

parameters of practice should be considered guidelines only.

Adherence to them will not ensure a successful outcome in

every patient, nor should they be construed as including all

proper methods of care or excluding other acceptable meth-

ods of care aimed at the same results. The ultimate judgment

regarding a particular clinical procedure or treatment plan

must be made in light of the clinical data presented by the

patient, the diagnostic and treatment options available, and

the patient’s values, expectations, and preferences. However,

we suggest that signiﬁcant departures from accepted guide-

lines should be documented in the patient’s medical records

at the time the relevant clinical decision is made.

SCOPE AND RATIONALE OF THE GUIDELINE

Lateral elbow tendinopathy (LET) is characterized by pain at

the common wrist extensors at or near the lateral epicondyle

that is aggravated by loading of the involved muscles.

The

extensor carpi radialis brevis (ECRB) and extensor digitorum

muscles are the most frequently injured,

while the pain is be-

lieved to originate from excessive tensile force on the injured

musculotendinous structures and periosteal junction. Lateral

elbow tendinopathy is commonly known as tennis elbow, yet

despite the name, many individuals who present with symp-

toms of LET are not involved in racquet sports.

193

Athletes

of all types and individuals who repetitively use their upper

extremity (UE), particularly involving their wrist extensors,

can be at risk for developing LET. Although many describe

the condition as self-limiting and likely to resolve on its own,

high recurrence rates and extended sick leave highlight the

challenge for the nonsurgical management of individuals

with LET.

14,22

Therefore, there is a need to assemble a com-

prehensive set of guidelines for assessing and treating LET.

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

As the understanding of the histology underpinning the ten-

don pathology associated with LET has evolved, clinicians are

beginning to recognize the complexity of the diagnosis. The

interrelationship of histological and structural changes to the

tendon itself, the associated impairments in motor control,

and potential changes in pain processing can all contribute

to the presentation of symptoms in any given individual.

36,59

This clinical practice guideline (CPG) includes studies re-

porting on LET pertinent to physical therapist practice. Ep-

idemiology, functional anatomy and pathophysiology, risk

factors, clinical course, prognosis, dierential diagnosis, tests

and measures, and interventions are included. This CPG ex-

cluded studies that addressed pathologies closely related to

LET. For example, cervical radiculopathy, primary peripheral

nerve entrapment, and joint pathology including plica syn-

drome, radiocapitellar chondromalacia, and posterolateral

rotatory instability as causes of lateral elbow pain were ex-

cluded. Finally, this CPG excluded interventions outside the

scope of physical therapist practice including but not limited

to pharmacological and surgical interventions unless directly

compared to physical therapy management.

Methods

The AHUEPT and the AOPT of the APTA appointed content

experts to develop CPGs for musculoskeletal conditions of

elbow, forearm, wrist, and hand. The aims of this review were

to provide a concise summary of the contemporary evidence

and to develop recommendations to support evidence-based

practice. The authors of this guideline worked with the CPG

editors and medical librarians for methodological guidance.

One author (R.L.M.) served as the team’s methodologist.

Research librarians were chosen for their expertise in sys-

tematic review and rehabilitation literature searching and

to perform systematic searches for concepts associated with

classiﬁcation, examination, and intervention strategies for

LET. Brieﬂy, the following databases were searched between

January 2001 to November 2021: PubMed including Med-

line, CINAHL, and the Cochrane Library (see

APPENDIX A for

full search strategies, dates, and results, available at www.

jospt.org and www.handpt.org).

The authors declared relationships and developed a con-

ﬂict management plan, which included submitting a con-

ﬂict-of-interest form to the AOPT. Articles authored by

members of the CPG team were assigned to an alternate

reviewer. The AOPT and AHUEPT funded the CPG devel-

opment team for travel and CPG development training. The

CPG development team maintained editorial independence

with regards to the funding agencies.

Articles contributing to recommendations were reviewed

based on prespeciﬁed inclusion and exclusion criteria with

the goal of identifying evidence relevant to physical therapist

clinical decision-making for adults with LET. Two members

of the CPG development team independently screened the ti-

tle and abstract prior to full text review to obtain the ﬁnal set

of articles used to make the recommendations. (See

APPEN-

DIX B for inclusion and exclusion criteria, available at www.

jospt.org and www.handpt.org.) The team leader (A.M.L.)

provided the ﬁnal decision for discrepancies that were not

resolved by the review team (see

APPENDIX C for the ﬂowchart

of articles, available at www.jospt.org). Data extraction and

assignment of level of evidence was also performed and were

conﬁrmed by members of the CPG development team. For

selected relevant topics for which recommendations were

not developed, which included incidence, risk factors, dier-

ential diagnosis, imaging, and prognosis, articles were not

subject to systematic review process and were not included

in the ﬂowchart. Evidence tables for this CPG are available

on the CPG page of the AOPT of the APTA websites: www.

orthopt.org and www.handpt.org.

This guideline was issued in 2022, based on the published

literature from January 2001 to November 30, 2021, and

will be considered for review in 2027, or sooner if import-

ant evidence becomes available. Any updates to the guide-

line in the interim period will be noted on the AOPT and

AHUEPT of the APTA websites: www.orthopt.org and

www.handpt.org.

LEVELS OF EVIDENCE

Individual clinical research articles were graded according to

criteria adapted from the Centre for Evidence-Based Med-

icine, Oxford, UK (http://www.cebm.net)

for diagnostic,

prospective, and therapeutic studies. In teams of 2, each re-

viewer independently assigned a level of evidence and evalu-

ated the quality of each article using a critical appraisal tool.

If the 2 reviewers did not agree on levels of evidence for a

particular article, a third content expert was used to resolve

the issue. (See

APPENDICES D and E for Levels of Evidence table

and details on procedures used for assigning levels of evi-

dence, available at www.jospt.org and www.handpt.org.) The

evidence was organized from the highest to lowest level of

evidence. An abbreviated version of the grading system is

provided in

TABLE 1.

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

GRADES OF EVIDENCE

The overall strength of the evidence supporting recommenda-

tions made in these guidelines was graded according to guide-

lines described by Guyatt et al,

as modiﬁed by MacDermid

114

and adopted by the coordinator and reviewers of this project.

In this modiﬁed system, the typical A, B, C, and D grades of

evidence have been modiﬁed to include the role of consensus

expert opinion and basic science research to demonstrate bi-

ological or biomechanical plausibility (

TABLE 2). In developing

their recommendations, the authors considered the strengths

and limitations of the body of evidence and the health bene-

ﬁts, side eects, and risks of tests and interventions.

GUIDELINE REVIEW PROCESS AND VALIDATION

Identiﬁed reviewers who are experts in UE injury manage-

ment and rehabilitation reviewed a prepublication draft of

this CPG content and methods for integrity, accuracy, and

that it fully represents the condition. Any comments, sugges-

tions, or feedback from the expert reviewers were delivered

to the author and editors for consideration and appropriate

revisions. These guidelines were also posted for public com-

ment on the AOPT website (www.orthopt.org), and a notiﬁ-

cation of this posting was sent to the members of the AOPT

and AHUEPT. Any comments, suggestions, and feedback

gathered from public commentary were sent to the authors

TABLE 1

Levels of Evidence

I Evidence obtained from high-quality diagnostic studies, prospective

studies, systematic reviews, or randomized controlled trials

II Evidence obtained from lesser-quality diagnostic studies, systematic

reviews, prospective studies, or randomized controlled trials (eg, weaker

diagnostic criteria and reference standards, improper randomization, no

blinding, <80% follow-up)

III Case-controlled studies or retrospective studies

IV Case series

V Expert opinion

TABLE 2

Grades of Recommendation

Grades of

Recommendation Strength of Evidence

Level of

Obligation

A Strong evidence A preponderance of level I and/or level

II studies support the recommen-

dation. This must include at least 1

level I study

Must or

should

B Moderate evidence A single high-quality randomized

controlled trial or a preponderance

of level II studies support the recom-

mendation

Should

C Weak evidence A single level II study or a prepon-

derance of level III and IV studies,

including statements of consensus

by content experts, support the

recommendation

May

D Conﬂicting

evidence

Higher-quality studies conducted on this

topic disagree with respect to their

conclusions. The recommendation is

based on these conﬂicting studies

E Theoretical/

foundational

evidence

A preponderance of evidence from

animal or cadaver studies, from

conceptual models/principles or

from basic sciences/bench research,

supports this conclusion

May

F Expert opinion Best practice based on the clinical

experience of the guideline develop-

ment team

May

TABLE 3

Planned Strategies and Tools to Support the Dissemination

and Implementation of This CPG

Abbreviations: APTA, American Physical Therapy Association; CPG, clinical practice guideline.

Tool Strategy

JOSPT’s “Perspectives for Patients” and “Perspectives for Practice” articles Patient- and clinician-oriented guideline summaries available at www.jospt.org

Mobile app of guideline-based exercises for patients/clients and health care practitioners Marketing and distribution of app via www.orthopt.org and www.handpt.org

Clinician’s Quick-Reference Guide Summary of guideline recommendations available at www.orthopt.org and www.

handpt.org

JOSPT’s Read for Credit

continuing education units Continuing education units available for physical therapists at www.jospt.org

Webinars and educational oerings for health care practitioners Guideline-based instruction available for practitioners at www.orthopt.org and www.

handpt.org

Mobile and web-based app of guideline for training of health care practitioners Marketing and distribution of app via www.orthopt.org

Non-English versions of the guidelines and guideline implementation tools Development and distribution of translated guidelines and tools to JOSPT’s international

partners and global audience via www.jospt.org

APTA CPG+ Dissemination and implementation aids

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

and editors to consider and make appropriate revisions in

the guideline. In addition, a panel of consumer/patient rep-

resentatives and external interested parties, such as claims

reviewers, medical coding experts, academic educators,

clinical educators, physician specialists, and researchers,

also reviewed the guideline and provided feedback and rec-

ommendations that were given to the authors and editors

for further consideration and revisions. The AOPT Clinical

Practice Guideline Advisory Panel reviews guideline devel-

opment methods, policies, and implementation processes on

a yearly basis.

DISSEMINATION AND IMPLEMENTATION TOOLS

In addition to publishing these guidelines in the Journal of

Orthopaedic & Sports Physical Therapy (JOSPT), these guide-

lines will be posted on CPG (free access) areas of the JOSPT,

AOPT, and AHUEPT websites and submitted to be available

for free access on the ECRI Guidelines Trust (guidelines.ecri.

org) and the Physiotherapy Evidence Database (www.PEDro.

org.au). The planned implementation tools for patients, clini-

cians, educators, payers, policy makers, and researchers, and

the associated implementation strategies are listed in

TABLE 3.

ORGANIZATION OF THE GUIDELINE

When systematic reviews were conducted to support speciﬁc

actionable recommendations, summaries of studies with the

corresponding evidence levels were followed by evidence syn-

thesis and rationale for the recommendation(s) with harms

and beneﬁts statements and gaps in knowledge. Topics for

which a systematic review was conducted and recommenda-

tions provided include patient-reported outcome measures

(PROMs), physical impairment measures, and interventions.

For other topics where a systematic review was outside the

scope of this CPG, a summary of the literature is provided.

This includes incidence/prevalence, pathoanatomical fea-

tures, risk factors, clinical course, prognosis, diagnostic clas-

siﬁcation, and dierential diagnosis, and imaging.

CLASSIFICATION

The primary International Classiﬁcation of Diseases 10th

Revision (ICD-10) codes and conditions associated with lat-

eral elbow pain and muscle function impairments (LET) are

outlined in

TABLE 4.

TABLE 4

ICD and ICF Codes

Associated With Lateral

Elbow Pain

Abbreviations: ICD, International Classiﬁcation of Diseases; ICF,

International Classiﬁcation of Functioning, Disability and Health.

International Statistical Classiﬁcation of Diseases and Related Health Problems

(ICD-10) 2015

ICD-10 M 7 7. 1 Lateral epicondylitis

International Classiﬁcation of Functioning, Disability and Health (ICF)

ICF Codes Description

Muscle Function Impairments

b730-b74

b730

b7300

b7301

b740

b7400

b7401

Muscle functions

Muscle power functions

Power of isolated muscles and muscle groups

Power of muscles of one limb

Muscle endurance functions

Endurance of isolated muscles

Endurance of muscle groups

Pain

b280

b28014

Sensation of pain

Pain in upper limb

Motor Control Impairments

b1471

b760

b7602

b7603

Quality of psychomotor functions

Control of voluntary movement functions

Coordination of voluntary movements

Supportive functions of arm or leg

Activity Limitations

d445

d4453

d430

d4300

d440

d4400

d4454

Hand and arm use

Turning or twisting the hands or arms

Lifting and carrying objects

Lifting

Fine hand use

Picking up

Throwing

Participation Restrictions

d920

d9201

d840-d859

d850

d8500

d8501

d8502

d855

Recreation and leisure

Sports

Work and employment

Remunerative employment

Self-employment

Part-time employment

Full-time employment

Nonremunerative employment

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

CLINICAL PRACTICE GUIDELINES

Impairment/Function-Based Diagnosis

PREVALENCE/INCIDENCE

A large population-based study suggested an overall annual

incidence of LET in the United States of 3%, although the

rates for those 40-60 years old were higher, ranging between

7% and 10%.

158

The prevalence of LET has been reported to

be as high as 29% in workers in occupations that required

a high demand of wrist and hand movements.

170,198

A 2015

systematic review of UE work-related musculoskeletal dis-

orders reports LET incidence ranges from 0.45 to 7 new

cases per 100 workers and prevalence ranges from 1 to 12.2

new cases per 100 workers.

An average of 12 weeks of sick

leave from work is taken in approximately 30% of those in-

dividuals with LET.

13,17

Additionally, incomplete resolution

or recurrence of symptoms at 6-12 months in individuals

receiving local nonsurgical management has been shown to

range between 20% and 38%.

At 2 years follow-up, the rate

of recurrence has been shown to be as high as 54%.

134

tennis players, the 2-month prevalence has been reported

at 14%, with recurrent cases being more common than new

cases, and rates increasing in players over 40 years of age.

A twin study estimated that heritability was 40%, after ad-

justing for age.

197

Pathoanatomical Features

The lateral epicondyle of the humerus, located just above

the capitellum, is the origin of the extensor-supinator mus-

cles.

126,130

The most common site of pathology in LET is the

juncture of the common extensor muscle origin of the lateral

epicondyle.

The enthesis or insertion of the common ex-

tensor tendon is characterized by a load sharing mechanism

where ﬁbers of the ECRB tendon fuses with the lateral collat-

eral ligament of the elbow and joint capsule and subsequent-

ly with the annular ligament of the proximal radial ulnar

joint.

125

Stress is dissipated throughout the entire enthesis

organ and may explain the somewhat diuse distribution of

pain at the lateral elbow with LET.

The common extensor tendon of the wrist and ﬁngers at the

elbow may be injured not only by repetitive tensile loading

but also by shearing forces against the capitellum with fore-

arm rotation.

The ECRB tendon has a unique anatomic lo-

cation that makes its undersurface vulnerable to contact and

abrasion against the lateral edge of the capitellum during

forearm pronation and supination.

275

Relative hypovascular-

ity of the ECRB tendon may further contribute to the sus-

ceptibility of the tendon to injury and may negatively impact

healing.

8,161

The extensor carpi radialis longus and extensor

digitorum tendons may also be involved. This may explain

why repetitive loading of the elbow, forearm, wrist, and/or

digits during work or athletic activities increases the risk of

LET.

48,171

However, similar biomechanical loading can poten-

tially injure adjacent structures; therefore, a thorough exam-

ination is required to dierentiate lateral elbow pain caused

by tendinopathy from other sources of symptoms such as

muscle, joint, or nerve pathology.

There has been a shift in understanding of tendon pathology

over the past 20 years. Tendinopathy refers to a nonrupture

injury in the tendon or peritendon (paratenon and epitenon)

that is aggravated by mechanical loading.

The term tendini-

tis characterizes an acute condition with a cell-mediated in-

ﬂammatory response. Tendinosis is a term that has been used

to describe chronic degenerative tendon pathology, charac-

terized by an abundance of ﬁbroblasts, vascular hyperplasia,

and unstructured collagen. Over time, clinical terminology

has changed from tendinitis or tendinosis to tendinopathy,

which represents the pain and impaired muscle function re-

lated to a broad spectrum of potential intratendinous changes

in structure, histology, and chemical mediators of pain and/

or inﬂammation.

In those with LET, as with other forms of

tendinopathy, individuals present somewhere in the continu-

um between acute and chronic conditions that may ﬂuctuate

over an episode of care. Therefore, it is possible that low-grade

inﬂammation may be intermittent and may occur for short

periods after intense tendon loading in chronic situations

characterizing an acute-on-chronic condition in some cases.

It has been postulated that LET is acquired by irritation of

the hypovascular zone of the common extensor tendon at its

attachment on the lateral epicondyle, which leads to subse-

quent neovascularization

that has been described as “an-

gioﬁbroblastic tendinosis.”

Chronic LET is characterized by

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

disorganization of collagen ﬁbers, an increase in the number

of vessels and sensory nerves, disorganized (smaller) type III

collagen ﬁbers,

161

and areas of hypocellularity or ﬁbroblast

reaction.

13,162

It is important to recognize that, despite the

lack of consistent evidence relating to the presence or ab-

sence of inﬂammatory cells locally,

other proinﬂammatory

chemical agents including inﬂammatory cytokines, growth

factors, prostaglandins, and neuropeptides have been detect-

ed in cases of chronic tendinopathy.

Neurochemicals are

important in the regulation of local tendon vascular supply

but are also believed to contribute to neurogenic inﬂamma-

tion. More recent evidence also points to altered nociceptive

processing as a contributor to persistent pain associated with

LET.

15,37

Preliminary evidence highlights the association of

nervous system sensitization in patients with chronic ten-

dinopathy.

147

It is important to appreciate the hypothesized

underlying tissue pathology in the context of the complex

processes related to the neuromodulation of pain, both pe-

ripherally and centrally.

The complex underlying pathophysiologic mechanisms asso-

ciated with LET may explain why it is dicult to accurately

classify and subgroup individuals with LET in a single/simple

classiﬁcation system and may also explain why its symptoms

are sometimes dicult to bring to full resolution. It is import-

ant to assess the intensity, irritability, and distribution of the

individual’s symptoms while considering their history and their

required activity levels to properly manage the condition.

113

SUMMARY

Most pathological changes in LET occur within the common

extensor tendon origin at the lateral epicondyle, common-

ly within the ﬁbers associated with the ECRB muscle. It is

known that structural, cellular, and chemical alterations in

the tendon can all exist with tendinopathy, but do not nec-

essarily correspond with the severity of clinical presentation.

Clinicians should recognize that histological conﬁrmation of

the underlying pathophysiology in LET for any patient is not

realistic in practice settings. Therefore, the acuity, irritability,

and the severity of LET symptoms at any given time should

guide management of this condition. In chronic cases of LET,

intense loading of the tendon with activity may result in low

grades of inﬂammation creating an acute aggravation of a

chronic condition.

Risk Factors

For this CPG, the term risk will be reserved speciﬁcally for

risk factors for new onset of LET, whereas prognosis (dis-

cussed later) will refer to the predicted course of the condi-

tion after onset. A systematic review of 5 prospective cohort

studies found a signiﬁcant association between combined

biomechanical exposure involving the wrist and elbow and

incidence of LET (pooled odds ratio [OR] = 2.6; 95% CI:

1.9, 3.5).

A case-control study that included the general

population with a diagnosis of LET reported a higher risk

for women for handling tools >1 kg (women OR = 3.0; 95%

CI: 1.6, 5.5; men OR = 2.1; 95% CI: 1.1, 3.8).

Shiri et al,

171

their cross-sectional cohort study, found a signiﬁcant associ-

ation between LET and jobs that involve handling loads >20

kg at least 10 times/day for more than 20 years in a cohort

of working population from a national registry (OR = 2.6;

95% CI: 1.3, 5.1).

After adjusting for age, lack of social support, and obesity in

a cohort of more than 1000 newly employed workers without

symptoms of LET, those who reported wrist bending/twist-

ing and forearm twisting/rotating/screwing motion were at

elevated risk of developing LET.

Hard perceived physical

exertion combined with elbow ﬂexion/extension (>2 hours/

day) (men OR = 2.6; 95% CI: 1.9, 3.7) and wrist bending (>2

hours/day) (men OR = 5.6; 95% CI: 2.8, 11.3 and women OR

= 2.9; 95% CI: 1.3, 6.5) was found to be signiﬁcant risk factors

for LET.

In a population-based study, signiﬁcant associa-

tions between LET and repetitive movements of the hand or

wrist for at least 2 hours/day for those with 9 to 19 years ex-

posure (OR = 2.4; 95% CI: 1.2, 4.9) and for 20 or more years

of exposure (OR = 2.8; 95% CI: 1.4, 5.8) were identiﬁed.

171

Park et al,

141

in their case-control study that included 937 par-

ticipants from a rural agricultural setting, found signiﬁcant

associations between LET and dominant-side involvement

(OR = 3.21; 95% CI: 2.24, 4.60), female sex (OR = 2.47; 95%

CI: 1.78, 3.43), manual labor (OR = 2.25; 95% CI: 1.48, 3.43),

and ipsilateral rotator cu tear (OR = 2.77; 95% CI: 1.96,

3.91).

141

Another study that included 1824 workers found a

signiﬁcant association between cardiovascular disease and

LET symptoms (OR = 3.81; 95% CI: 2.11, 6.85), positive ex-

amination ﬁndings for LET (OR = 2.85; 95% CI: 1.59, 5.12),

and combined symptoms and physical examination (OR =

6.20; 95% CI: 2.04, 18.82).

In a case-control study

183

of 4998 patients with LET matched

by age/sex from general practice settings, a multivariate

analysis identiﬁed signiﬁcant association between LET and

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

rotator cu pathology (OR = 4.95; 95% CI: 3.64, 6.71), De

Quervain’s disease (OR = 2.48; 95% CI: 1.14, 5.37), carpal

tunnel syndrome (OR = 1.50; 95% CI: 1.14, 1.98), oral corti-

costeroid therapy (OR = 1.68; 95% CI: 1.47, 1.92), and pre-

vious smoking history (OR = 1.20; 95% CI: 1.06, 1.36). In

addition, diabetes mellitus, current smoking, trigger ﬁnger,

rheumatoid arthritis, alcohol intake, and obesity were deter-

mined not to be associated with LET.

183

An earlier systematic

review

190

of 13 studies identiﬁed associations between LET

and the psychosocial risk factors of low control over work

duties (OR = 2.2; 95% CI: 1.4, 3.2) and low social support

(OR = 1.8; 95% CI: 1.2, 2.7).

190

SUMMARY

Female sex, dominant-side involvement, previous smoking

history, rotator cu injuries, De Quervain’s disease, carpal

tunnel syndrome, and oral corticosteroid therapy use rep-

resent nonmodiﬁable risk factors for LET. Modiﬁable risk

factors for LET include low job control, low social support,

handling heavy tools greater than 20 kg, repetitive elbow/

wrist ﬂexion/extension for more than 2 hours a day, and

repetitive forearm twisting/rotating/screwing movements.

Diabetes, trigger ﬁnger, rheumatoid arthritis, alcohol in-

take, and obesity were not associated with the incidence

of LET.

Clinical Course

Lateral elbow tendinopathy can be a source of lasting pain

and disability for many individuals. The clinical course of

LET depends heavily on the extent to which individuals are

exposed to repetitive irritation of the involved structures.

While some experience full and expedient resolution of

symptoms with nonsurgical care, more than half of patients

seeking general medical care continue to report symptoms

after 1 year.

Regardless of past treatments, up to 20% of in-

dividuals report persistent pain for 3-5 years after care.

Ex-

posure to various occupational or sports-speciﬁc stresses, as

in tennis, may negatively impact prognosis and can result in

lost work time due to injury.

198

Up to 55% of individuals with

LET have been shown to have lingering pain and functional

loss for more than 2 years after the onset of symptoms.

133

Therefore, LET may not always follow the typical course and

time frames of the normal healing process. By the time an

individual seeks medical care, the inﬂammatory process has

often resolved, yet symptoms remain.

The age- and sex-adjusted annual incidence of LET in the

general population has decreased signiﬁcantly over time

from 4.5/1000 people in 2000 to 2.4/1000 in 2012.

158

the other hand, the proportion of surgically treated cases has

tripled (1.1% in 2000-2002 to 3.2% from 2009 to 2011).

158

About 1 in 10 patients with persistent symptoms at 6 months

were treated with surgery.

158

The course of the tendinopathy is important to consider as a

descriptive element as this can range from a single isolated

initial episode to a re-occurrence, to an episodic condition, or

it may be persistent. In persistent chronic LET, exacerbations

are typically associated with an activity that in some cases

may be predicted based on the amount and nature of the

activity. Determining level of irritability by using pain level,

distribution of pain, and level of disability can be useful in

directing treatment.

SUMMARY

Although many believe the condition to be benign, LET can

be debilitating for some individuals, resulting in an inability

to fully perform their job, household tasks, or athletic in-

terests. Nonsurgical interventions are the mainstay of LET

management. While some individuals can fully and quickly

recover, many experience persistent pain or recurrence of

symptoms, contributing to a poor prognosis regarding pro-

longed discomfort. Protection from repetitive irritation may

help minimize or eliminate exacerbations or recurrence of

symptoms.

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

Prognosis

Prognosis refers to the predicted course of LET after its

onset. Some factors may assist the clinician in predicting

short-term physical therapy treatment outcome, as well as

the eventual long-term outcome of LET management.

Analysis of data from a randomized control trial (RCT) with

62 subjects (mean age = 48.2 years) undergoing physical

therapy that consisted of 5 treatment sessions of mobilization

with movement (MWM) and exercise, found several factors

at baseline associated with improved outcomes.

195

Age <49

years, pain-free grip strength (PFGS) >112 N on the aected

side, and PFGS <336 N on the unaected side predicted a

self-report of symptoms being improved at 3 weeks (P<.01,

Nagelkerke’s R

= 0.45). The probability of improvement was

87%, 93%, and 100% if one, two, or three of the indicators

were present, respectively.

195

The authors of a multicenter prospective trial with 83 sub-

jects (mean age = 44.2 years; 47 women, 36 men) under-

going physical therapy, consisting of 10 visits over 8 weeks

with ultrasound (US), soft tissue massage, stretching,

and strengthening components, determined predictors of

8-week outcomes.

201

Predictors for greater disability (r

0.61, P = .0001) included higher baseline Disabilities of the

Arm, Shoulder and Hand (DASH) scores (β = .50; 95% CI:

0.34, 0.66), sex (female) (β = 8.92; 95% CI: 3.3, 14.5), and

self-reported nerve symptoms (β = 7.32; 95% CI: 0.8, 13.8).

Predictors for higher pain visual analog scale (VAS) scores

= 0.31, P = .0003) included baseline pain VAS (β = .19;

95% CI: 0.01, 0.37), sex (female) (β = 9.26; 95% CI: 0.4,

18.2), and self-reported nerve symptoms (β = 15.08; 95%

CI: 4.7, 25.5). Age, duration of symptoms, elbow joint signs,

cervical joint signs, and jobs with repetition did not contrib-

ute to the prognostic models (P>.05).

201

Follow-up on these

subjects at 6 months found performing a repetitive job to

be the best predictor for higher DASH (r

= 0.52, P = .0001)

and pain VAS (r

= 0.14, P = .0151) scores.

200

Similar ﬁndings

related to type of occupation were noted by Paoloni et al

140

and Lewis et al,

107

as those performing manual labor jobs

were less likely to improve by 6 months.

Prognostic factors were examined in 131 subjects (mean

age = 44 years; 80 females, 51 males) who were followed

after initiation of conservative treatment that consisted of

self-stretching and use of a counterforce brace.

153

Increased

patient-reported disability on the DASH at 6 months was

associated with initial lower pain thresholds to pressure (β =

−1.28; 95% CI: −1.79, −0.78), initial higher (increased) pain

sensitivity (Pain Sensitivity Questionnaire) scores (β = 1.69;

95% CI: 0.92, 2.49), and involvement in a manual labor job

(β = 1.12; 95% CI: 0.84, 1.41). These 3 factors accounted for

36% of the variance in 6-month DASH scores.

153

Analysis from an RCT of 266 subjects (163 were >40 years of

age; 144 females, 122 males) found that the primary factor

associated with pain reduction less than 50% at 1-year fol-

low-up was LET on the dominant side (OR = 3.1; 95% CI:

1.4, 6.8). Age, being greater or less than 40 years of age, and

sex were not signiﬁcant prognostic factors.

Similarly, Hol-

medal et al

also found when looking at 177 subjects (mean

age = 47 years; 71 women, 106 men) in an RCT, age, sex,

and duration of symptoms not to be signiﬁcant (P>.05) in

predicting treatment success, as deﬁned by a report of be-

ing much better or completely recovered, at 26- or 52-week

follow-up.

A prospective international study followed 349 subjects

(mean age = 48 years, 171 females, 178 males) from 2 RCTs

investigating conservative interventions for LET in a primary

care setting. These authors noted a combination of 20 prog-

nostic variables, including the covariates country and treat-

ment, contributed to only 12% of the variance in predicting

pain intensity at 12-month follow-up.

205

SUMMARY

When looking at the eect of physical therapy interventions

in short term follow-up, grip strength and age were found

to be useful in predicting 3-week outcomes, whereas base-

line disability, female sex, and self-reported nerve symptoms

may be useful in predicting 8-week outcomes. For 6-month

follow-up, occupation may be important to consider as re-

petitive and manual labor jobs may help in predicting those

with a potential for poorer outcomes. When looking at all

individuals independent of treatment, the involvement of the

dominant arm may be useful in predicting outcomes at 1 year.

However, predicting long-term outcomes may generally be

challenging, as prognostic variables do not seem to accurately

predict outcomes.

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

Diagnosis/Classiﬁcation

OVERVIEW

An accurate diagnosis of LET is very important to provide ade-

quate and appropriate treatment. Diagnosis and classiﬁcation of

LET is based on adequate history taking, physical ﬁndings, and

special tests (

TABLES 5-7). An accurate diagnosis with a better un-

derstanding of the classiﬁcation of LET may aid in planning a re-

turn to work and activity and may help prevent future reinjuries.

CLASSIFICATION

Classiﬁcation systems are typically designed as descriptive

tools, although ideally, they would be useful in directing ap-

propriate treatment or predicting outcomes. However, limited

research exists to support the use of reported classiﬁcation

systems related to tendinopathy in general and LET in specif-

ic. Most classiﬁcation systems proposed are based on the acu-

ity, severity, and irritability of LET individually as stand-alone

classiﬁcations or a combination of these dimensions.

20,135,162,203

Making the classiﬁcation of LET even more challenging, in-

dividuals with dierent occupational or athletic demands and

those with multiple recurrences tend to vary in their response

to interventions. MacDermid and Silbernagel

113

proposed a

descriptive classiﬁcation (

TABLE 8) that considers 6 classiﬁ-

cation axes, including irritability and distribution of symp-

toms while including descriptive information on the context

(general population, sports, worker’s compensation, etc), the

acuity, the likely underlying pathology (usually determined

by imaging), and the course (recurrent vs isolated episode or

persistent symptoms). This, when used appropriately, would

provide the clinician with a holistic picture of patients with

LET and can be eective in tracking progress and guiding

treatment. For example, when determining the stage of irri-

tability, self-reported pain scores (NRPS) help quantify pain

intensity as either mild intensity (≤3/10), moderate intensity

(4-6/10), or severe intensity ≥7/10). Distribution of symptoms

can be classiﬁed as unilateral and localized to the lateral epi-

condyle (type 1), bilateral and localized to the lateral epicon-

dyles (type 2), or diuse symptoms at the elbow along with

cervical or diuse UE pain or neuropathic pain (type 3).

An assessment of how symptom irritability aects function

using PTREE scores can indicate mild disability (score of

Abbreviations: ECRB, extensor carpi radialis brevis; ICF, International

Classiﬁcation of Functioning, Disability and Health; LET, lateral elbow

tendinopathy.

TABLE 5

Resisted Middle

Finger Extension Test

(Maudsley’s Test)

117

ICF Category Measurement of Impairment of Body Function

Description Special test to assist with the diagnosis of LET

Measurement method Patient position:

The patient can be in sitting or standing with the elbow

in full extension, forearm pronation, and ﬁngers in

extension.

Test:

The examiner supports the distal end of the forearm and

applies resistance to the dorsum of the distal phalanx

of the third digit of the hand, indirectly stressing the

ECRB muscle and tendon.

Positive test:

Reproduction of pain at the lateral epicondyle of the hu-

merus or within 2 cm distal to the common extensor

tendon insertion site.

Nature of variable Nominal/dichotomous

Units of measurement None

Measurement properties Maudsley’s test showed little association with pressure

pain threshold (β = .293).

145

Sensitivity = 88%

159

Sensitivity = 66%; 95% CI: 53%, 76%

Abbreviations: ICF, International Classiﬁcation of Functioning, Dis-

ability and Health; LET, lateral elbow tendinopathy.

TABLE 6

Resisted Wrist Extension

Test or Cozen’s Test

or LET Test

117

ICF Category Measurement of Impairment of Body Function

Description Special test to assist with the diagnosis of LET

Measurement method Patient position:

The patient can be in sitting or standing with the elbow

fully extended, forearm pronated, and the wrist

extended to 30°.

Test:

The patient’s elbow is stabilized by the examiner’s

thumb, which rests on the patient’s lateral epicon-

dyle. The examiner then provides pressure to the

dorsum of the second and third metacarpals using

the other hand to resist active wrist extension.

Positive test:

Reproduction of pain at the lateral epicondyle of the hu-

merus or within 2 cm distal to the common extensor

tendon insertion site.

Nature of variable Nominal/dichotomous

Units of measurement None

Measurement properties Cozen’s test showed fair association with pressure pain

threshold (β = .436).

145

Sensitivity = 84%

159

Sensitivity = 91%; 95% CI: 81%, 96%

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

<20/50), moderate disability (score between 21 and 34/50),

or severe disability (score >30). The presentation of symp-

toms can ﬂuctuate widely depending on the individual’s oc-

cupational or athletic demands during treatment.

As systems for subclassifying LET evolve and become validat-

ed, it may be possible to direct treatment to more eectively

manage symptoms in speciﬁc subpopulations of individuals

with LET. Physical therapists may document the classiﬁca-

tion of LET considering context, acuity, pathology, course,

distribution of symptoms, and irritability, and consider these

factors in treatment planning. Empirical validation of clas-

siﬁcation systems is needed to better guide treatment and

future research initiatives.

SUMMARY

An accurate clinical diagnosis of LET is very important to

plan treatment and to prevent recurrence. The ICD diagnosis

of LET and the associated ICF diagnosis of pain and muscle

function impairments are typically made when, on clinical

examination, the patient presents with reports of pain local

to the lateral epicondyle reproduced with palpation, resist-

ed wrist and/or digit extension, and stretch/elongation of

the long wrist extensors. There are 3 common special tests

(Maudsley’s, Cozen’s, and Mill’s stretch) that are used to

arrive at a clinical diagnosis of LET. These tests have weak

evidence supporting their diagnostic usefulness.

188,211

problematic in the clinical diagnosis of LET is that sever-

al other pathologies result in a similar distribution of pain;

therefore, a thorough physical examination based on the ex-

clusion of other disorders as the cause of lateral elbow pain is

especially important for a more conﬁdent diagnosis of LET.

The classiﬁcation system that is presented here can be uti-

lized. However, research is required to validate classiﬁcation

systems and to assess their eectiveness on outcomes. Scien-

tiﬁc inquiry into the value of subclassifying individuals into

groups to allow for intervention-matching is needed.

The CPG team feels that the classiﬁcation of patients with

LET based on level of irritability can be useful to direct treat-

ment. Self-reported pain, distribution of symptoms, and level

of disability should all be considered in the stage of irrita-

bility. For those who have severe pain, type 3 distribution,

and high disability, the focus of treatment can be on symp-

tom modulation. Joint and soft-tissue mobility is the focus

of treatment for those with moderate pain, type 3 distribu-

tion, and moderate disability. When mild pain with type 1-2

distribution and low disability is achieved, loading the wrist

extensors can be done while return to function can be the

focus of treatment for those with mild-absent pain, type 1-2

distribution, and mild-absent disability. It should be noted

that shifting between categories is ﬂuid and patients may of-

ten ﬁt more than one category at a given time.

DIFFERENTIAL DIAGNOSIS

Physical therapists should be able to identify other musculo-

skeletal and nonmusculoskeletal conditions that mimic the

clinical presentation of LET and promptly refer patients to

other health care professionals for further evaluation and

management, if appropriate. The steps in developing a dier-

ential diagnosis include history taking, physical examination

(including proper examination of special tests), and possibly,

imaging. The conditions to consider with a dierential diag-

nosis of lateral elbow pain, although not all-inclusive, include

the following:

• Cervical radiculopathy

103

• Radial tunnel syndrome

54,154

• Posterior interosseous syndrome

• Plica syndrome

156,176

• Radio-capitellar chondromalacia,

104

• Posterolateral rotatory instability

• Myofascial trigger points in the wrist extensors

History and physical exam ﬁndings are considered the gold

standard used to conﬁrm the diagnosis. Imaging, however,

can be useful in evaluating the extent of disease, identifying

associated pathology, and excluding other sources of elbow

pain; particularly in cases where initial nonsurgical treat-

ment is unsuccessful. For refractory cases of LET, initial im-

aging should include radiographs. Radiographs are usually

negative but may demonstrate calcium deposition adjacent

to the lateral epicondyle and can be used to exclude other

Abbreviations: ICF, International Classiﬁcation of Functioning, Dis-

ability and Health; LET, lateral elbow tendinopathy.

TABLE 7

Mill’s Stretch Test or

Long Extensor Stretch

124

ICF Category Measurement of impairment of body function

Description Special test to assist with the diagnosis of LET

Measurement method Patient position:

The patient can be in sitting or standing beginning with the

elbow ﬂexed to 90°, with the forearm pronated, and the

wrist fully ﬂexed.

Test:

The examiner extends the elbow slowly while palpating the

lateral epicondyle.

Positive test:

Reproduction of pain at the lateral epicondyle of the

humerus or within 2 cm distal to the common extensor

tendon insertion site.

Nature of variable Nominal/dichotomous

Units of measurement None

Measurement

properties

Mill’s test showed little association with pressure pain

threshold (β = .267).

145

Sensitivity = 53%; Speciﬁcity = 100%

159

Sensitivity = 76%; 95% CI: 63%, 85%

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Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

pathologies. The advanced imaging modality most widely

used is magnetic resonance imaging (MRI), followed by US.

The sensitivity of MRI in detecting LET is reported to range

between 90% and 100% and speciﬁcity from 83% to 100%.

123

Classic MRI ﬁndings include increased signal within or

around the common extensor tendon, a discrete collection of

ﬂuid between the common extensor tendon and radial col-

lateral ligament, and tendon thickening.

149

A meta-analysis

demonstrated that MRI signal change occurred in 90% of el-

bows with a clinical diagnosis of LET compared to only 14% of

controls.

142

Magnetic resonance imaging is often used to grade

the severity of disease (mild, moderate, and severe).

While

some authors report no statistically signiﬁcant association

between imaging measures and symptoms,

31,199

Qi et al

149

re-

ported a positive correlation between the grade of tendinopa-

thy and patient-reported pain and disability. When combined

with an appropriate clinical assessment, MRI can be useful in

establishing a plan of care for individuals with LET.

Ultrasound can also be used to evaluate LET.

Findings in-

clude tendon thickening and tendon heterogeneity, tendon

tears (hypoechoic regions), and tendon discontinuity.

Sur-

rounding ﬂuid and calciﬁcation can also be detected. A sys-

tematic review

examining the diagnostic accuracy of US in

LET found that hypoechogenicity of the common extensor

origin was both moderately sensitive (0.64; 95% CI: 0.56,

0.72) and highly speciﬁc (0.82; 95% CI: 0.72, 0.90) in deter-

mining which elbows had LET. Ultrasound features of chron-

ic LET that showed high speciﬁcity included neovascularity

(speciﬁcity, 1.00; 95% CI: 0.97, 1.00), calciﬁcations (0.97;

95% CI: 0.94, 0.99), and cortical irregularities (0.96; 95%

TABLE 8

Descriptive Classification of Lateral Elbow Tendinopathy

VAS Pain Score ______ PRTEE Pain Score ______ PRTEE Total score ______

^The highest stage the person is most aligned with preferably deﬁned by validated pain and disability measures

*Mild pain: ≤3/10 on VAS; 20/50 on PRTEE pain scale and 40/100 on PRTEE full scale

**Moderate Pain: 4-6/10 VAS; 21-34/50 on PRTEE pain scale and 41-69/100 on PRTEE full scale

***Severe Pain: >7/10 VAS; >36/50 on PRTEE pain scale and >70/100 on PRTEE full scale

Table adapted with permission from Joy MacDermid.

Axis I

Context

Axis II

Acuity

Axis IV

Course

◽ General Population (screening/prevention)

◽ Mixed Clinical Setting (Treatment)

◽ Special Population

◽ Athlete _____

◽ Work _______

◽ Claim (Workers’ Compensation)

◽ Other _____________

◽ Acute (0-6 wk)

◽ Subacute (<3 mo)

◽ Chronic (>3 mo)

◽ Isolated episode

◽ Recurrent

◽ Persistent

◽ predictable

◽ unpredictable

Axis III

Pathology

◽ Tendinosis

◽ Paratenonitis

◽ Mixed

Axis V

Distribution

Axis VI^

Irritability

◽ Type 1: Unilateral signs/symptoms localized to lateral elbow

◽ Type 2: Bilateral signs/symptoms that are localized to lateral elbows

◽ Type 3 : Elbow + Cervical: Lateral elbow symptoms/signs combined with

cervical signs/symptoms or neuropathic pain

◽ Level 1: Mild pain* occurring after exercise/work,

lasts <6 hours

Mild

◽ Level II: Mild pain* occurring after exercise/work

that lasts 7-48 hours

◽ Level III: Mild pain* occurring during exercise/

work that persists after activity, but does not limit

activity

◽ Level IV: Mild* to moderate** pain that occurs

during exercise/work activity, persists >6 hours

and limits activity

Moderate

◽ Level V: Moderate** overall pain ratings; severe

pain with heavy activities of daily living

◽ Level VI: Moderate** to severe*** overall pain

ratings; severe pain with light activity; intermittent

pain at rest

Severe

◽ Level VII: Constant pain at rest, severe*** pain

with activity, pain disturbs sleep

Journal of Orthopaedic & Sports Physical Therapy®

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journal of orthopaedic & sports physical therapy | volume 52 | number 12 | december 2022 | cpg15

Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice GuidelinesLateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines

CI: 0.88, 0.99).

Although US represents a less costly imag-

ing option than MRI, its diagnostic accuracy is ultimately de-

pendent on numerus variables such as operator experience,

equipment, and stage of pathology.

Nonimaging techniques

using electrodiagnostic studies, including electromyography

and nerve conduction studies, may also be used to rule out

compressive neuropathy involving the radial nerve as a cause

of lateral elbow pain.

Examination

OUTCOME, ACTIVITY LIMITATIONS,

SELF-REPORT MEASURES

Overview

Several outcome measures have been developed to assess

patients with LET. The PROMs that are most widely used

are the Patient Rated Tennis Elbow Evaluation (PRTEE), the

DASH questionnaire, the numeric pain-rating scale (NPRS),

and the Patient-Speciﬁc Functional Scale (PSFS) (

TABLES 9-12).

The commonly used clinician-based outcome measures are

the Mayo Elbow Performance Index (MEPI) and Roles and

Maudsley score (RM Score) (

TABLES 13-14).

ACTIVITY LIMITATIONS PHYSICAL

PERFORMANCE MEASURES

Activity limitation measures have not been reported in the lit-

erature, other than what is indicated for the patient self-report

questionnaires. The objective quantiﬁcation of the following

activities can help the clinician to assess changes in the pa-

tient’s level of function over time: hand and arm use; turning

or twisting the hands or arms; lifting and carrying objects; ﬁne

motor use of hand; throwing, bat, and racket activity in sport.

Clinicians can utilize easily reproducible activity limitation

and participation restriction measures associated with their

patients’ elbow pain to assess the changes in the patient’s

level of UE function over the episode of care.

Evidence Synthesis

Based on the results from high-quality clinical measurement

studies, the PRTEE, DASH, PSFS, and VAS all have demon-

strated excellent test-retest reliability, moderate to high levels

of construct validity, high levels of sensitivity to change, and

responsiveness in several populations. However, except for

the PRTEE, all the other self-report measures lack validation

in an LET population. Because the PSFS assesses restriction

of functional activities important to each individual, rigorous

activities that are not assessed in other self-report measures

(eg, work, hobbies, or athletic endeavors) can be monitored

objectively over time. Optional work and sports/performing

arts modules of the DASH may also provide valid, reliable,

and responsive measures of important functional tasks in-

volving the UE. The clinician-based outcome measures

(MEPI and RM Score) have demonstrated acceptable levels

of clinical measurement properties; however, there is a pau-

city of evidence in terms of the number of studies. Neither

the RM Score or the MEPI have been validated extensively

in a population of individuals with LET. Validated outcome

measure(s) should be administered at baseline and discharge

with other follow-up points being obtained as needed to as-

sess change for all patients with LET.

Gaps in Knowledge

More high-quality studies are required to evaluate the

clinical measurement properties, especially construct va-

lidity and responsiveness, including MCID of the DASH,

PSFS, and VAS in the LET population. The clinical mea-

surement properties of the RM Score and MEPI need to be

evaluated in the LET population to further support their

use and effectiveness in an LET population. Studies are

also needed to support the interpretation of objective and

reproducible measures of activity limitation and perfor-

mance measures.

RECOMMENDATION

Clinicians should use the diagnosis-speciﬁc PRTEE

to assess pain/irritability and function and/or the

region-speciﬁc DASH to assess UE function at

baseline and at least one other follow-up point, which in-

cludes discharge, for individuals with LET.

Clinicians should use the PSFS for patients with

high-demand activities and/or should administer a

scale that assesses activity-speciﬁc disability (eg,

DASH work or sports/performing arts module) at baseline

and at least one other follow-up point, which includes dis-

charge, for individuals with LET.

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