Conservative care options for work-related epicondylosis

The type of supporting evidence is not specifically stated for each recommendation.

In general, the recommendations were based primarily on a comprehensive review of peer-reviewed published scientific literature. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the committee.

An implementation strategy was not provided.

Although the corticosteroid injection had significant short term benefit, this benefit reversed after 6 weeks with high recurrence rates. Due to this, corticosteroid injection treatment should be used with caution when treating lateral epicondylitis.

This document is intended to inform care options and shared decision-making. It is not a standard of care, claim management standard, or a substitute for clinical judgment in an individual case. This practice resource does not change Washington State Department of Labor and Industries coverage or payment.

An extensive search was done on lateral epicondylitis/epicondylosis, medial epicondylitis/epicondylosis on PubMed and other electronic databases. Articles were retrieved by the Labor and Industries librarians. Additionally citation tracking was performed by department staff and committee members for potentially relevant studies not retrieved from electronic databases. Based on apparent topic relevance, additional database searches were conducted on specific tests and treatments.

The bulk of the literature search and review for this update was conducted between January and February 2014. Additional searches were conducted as requested by the Industrial Insurance Chiropractic Advisory Committee Subcommittee members. Search results were limited to human adults only and English only. The original literature search was conducted in spring 2011. Studies that were published in the last 10 years were emphasized.

The following keywords were used in PubMed:

Terms for epicondylosis (the condition) were searched in combination with terms for each of the other categories (diagnosis, conservative treatment, and outcome).

• The condition: Lateral epicondylitis, medial epicondylitis, lateral epicondylosis, medial epicondylosis, tennis elbow, golfers elbow
• Work-relatedness: Occupational health, injury, disease, workers compensation, return to work, disability
• Diagnosis: Diagnosis, symptoms, signs, validity, reliability, sensitivity, specificity, electrodiagnostic studies
• Treatment: Treatment, conservative therapy, interventions

148 reviewed (71 cited)

Evidence was graded on a 1-5 scale with 1 being the highest grade:

1 = Randomized controlled trial

2 = Cohort study, prospective or historical

3 = Case-control study

4 = Cross-sectional study

5 = Case series

Individual articles were reviewed by both a clinical expert and epidemiologist with subsequent clinical expert group review to resolve inconsistencies.

Assessing Study Methodologic Quality

Attributes of study methodology quality vary according to the clinical procedure (e.g., diagnostic, therapeutic intervention) looked at, and specific research questions being studied. The American Academy of Neurology's Clinical Practice Guideline Process Manual offers a comprehensive guide to systematic evidence review, quality attributes and consensus process that generally serves as the approach taken by Industrial Insurance Chiropractic Advisory Committee (IICAC).

General attributes identified when extracting evidence from studies include identification of population, the intervention and co-interventions and outcomes being addressed in each study. The clinical questions addressed such as diagnostic accuracy, therapeutic effectiveness, or causation are determined. Studies are extracted into evidence tables including quality attributes and/or ratings which are reviewed both by department staff and committee members (usually 2 per study).

Specific quality attributes include: Diagnostic Accuracy – design, spectrum of patients, validity and relevance of outcome metric; Therapeutic Interventions – comparison groups (no treatment, placebo, comparative intervention), treatment allocation, blinding/masking (method and degree: single, double, independent), follow-up (period and completion), and analysis (statistical power, intent-to-treat). Specific attention is paid to several factors including reporting of outcomes (primary vs. secondary), relevance of outcome (e.g., function versus pain), and meaningfulness (clinically important change versus minimally detectable change).

Synthesizing Evidence

Consideration of study quality (class), significance (statistical precision), consistency across studies, magnitude of effect, and relevance to populations and procedures were taken into account in preparing draft summaries. Special attention was given to clarifying conclusions related to the clinical questions of interest. Evidence, particularly with low tech and highly diffused examination and conservative procedures addressed here, is rarely truly "definitive," even when multiple studies exist. Inconsistent conclusions typically reflect error (systematic, random) and/or bias in studies. Data pooling via meta-analysis is useful to reduce random error when studies are of sufficient power and methodologic strength. Larger meaningful effect size may increases confidence in findings.

The conservative care resource/guideline process can be described in the following steps:

• Once a topic for a resource/guideline is selected, a subcommittee of the Industrial Insurance Chiropractic Advisory Committee (IICAC) made up of regular members identifies additional content experts to join the subcommittee and/or serve as consultants. Various clinical specialists may provide specific input or be invited to give a presentation to the subcommittee.
• A systematic review and summary of the relevant peer reviewed clinical and scientific literature is done (primarily by department staff and subcommittee members with specific interest and/or expertise in a topic). Claim and billing data from Labor & Industries may also be reviewed.
• Literature is retrieved, assessed for quality and summarized in evidence tables which are presented to the subcommittee for review. Then at a variable series of group meetings and phone conferences, the evidence with greatest relevance to the resource/guideline topic is highlighted.
• Based on this literature review and assessment by the subcommittee, department staff typically develop an initial draft resource guideline generally organized as follows:
  • General summary of topic, case definition, clinical evaluation, interventions, and clinical progress
  • Checklist for general chronological management with expected clinical and progress thresholds
  • Readily usable functional progress instruments for a given condition
  • Evidence summaries for clinical assessment (e.g., history, examination, imaging and special studies, prognostic and management issues, workers' compensation issues)
  • Evidence summaries for conservative interventions (e.g., physiotherapeutic modalities, bracing, manipulation and mobilization, soft tissue techniques, exercise and rehabilitation approaches, special interventions, common medications [injected and oral]), and workers compensation specific interventions (e.g., ergonomic interventions)
  • Additional materials (glossaries, procedure descriptions, instrument scoring)
  • Evidence and methodology process used in development
  • Citations
• Subcommittee members critique and revise the guideline based on what is most useful for the clinician in diagnosing and treating the condition in question. Additional expertise, consultation, and literature searches may also be added. This results in a second draft guideline that is then shared with the full advisory committee to obtain their input. At this stage specific content experts/reviewers may be sought as the subcommittee identifies particular issues.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Not applicable: The guideline was not adapted from another source.

Washington State Department of Labor and Industries

The Washington State Department of Labor and Industries' Industrial Insurance Chiropractic Advisory Committee's Subcommittee on Policy, Practice, and Quality

Subcommittee Members: J.F. Lawhead DC; Robert Baker, DC; Linda DeGroot, DC; Michael Neely, DC

Department Staff: Robert D. Mootz, DC, Associate Medical Director; Bintu Marong, MS, Epidemiologist; Reshma Kearny, MPH, Epidemiologist

Consultant: Thomas A. Souza, DC

The Washington State Department of Labor and Industries is a public state agency and did not receive any outside funding and has no conflicts of interest to report.

This is the current release of the guideline.

Electronic copies: Available from the Washington State Department of Labor and Industries Web site.

A progress checklist, patient-rated tennis elbow evaluation rating scale, upper extremity functional index, and an upper limb functional index are included in the original guideline document.

None available

This NGC summary was completed by ECRI Institute on July 15, 2014. This summary was updated by ECRI Institute on September 21, 2015 following the U.S. Food and Drug Administration advisory on non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs).

This NGC summary is based on the original guideline, which is in the public domain. Washington State Department of Labor and Industries (L&I) does not copyright its medical treatment guidelines.

Work-related lateral and medial epicondylosis (epicondylitis)

Workers with, or at risk for, work-related epicondylosis

Diagnosis/Evaluation

1. Functional questionnaires
2. Clinical examination (not recommended)
3. Differential diagnosis (ruling out non-mechanical causes)

Treatment/Management

1. Ice
2. Avoidance of provoking activities
3. Eccentric extensor contraction exercise
4. Soft tissue work (effleurage massage, trigger point pressure, mechanically assisted tissue work)
5. Extension bracing
6. Activity modification
7. Iontophoresis- and phonophoresis-applied non-steroidal anti-inflammatory drugs (NSAIDs)
8. Corticosteroid injections
9. Myofascial release
10. Manipulation of elbow structures
11. Self-management
12. Monitoring of progress

Practical Application Points

• Several conservative interventions provide rapid relief of pain and improved pain-free grip including: eccentric extension exercise, elbow manipulation, soft tissue procedures (e.g., trigger point pressure in extensor muscles), and corticosteroid injections.
• Set outcome goals for sustainable self-management (exercise, massage, activity modification) to maintain pain reduction and improved function.
• One tennis elbow specific questionnaire and two more general upper arm function questionnaires have been shown to be sensitive to measure functional change in epicondylosis.

Work-Related Epicondylosis (Epicondylitis)

Epicondylosis is characterized by medial or lateral elbow pain that worsens when muscles originating from the condyles are contracted, placing stress on the attachments. Lateral epicondylosis or "tennis elbow" is common, often associated with direct trauma to the lateral elbow. Repetitive work does not appear to be a risk factor; although there may be a relationship between combined factors such as force, posture, trauma, and repetition. Diagnosis is clinical; no studies on diagnostic accuracy or reliability of clinical examination were found. Pain is related to degenerative change more so than inflammation. The condition is frequently self-limiting within 6 to 24 months.

Case Definition

• Work-related lateral epicondylosis (LE) is lateral elbow pain subsequent to a documented workplace exposure that is worsened by gripping and resisted wrist extension.

Evaluation Summary

• Rule out non-mechanical causes (typically by assessing for red flags for trauma/fracture, tumor, etc.)
• Pain over the epicondyles provoked by resisted extensor contraction (e.g., gripping, twisting motions) is consistent with epicondylosis.

Intervention Summary

• Most acute/sub-acute cases self-resolve within weeks to months. Rapid resolution has been reported with slow stretching, eccentric resisted contraction exercise, elbow manipulation, soft tissue wok (effleurage massage, trigger point pressure, mechanically assisted tissue work). Extension bracing and/or activity modification may be helpful.
• Benefit has been reported in lesser quality studies with iontophoresis and phonophoresis applied non-steroidal anti-inflammatory drugs (NSAIDs). Ultrasound does not appear to provide any advantage over placebo.
• Short-term relief for corticosteroid injection may be outweighed by poorer one-year outcomes compared to physiotherapy or wait and see approaches.
• Chronic conditions are thought by some to be related to tendon degeneration more than an inflammatory process from microtears. Treatment options are similar with some consideration.

Improvement Progress

• Achieving and monitoring functional progress is central to effective care of epicondylosis. The best overall long-term outcomes are believed to be associated with consistent, incremental increases in functional ability (e.g., pain-free grip strength, improving mobility, return to usual activities including work).
• Refractory cases warrant consideration for additional diagnostics to assess for tendon rupture or muscle tear.

Typical Interventions and Response Thresholds

None provided