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Review
. 2024 May 28;5(5):CD013042.
doi: 10.1002/14651858.CD013042.pub2.

Manual therapy and exercise for lateral elbow pain

Jason A Wallis  1 , Allison M Bourne  1 , Rebecca L Jessup  1 , Renea V Johnston  1 , Aviva Frydman  1 , Sheila Cyril  1 , Rachelle Buchbinder  1
Affiliations
Review

Manual therapy and exercise for lateral elbow pain

Jason A Wallis et al. Cochrane Database Syst Rev. .

Abstract

Background: Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain.

Objectives: To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain.

Search methods: We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication.

Selection criteria: We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises.

Data collection and analysis: Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals.

Main results: Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials).

Authors' conclusions: Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.

PubMed Disclaimer

Conflict of interest statement

Wallis J: none known

Bourne A: none known

Jessup R: none known

Johnston R: none known

Frydman A: none known

Cyril S: none known

Buchbinder R: none known

Figures

1
1
2
2
3
3
4
4
1.1
1.1. Analysis
Comparison 1: Manual therapy versus placebo manual therapy, Outcome 1: Mean pain (0 to 10, 0 is no pain)
1.2
1.2. Analysis
Comparison 1: Manual therapy versus placebo manual therapy, Outcome 2: Mean disability (0 to 100, 0 is no disability)
1.3
1.3. Analysis
Comparison 1: Manual therapy versus placebo manual therapy, Outcome 3: Mean grip strength (lb/in2)
2.1
2.1. Analysis
Comparison 2: Manual therapy, prescribed exercises or both versus minimal or no intervention, Outcome 1: Mean pain (0 to 10, 0 is no pain)
2.2
2.2. Analysis
Comparison 2: Manual therapy, prescribed exercises or both versus minimal or no intervention, Outcome 2: Mean disability (0 to 100, 0 is no disability)
2.3
2.3. Analysis
Comparison 2: Manual therapy, prescribed exercises or both versus minimal or no intervention, Outcome 3: Health‐related quality of life (SMD)
2.4
2.4. Analysis
Comparison 2: Manual therapy, prescribed exercises or both versus minimal or no intervention, Outcome 4: Participant reported treatment success
2.5
2.5. Analysis
Comparison 2: Manual therapy, prescribed exercises or both versus minimal or no intervention, Outcome 5: Proportion of overall withdrawals
2.6
2.6. Analysis
Comparison 2: Manual therapy, prescribed exercises or both versus minimal or no intervention, Outcome 6: Proportion with any adverse event
2.7
2.7. Analysis
Comparison 2: Manual therapy, prescribed exercises or both versus minimal or no intervention, Outcome 7: Pain‐free grip strength (SMD)
2.8
2.8. Analysis
Comparison 2: Manual therapy, prescribed exercises or both versus minimal or no intervention, Outcome 8: Proportion on sick leave
3.1
3.1. Analysis
Comparison 3: Manual therapy and prescribed exercises versus minimal or no intervention, Outcome 1: Mean pain (0 to 10, 0 is no pain)
3.2
3.2. Analysis
Comparison 3: Manual therapy and prescribed exercises versus minimal or no intervention, Outcome 2: Mean disability (0 to 100, 0 is no disability)
3.3
3.3. Analysis
Comparison 3: Manual therapy and prescribed exercises versus minimal or no intervention, Outcome 3: Mean health related quality of life
3.4
3.4. Analysis
Comparison 3: Manual therapy and prescribed exercises versus minimal or no intervention, Outcome 4: Participant reported treatment success
3.5
3.5. Analysis
Comparison 3: Manual therapy and prescribed exercises versus minimal or no intervention, Outcome 5: Proportion of overall withdrawals
3.6
3.6. Analysis
Comparison 3: Manual therapy and prescribed exercises versus minimal or no intervention, Outcome 6: Proportion with any adverse event
3.7
3.7. Analysis
Comparison 3: Manual therapy and prescribed exercises versus minimal or no intervention, Outcome 7: Pain free grip strength (SMD)
3.8
3.8. Analysis
Comparison 3: Manual therapy and prescribed exercises versus minimal or no intervention, Outcome 8: Proportion on sick leave
4.1
4.1. Analysis
Comparison 4: Manual therapy versus minimal or no intervention, Outcome 1: Mean pain (0 to 10, 0 is no pain)
4.2
4.2. Analysis
Comparison 4: Manual therapy versus minimal or no intervention, Outcome 2: Mean disability (0 to 100, 0 is no disability)
4.3
4.3. Analysis
Comparison 4: Manual therapy versus minimal or no intervention, Outcome 3: Mean health related quality of life
4.4
4.4. Analysis
Comparison 4: Manual therapy versus minimal or no intervention, Outcome 4: Proportion of overall withdrawals
4.5
4.5. Analysis
Comparison 4: Manual therapy versus minimal or no intervention, Outcome 5: Proportion with any adverse event
4.6
4.6. Analysis
Comparison 4: Manual therapy versus minimal or no intervention, Outcome 6: Mean pain free grip strength (kg)
5.1
5.1. Analysis
Comparison 5: Prescribed exercises versus minimal or no intervention, Outcome 1: Mean pain (0 to 10, 0 is no pain)
5.2
5.2. Analysis
Comparison 5: Prescribed exercises versus minimal or no intervention, Outcome 2: Mean disability (0 to 100, 0 is no disability)
5.3
5.3. Analysis
Comparison 5: Prescribed exercises versus minimal or no intervention, Outcome 3: Mean health‐related quality of life
5.4
5.4. Analysis
Comparison 5: Prescribed exercises versus minimal or no intervention, Outcome 4: Participant‐reported treatment success
5.5
5.5. Analysis
Comparison 5: Prescribed exercises versus minimal or no intervention, Outcome 5: Proportion of overall withdrawals
5.6
5.6. Analysis
Comparison 5: Prescribed exercises versus minimal or no intervention, Outcome 6: Proportion with any adverse event
5.7
5.7. Analysis
Comparison 5: Prescribed exercises versus minimal or no intervention, Outcome 7: Pain‐free grip strength (SMD)
6.1
6.1. Analysis
Comparison 6: Manual therapy and prescribed exercises versus prescribed exercises alone, Outcome 1: Mean pain (0 to 10, 0 is no pain)
6.2
6.2. Analysis
Comparison 6: Manual therapy and prescribed exercises versus prescribed exercises alone, Outcome 2: Mean disability (0 to 100, 0 is no disability)
6.3
6.3. Analysis
Comparison 6: Manual therapy and prescribed exercises versus prescribed exercises alone, Outcome 3: Participant‐reported treatment success
6.4
6.4. Analysis
Comparison 6: Manual therapy and prescribed exercises versus prescribed exercises alone, Outcome 4: Proportion of overall withdrawals
6.5
6.5. Analysis
Comparison 6: Manual therapy and prescribed exercises versus prescribed exercises alone, Outcome 5: Mean grip strength (kg)
7.1
7.1. Analysis
Comparison 7: Manual therapy, prescribed exercises and glucocorticoid injection versus prescribed exercises and glucocorticoid injection alone, Outcome 1: Mean pain (0 to 10, 0 is no pain)
7.2
7.2. Analysis
Comparison 7: Manual therapy, prescribed exercises and glucocorticoid injection versus prescribed exercises and glucocorticoid injection alone, Outcome 2: Mean disability (0 to 100, 0 is no disability)
7.3
7.3. Analysis
Comparison 7: Manual therapy, prescribed exercises and glucocorticoid injection versus prescribed exercises and glucocorticoid injection alone, Outcome 3: Mean health‐related quality of life (1 to 3, 1 = perfect health)
7.4
7.4. Analysis
Comparison 7: Manual therapy, prescribed exercises and glucocorticoid injection versus prescribed exercises and glucocorticoid injection alone, Outcome 4: Proportion of overall withdrawals
7.5
7.5. Analysis
Comparison 7: Manual therapy, prescribed exercises and glucocorticoid injection versus prescribed exercises and glucocorticoid injection alone, Outcome 5: Proportion with any adverse event
7.6
7.6. Analysis
Comparison 7: Manual therapy, prescribed exercises and glucocorticoid injection versus prescribed exercises and glucocorticoid injection alone, Outcome 6: Mean grip strength (pain‐free, kg)
8.1
8.1. Analysis
Comparison 8: Manual therapy, prescribed exercises or both, and glucocorticoid injection versus glucocorticoid injection alone, Outcome 1: Mean pain (0 to 10, 0 is no pain)
8.2
8.2. Analysis
Comparison 8: Manual therapy, prescribed exercises or both, and glucocorticoid injection versus glucocorticoid injection alone, Outcome 2: Mean elbow disability (0 to 100, 0 is no disability)
8.3
8.3. Analysis
Comparison 8: Manual therapy, prescribed exercises or both, and glucocorticoid injection versus glucocorticoid injection alone, Outcome 3: Mean health‐related quality of life (EQ‐5D utility score)
8.4
8.4. Analysis
Comparison 8: Manual therapy, prescribed exercises or both, and glucocorticoid injection versus glucocorticoid injection alone, Outcome 4: Participant‐reported treatment success
8.5
8.5. Analysis
Comparison 8: Manual therapy, prescribed exercises or both, and glucocorticoid injection versus glucocorticoid injection alone, Outcome 5: Proportion of overall withdrawals
8.6
8.6. Analysis
Comparison 8: Manual therapy, prescribed exercises or both, and glucocorticoid injection versus glucocorticoid injection alone, Outcome 6: Proportion with any adverse event
8.7
8.7. Analysis
Comparison 8: Manual therapy, prescribed exercises or both, and glucocorticoid injection versus glucocorticoid injection alone, Outcome 7: Mean grip strength (affected side/unaffected side x 100)
9.1
9.1. Analysis
Comparison 9: Manual therapy, prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 1: Mean pain (0 to 10, 0 is no pain)
9.2
9.2. Analysis
Comparison 9: Manual therapy, prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 2: Mean elbow disability (0 to 100, 0 is no disability)
9.3
9.3. Analysis
Comparison 9: Manual therapy, prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 3: Mean health‐related quality of life (EQ‐5D utility score)
9.4
9.4. Analysis
Comparison 9: Manual therapy, prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 4: Participant‐reported treatment success
9.5
9.5. Analysis
Comparison 9: Manual therapy, prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 5: Proportion of overall withdrawals
9.6
9.6. Analysis
Comparison 9: Manual therapy, prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 6: Proportion with any adverse event
10.1
10.1. Analysis
Comparison 10: Prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 1: Mean pain (0 to 10, 0 is no pain)
10.2
10.2. Analysis
Comparison 10: Prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 2: Mean elbow disability (0 to 100, 0 is no disability)
10.3
10.3. Analysis
Comparison 10: Prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 3: Participant‐reported treatment success
10.4
10.4. Analysis
Comparison 10: Prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 4: Proportion of overall withdrawals
10.5
10.5. Analysis
Comparison 10: Prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 5: Proportion with any adverse event
10.6
10.6. Analysis
Comparison 10: Prescribed exercises and glucocorticoid injection versus glucocorticoid injection alone, Outcome 6: Mean grip strength (affected side/unaffected side x 100)
11.1
11.1. Analysis
Comparison 11: Subgroup analysis short‐term vs long‐term symptoms, Outcome 1: Subgroup analysis: pain end of intervention
11.2
11.2. Analysis
Comparison 11: Subgroup analysis short‐term vs long‐term symptoms, Outcome 2: Subgroup analysis: disability end of intervention
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References

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References to studies excluded from this review

Abbott 2001a {published data only}
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ACTRN12612000993897 {published data only}
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ACTRN12617000219381 {published data only}
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Altun 2018 {published data only}
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Anitha 2018 {published data only}
    1. Anitha A, Prachi G. Effectiveness of eccentric strengthening of wrist extensors along with conventional therapy in patients with lateral epicondylitis. Research Journal of Pharmacy and Technology 2018;11(12):5340-4.
Bateman 2024 {published data only}
    1. Bateman M, Skeggs A, Whitby E, Fletcher-Barrett V, Stephens G, Dawes M, et al. Optimising physiotherapy for people with lateral elbow tendinopathy - results of a mixed-methods pilot and feasibility randomised controlled trial (OPTimisE). Musculoskeletal Science & Practice 2024;69:102905. [DOI: 10.1016/j.msksp.2023.102905] - DOI - PMC - PubMed
Cleland 2005 {published data only}
    1. Cleland JA, Flynn TW, Palmer JA. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. Journal of Manual and Manipulative Therapy 2005;13(3):143-51.
Coombes 2016 {published data only}
    1. Coombes BK, Wiebusch M, Heales L, Stephenson A, Vicenzino B. Isometric exercise above but not below an individual’s pain threshold influences pain perception in people with lateral epicondylalgia. Clinical Journal of Pain 2016;32:1069–75. - PubMed
Croisier 2007 {published data only}
    1. Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. British Journal of Sports Medicine 2007;41(4):269-75. - PMC - PubMed
CTRI/2022/02/040270 {published data only}
    1. CTRI/2022/02/040270. Efficacy of marma therapy in comparison with physical therapy in management of tennis elbow. http://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=64678.
Day 2019 {published data only}
    1. Day JM, Lucado AM, Uhl TL. A comprehensive rehabilitation program for treating lateral elbow tendinopathy. International Journal of Sports Physical Therapy 2019;14(5):818-34. - PMC - PubMed
Drechsler 1997 {published data only}
    1. Drechsler WI, Knarr JF, Snyder-Mackler L. A comparison of two treatment regimens for lateral epicondylitis: a randomized trial of clinical interventions. Journal of Sport Rehabilitation 1997;6(3):226-34.
Fernandez‐Carnero 2008 {published data only}
    1. Fernandez-Carnero J, Fernandez-de-las-Penas C, Cleland JA. Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. Journal of Manipulative & Physiological Therapeutics 2008;31(9):675-81. - PubMed
Fernandez‐Carnero 2011 {published data only}
    1. Fernandez-Carnero J, Cleland JA, Arbizu RL. Examination of motor and hypoalgesic effects of cervical vs thoracic spine manipulation in patients with lateral epicondylalgia: a clinical trial. Journal of Manipulative & Physiological Therapeutics 2011;34(7):432-40. - PubMed
Gunduz 2012 {published data only}
    1. Gunduz R, Malas FU, Borman P, Kocaoglu S, Ozcakar L. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical and ultrasonographical comparison. Clinical Rheumatology 2012;31(5):807-12. - PubMed
Gupta 2021 {published data only}
    1. Gupta R, Chahal A. Comparative effect of dry needling and neural mobilization on pain, strength, range of motion, and quality of life in patients with lateral epicondylitis: protocol for randomized clinical trial. Journal of Chiropractic Medicine 2021 ;20(2):77-84. - PMC - PubMed
Hsu 2016 {published data only}
    1. Hsu CY, Lee KH, Huang HC, Chang ZY, Chen HY, Yang TH. Manipulation therapy relieved pain more rapidly than acupuncture among lateral epicondylalgia (tennis elbow) patients: a randomized controlled trial with 8-week follow-up. Evidence-based Complementary and Alternative Medicine 2016;3079247:1-7. - PMC - PubMed
IRCT848 {published data only}
    1. IRCT848. Effect of dry needling on radiated pain of shoulder muscles trigger points in tennis elbow patients. https://en.irct.ir/trial/848.
Kamal 2022 {published data only}
    1. Kamal KC, Traistaru MR, Alexandru DO, Kamal AM, Maria DT, Kamal D. Complex rehabilitation program in patients with lateral epicondylitis. Aging Clinical and Experimental Research 2022;34(Suppl 1):S335. [DOI: 10.1007/s40520-022-02147-3] - DOI
Kaux 2022 {published data only}
    1. Kaux JF, Forthomme F, Croisier JL, Demoulin C, Vanderthommen M. Effectiveness of tecar therapy combined with eccentric exercises in lateral elbow tendinopathy. Aging Clinical and Experimental Research 2022;34(Suppl 1):S189. [DOI: 10.1007/s40520-022-02147-3] - DOI
KCT0007378 {published data only}
    1. KCT0007378. Effect of blood flow restriction exercise program on auto-parts factory workers with lateral elbow tendinopathy: randomized controlled trial. https://cris.nih.go.kr/cris/search/detailSearchEn.do?seq=22097.
Khandaker 2014 {published data only}
    1. Khandaker MN, Islam S, Emran A, Islam J, Ahmed SM, Khan MM, et al. The effect of stretching exercise in the management of lateral epicondylitis. Bangladesh Medical Journal 2014;43(2):61-6.
    1. Nuruzzaman KM, Mozaffar AS, Rahman KM, Salek AKM, Emran A. Effect of stretching and strengthening exercise in the management of lateral epicondylitis. International Journal of Rheumatic Diseases 2017;20(Suppl 1):29.
Kucuksen 2013 {published data only}
    1. Kucuksen S, Yilmaz H, Salli A, Ugurlu H. Muscle energy technique versus corticosteroid injection for management of chronic lateral epicondylitis: randomized controlled trial with 1-year follow-up. Archives of Physical Medicine & Rehabilitation 2013;94(11):2068-74. - PubMed
Lee 2018 {published data only}
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    1. Shirzhadi Z. The effect of the shoulder muscles strengthening in treatment of patients with tennis elbow. WHO 2018.
Manias 2006 {published data only}
    1. Manias P, Stasinopoulos D. A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. British Journal of Sports Medicine 2006;40(1):81-5. - PMC - PubMed
Martinez‐Silvestrini 2005 {published data only}
    1. Martinez-Silvestrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P, Arendt KW. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. Journal of Hand Therapy 2005;18(4):411-9. - PubMed
McLean 2002 {published data only}
    1. McLean S, Naish R, Reed L, Urry S, Vicenzino B. A pilot study of the manual force levels required to produce manipulation induced hypoalgesia. Clinical Biomechanics 2002;17(4):304-8. - PubMed
Mostafee 2020 {published data only}
    1. Mostafaee N, Divandari A, Negahban H, Kachooei AR, Moradi A, Ebrahimzadeh MH, et al. Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: a randomized controlled trial of patients with lateral elbow tendinopathy. Physiotherapy Theory and Practice 2022;38(9):1153-64. [DOI: 10.1080/09593985.2020.1821417] - DOI - PubMed
    1. Mostafaee N, Divandari A, Negahban H, RezaKachooei A, Moradi A, Ebrahimzadeh MH, et al. Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: a randomized controlled trial of patients with lateral elbow tendinopathy. Physiotherapy Theory and Practice 2020;38(9):1153-64. - PubMed
Nagrale 2009 {published data only}
    1. Nagrale AV, Herd CR, Ganvir S, Ramteke G. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial. Journal of Manual and Manipulative Therapy 2009;17(3):171-8. - PMC - PubMed
NCT00930709 {published data only}
    1. NCT00930709. Botulinum toxin versus active strength training in the treatment of lateral epicondylitis (BooST). https://clinicaltrials.gov/show/NCT00930709.
NCT01273688 {published data only}
    1. NCT01273688. Eccentric training with or without elbow brace for epicondylitis. https://clinicaltrials.gov/show/NCT01273688.
NCT01897259 {published data only}
    1. NCT01897259. Comparison of conservative methods for the treatment of lateral epicondylitis: a randomized, prospective study. https://clinicaltrials.gov/ct2/show/NCT01897259.
NCT02052089 {published data only}
    1. NCT02052089. Comparative study for the optimal treatment method of lateral epicondylosis. https://clinicaltrials.gov/ct2/show/NCT02052089.
NCT02304952 {published data only}
    1. NCT02304952. Eccentric exercise or radiofrequent microtenotomy as treatment of lateral epicondylalgia. https://clinicaltrials.gov/ct2/show/study/NCT02304952.
NCT02521298 {published data only}
    1. NCT02521298. Treatment of lateral elbow tendinopathy. https://clinicaltrials.gov/show/NCT02521298.
NCT02930304 {published data only}
    1. NCT02930304. Non-surgical treatment approaches in patients with newly diagnosed lateral epicondylitis: a randomized clinical trial. https://clinicaltrials.gov/show/NCT02930304.
NCT02991560 {published data only}
    1. NCT02991560. Effects of various taping techniques in lateral epicondylitis on functional and ultrasonographic outcomes. https://clinicaltrials.gov/ct2/show/NCT02991560.
NCT03074500 {published data only}
    1. NCT03074500. Kinesiotaping in lateral epicondylitis. https://clinicaltrials.gov/show/NCT03074500.
NCT03161782 {published data only}
    1. NCT03161782. The efficacy of different types of stretching on range of motion, pain and function in elbow limitation. https://clinicaltrials.gov/ct2/show/NCT03161782.
NCT03167710 {published data only}
    1. NCT03167710. Dry needling, manipulation and stretching vs. manual therapy, exercise and ultrasound for lateral epicondylalgia. https://clinicaltrials.gov/show/NCT03167710.
NCT03834090 {published data only}
    1. NCT03834090. Effectiveness of radial extracorporeal shock wave therapy and supervised exercises in lateral epicondylitis. https://clinicaltrials.gov/ct2/show/NCT03834090. - PMC - PubMed
NCT05238090 {published data only}
    1. NCT05238090. Evaluation of the applying a stretching protocol to lateral epicondylitis. https://clinicaltrials.gov/ct2/show/NCT05238090.
NCT05696327 {published data only}
    1. NCT05696327. Eccentric Tyler twist wrist extensor strengthening in lateral epicondylitis. https://clinicaltrials.gov/study/NCT05696327.
NCT06087081 {unpublished data only}
    1. NCT06087081. Mills manipulation and Mulligan PRP affect pain, grip strength and function on lateral epicondylitis. https://classic.clinicaltrials.gov/ct2/show/NCT06087081 2023.
Nilsson 2007 {published data only}
    1. Nilsson P, Thom E, Baigi A, Marklund B, Mansson J. A prospective pilot study of a multidisciplinary home training programme for lateral epicondylitis. Musculoskeletal Care 2007;5(1):36-50. - PubMed
Nilsson 2012 {published data only}
    1. Nilsson P, Baigi A, Sward L, Moller M, Mansson J. Lateral epicondylalgia: a structured programme better than corticosteroids and NSAID. Scandinavian Journal of Occupational Therapy 2012;19(5):404-10. - PubMed
Nishizuka 2017 {published data only}
    1. Nishizuka T, Iwatsuki K, Kurimoto S, Yamamoto M, Hirata H. Efficacy of a forearm band in addition to exercises compared with exercises alone for lateral epicondylitis: a multicenter, randomized, controlled trial. Journal of Orthopaedic Science 2017;22(2):289-94. - PubMed
NTR7223 {published data only}
    1. NTR7223. The effect of US-guided percutaneous needle tenotomy and physiotherapy in lateral elbow tendinopathy (tennis elbow). https://www.trialregister.nl/trial/6432.
Park 2010 {published data only}
    1. Park JY, Park HK, Choi JH, Moon ES, Kim BS, Kim WS, et al. Prospective evaluation of the effectiveness of a home-based program of isometric strengthening exercises: 12-month follow-up. Clinics in Orthopedic Surgery 2010;2(3):173-8. - PMC - PubMed
Paungmali 2003 {published data only}
    1. Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Physical Therapy 2003;83(4):374-83. - PubMed
Peterson 2014 {published data only}
    1. NCT00888225. Tennis elbow trial. https://clinicaltrials.gov/show/NCT00888225.
    1. Peterson M, Butler S, Eriksson M, Svardsudd K. A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy). Clinical Rehabilitation 2014;28(9):862-72. - PubMed
Pienimaki 1996 {published data only}
    1. Pienimaki TT, Tarvainen TK, Siira PT, Vanharanta H. Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy 1996;82(9):522-30.
Radpasand 2009 {published data only}
    1. Radpasand M, Owens E. Combined multimodal therapies for chronic tennis elbow: pilot study to test protocols for a randomized clinical trial. Journal of Manipulative & Physiological Therapeutics 2009;32(7):571-85. - PubMed
Ramteke 2020 {published data only}
    1. Ramteke S, Samal S. To study the effect of rotator cuff exercises on tennis elbow. Indian Journal of Public Health Research & Development 2020;11(3):611-4.
Sarkar 2013 {published data only}
    1. Sarkar B, Das PG, Equebal A, Mitra PK, Kumar R, Anwer S. Efficacy of low-energy extracorporeal shockwave therapy and a supervised clinical exercise protocol for the treatment of chronic lateral epicondylitis: a randomised controlled study. Hong Kong Physiotherapy Journal 2013;31(1):19-24.
Sethi 2018 {published data only}
    1. Sethi K, Noohu MM. Scapular muscles strengthening on pain, functional outcome and muscle activity in chronic lateral epicondylalgia. Journal of Orthopaedic Science 2018;23:777-82. - PubMed
Sevier 2015 {published data only}
    1. Sevier TL, Stegink-Jansen CW. Astym treatment vs. eccentric exercise for lateral elbow tendinopathy: a randomized controlled clinical trial. PeerJ 2015;e967:1-26. - PMC - PubMed
Sharma 2020 {published data only}
    1. Sunita Sharma S, Kumar P, Chaudhuri P, Malhotra N, Narula H, Chahal A. Is wrist manipulation and low-level laser therapy collectively beneficial for patients with lateral epicondylitis? Indian Journal of Public Health Research & Development 2020;11(5):489-95.
Slater 2006 {published data only}
    1. Slater H, Arendt-Nielsen L, Wright A, Graven-Nielsen T. Effects of a manual therapy technique in experimental lateral epicondylalgia. Manual Therapy 2006;11(2):107-17. - PubMed
Solveborn 1997a {published data only}
    1. Solveborn SA. Radial epicondylalgia ('tennis elbow'): treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements. Scandinavian Journal of Medicine & Science in Sports 1997;7(4):229-37. - PubMed
Stasinopoulos 2006 {published data only}
    1. Stasinopoulos D, Stasinopoulos I. Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis. Clinical Rehabilitation 2006;20(1):12-23. - PubMed
Stasinopoulos 2009 {published data only}
    1. Stasinopoulos D, Stasinopoulos I, Pantelis M, Stasinopoulou K. Comparing the effects of exercise program and low-level laser therapy with exercise program and polarized polychromatic non-coherent light (bioptron light) on the treatment of lateral elbow tendinopathy. Photomedicine and Laser Surgery 2009;27(3):513-20. - PubMed
Stasinopoulos 2010 {published data only}
    1. Stasinopoulos D, Stasinopoulos I, Pantelis M, Stasinopoulou K. Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy. British Journal of Sports Medicine 2010;44(8):579-83. - PubMed
Stasinopoulos 2017 {published data only}
    1. Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of Hand Therapy 2017;30(1):13-9. - PubMed
Struijs 2003 {published data only}
    1. Struijs PA, Damen PJ, Bakker EW, Blankevoort L, Assendelft WJ, Dijk CN. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Physical Therapy 2003;83(7):608-16. - PubMed
Svernlov 2001a {published data only}
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TCTR20200612001 {published data only}
    1. TCTR20200612001. Short-term effects of mindfulness deep transverse friction on tennis elbow. https://www.thaiclinicaltrials.org/show/TCTR20200612001.
Tyler 2010 {published data only}
    1. Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. Journal of Shoulder & Elbow Surgery 2010;19(6):917-22. - PubMed
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Vicenzino 1996 {published data only}
    1. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 1996;68(1):69-74. - PubMed
Vicenzino 2001 {published data only}
    1. Vicenzino B, Paungmali A, Buratowski S, Wright A. Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Manual Therapy 2001;6(4):205-12. - PubMed
Viswas 2012 {published data only}
    1. Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. The Scientific World Journal 2012;939645:1-8. - PMC - PubMed
Wegener 2016 {published data only}
    1. Wegener RL, Brown T, O'Brien L. A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis. Hand Therapy 2016;21(4):131-9.
Zunke 2020 {published data only}
    1. DRKS00013964. Manual mobilization of the thoracic spine: effect on pain free grip and sympathetic nervous system activity on patients with lateral epicondylitis humeri. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRI....
    1. Zunke P, Auffarth A, Hitzl W, Moursy M. The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri. A randomized, sample sized planned, placebo-controlled, patient-blinded monocentric trial. BMC Musculoskeletal Disorders 2020;21(186):1-11. - PMC - PubMed

References to studies awaiting assessment

Bartlett 2007 {published data only}
    1. ISRCTN89551492. An investigation of the effectiveness of a mobilisation with movement (MWM) technique for lateral epicondylagia on pain and function in clinical practice. http://www.isrctn.com/ISRCTN89551492 2007.

References to ongoing studies

Prat 2018 {published data only}
    1. Prat P I, Cibrowski D, Zuliani A, Stecco A. Efficacy of fascial manipulation and eccentric exercise for lateral elbow pain. In: Journal of Bodywork & Movement Therapies. Vol. 22. 2018:845-72.
Sahebjamei 2019 {published data only}
    1. IRCT20180812040773N1. The role of elbow exercises protocol in treatment of patients with lateral epycodylitis (tennis elbow). https://en.irct.ir/trial/33707 2019.
Sveinall 2022 {published data only}
    1. NCT04803825. The NOrwegian Tennis Elbow (NOTE) Study. https://clinicaltrials.gov/study/NCT04803825 2022.
Takamjani 2019 {published data only}
    1. IRCT20190315043058N1. The effect of Mulligan's techniques along with routine physiotherapy, in comparison with routine physiotherapy alone; on pain, grip strength, and function in patients diagnosed with chronic lateral epicondylitis. https://en.irct.ir/trial/38410 2019.

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References to other published versions of this review

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