Guideline sources The following summarized guidelines for the evaluation and management of lateral elbow tendinopathy are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2022), the American Physical Therapy Association (APTA 2022), and the American College of Occupational and Environmental Medicine (ACOEM 2013). 1 2 3 Guidelines 1. Diagnostic investigations Clinical assessment: use the diagnosis-specific PRTEE to assess pain/irritability and function and/or the region-specific Disabilities of the Arm, Shoulder and Hand to assess upper extremity function at baseline and at least one other follow-up point including discharge in patients with LET. A Show 2 more Diagnostic imaging: obtain elbow radiography as the initial imaging in patients with chronic elbow pain. B Show 5 more https://web.pathway.md/diseases/recGLXdtY80Zre7ON 1/5 6/29/23, 5:52 AM Lateral elbow tendinopathy Pathway 2. Medical management Analgesics: offer topical and oral NSAIDs in patients with lateral elbow pain. B Show 2 more Corticosteroid injections: consider offering local corticosteroid injections in patients with LET. C Blood product injections: insufficient evidence to recommend platelet-rich plasma and autologous blood injections in patients with LET. I Other periarticular injections: Insufficient evidence to recommend for or against periarticular sodium hyaluronate injections, glycosaminoglycan injections, or prolotherapy injections in patients with LET. I Do not offer polidocanol injections D and botulinum injections in patients with LET. D 3. Nonpharmacologic interventions Heat or ice: As per APTA 2022 guidelines: Consider offering cryotherapy to reduce pain in patients with irritable symptoms of LET. C Consider offering cryotherapy combined with burst transcutaneous electrical nerve stimulation to reduce pain in the short term in patients with symptoms of LET lasting > 30 days. C As per ACOEM 2013 guidelines, consider offering self-application of heat or ice in patients with lateral epicondylalgia. Physical therapy: As per APTA 2022 guidelines, offer isometric, concentric, and/or eccentric therapeutic resisted exercises of the wrist extensors for the treatment of patients with subacute or chronic LET. B Show 3 more As per ACOEM 2013 guidelines: Offer physical and occupational therapy in patients with LET. A Advise modified work duties precluding high-force exertions. Consider advising limitations of highly repetitive use (other than light force) or high-amplitude vibration. A Manual therapy: As per APTA 2022 guidelines, offer local elbow joint manipulation or mobilization techniques to reduce pain and increase pain-free grip strength in patients with LET, as a stand-alone or adjunctive treatment in improving short-term outcomes in patients able to tolerate the specific technique. B Show 4 more As per ACOEM 2013 guidelines: Insufficient evidence to recommend for or against massage (including friction massage) in patients with LET. I Do not offer soft tissue mobilization or joint mobilization/manipulation in patients with LET. D https://web.pathway.md/diseases/recGLXdtY80Zre7ON 2/5 6/29/23, 5:52 AM Lateral elbow tendinopathy Pathway Orthoses and taping: As per APTA 2022 guidelines, insufficient evidence to support the use of forearm counterforce or wrist support orthosis for the alleviation of intermediate or long-term symptoms in patients with LET. I Show 3 more As per ACOEM 2013 guidelines: Consider offering elbow straps in patients with LET. B Consider offering wrist braces as an adjunctive measure in either more severe cases or in patients with suboptimal results with elbow straps and bands. B Alternative and complementary therapies, acupuncture and dry needling: As per APTA 2022 guidelines, offer either tendon or trigger point dry needling for the treatment of pain and functional deficits associated with LET. B As per ACOEM 2013 guidelines, offer acupuncture in selected patients with chronic pain. A Alternative and complementary therapies, ultrasound: As per APTA 2022 guidelines, insufficient evidence to support the use of therapeutic ultrasound as a stand-alone treatment in patients with LET. I As per ACOEM 2013 guidelines, insufficient evidence to recommend therapeutic ultrasound in patients with LET. I Alternative and complementary therapies, laser therapy: As per APTA 2022 guidelines, consider offering laser therapy for improvements in pain and grip strength (seen in follow-up periods > 4 weeks to 6 months) in patients with LET. C As per ACOEM 2013 guidelines, do not offer low-level laser therapy in patients with LET. D Alternative and complementary therapies, phonophoresis and iontophoresis: As per APTA 2022 guidelines: Do not offer phonophoresis with 10% hydrocortisone gel, topical prednisolone (2 mg/day), or 1% diclofenac sodium gel for the treatment of patients with LET. D Consider offering iontophoresis with an anti-inflammatory drug early in the rehabilitation phase (no later than 2-4 weeks from onset or aggravation of symptoms) in patients presenting with highly irritable symptoms of LET. C As per ACOEM 2013 guidelines: Do not offer phonophoresis in patients with LET. D Consider offering iontophoresis with either corticosteroids or NSAIDs in patients with LET. C Alternative and complementary therapies (ergonomic interventions): consider offering ergonomic interventions for the management of symptoms in patients with LET. C Alternative and complementary therapies (other therapies): Insufficient evidence to recommend for or against the use of magnets and pulsed electromagnetic field, biofeedback, and diathermy in patients with LET. I Do not offer extracorporeal shockwave therapy in patients with LET. D https://web.pathway.md/diseases/recGLXdtY80Zre7ON 3/5 6/29/23, 5:52 AM Lateral elbow tendinopathy Pathway 4. Therapeutic procedures Transcutaneous electrical nerve stimulation: As per APTA 2022 guidelines: Consider offering burst transcutaneous electrical nerve stimulation applied to the painful region or high- or low-frequency transcutaneous electrical nerve stimulation applied to acupuncture points for short-term pain relief in patients with LET. C Consider offering cryotherapy combined with burst transcutaneous electrical nerve stimulation to reduce pain in the short term in patients with symptoms of LET lasting > 30 days. C As per ACOEM 2013 guidelines, insufficient evidence to recommend for or against transcutaneous electrical nerve stimulation in patients with LET. I 5. Surgical interventions Indications for surgery: Offer surgery A or radiofrequency microtenotomy B in patients inadequately responding to multiple evidence-based treatments. A Offer NSAIDs and exercises for postoperative care. Insufficient evidence to recommend for or against US-guided percutaneous tenotomy in patients with LET. I Clinical findings Symptoms Past medical history Elbow pain Carpal tunnel syndrome De Quervain tenosynovitis Past events Social history Repetitive wrist extension and supination Sports participation Tennis player Musculoskeletal exam Chair test Cozen's test Elbow tenderness Hand weakness Maudsley's test Mill's test References https://web.pathway.md/diseases/recGLXdtY80Zre7ON 4/5 6/29/23, 5:52 AM Lateral elbow tendinopathy Pathway 1. Expert Panel on Musculoskeletal Imaging, Jonelle M Thomas, Eric Y Chang et al. ACR Appropriateness Criteria Chronic Elbow Pain. J Am Coll Radiol. 2022 Nov;19 11S S256 S265. Open 2. Kurt T Hegmann, Harold E Hoffman, Roger M Belcourt et al. ACOEM practice guidelines: elbow disorders. J Occup Environ Med. 2013 Nov;55 11 1365 74. Open 3. Ann M Lucado, Joseph M Day, Joshua I Vincent et al. Lateral Elbow Pain and Muscle Function Impairments. J Orthop Sports Phys Ther. 2022 Dec;52 12 CPG1 CPG111. Open https://web.pathway.md/diseases/recGLXdtY80Zre7ON 5/5