Physiotherapy in themanagement of tennis elbow: a review

INTRODUCTION Tennis elbow is one of the most commonly encountered upper limb conditions [1]. Its incidence in general practice is 4–7 per 1000 per year [2], with as many as 15% of workers in highly repetitive jobs reporting the condition [3–5]. Its incidence peaks in the 35–54 year old age group [6]. Tennis elbow is a misnomer as it is predominantly seen in nontennisplayers [7]; however, elbowpain is encountered inup to50% of tennis players, with 75–80% of these cases being attributable to tennis elbow [8, 9]. The disorder is usually characterized by pain over the lateral aspect of the elbow commonly associated with resisted wrist and finger extension and gripping activities. This condition impacts substantially on society and health care systems, with between 10 and 30% of individuals with tennis elbow, taking a leave of absence of an average duration of 12 weeks [2]. It also has a huge economic impact in terms of workers’ compensation claims and even early retirement [10]. However, longitudinal studies have shown that a large proportion of patients improve over time with spontaneous recovery seen in 80–90% of patients within 2 years [11–13]. The aetiology of tennis elbow is poorly understood. Kraushaar & Nirschl’s [14] microscopic study demonstrated the presence of fibroblastic tissue and vascular invasion of the common extensor tendon, described as angiofibroblastic tendonosis, implying a degenerative tendinopathy. However, recent studies have demonstrated the presence of the neuropeptides, substance P and calcitonin related gene peptide (CRGP) in sensory nerve fibres supplying the extensor carpi radialis brevis (ECRB) [15, 16], which could imply the possibility of neurogenic sensitization as an additional source of pain [17]. This lack of understanding regarding its aetiology has led to a large number of treatments, including physiotherapy, being advocated. This would appear to represent a lack of consensus over what is best practice in the management of this condition. As up to 30%of all patients seen in primary carewith tennis elbow are referred to physiotherapy [2], the aim of this review is to examine the evidence of effectiveness of frequently used physiotherapy modalities in the management of tennis elbow. For the purpose of this review, modalities were classified as electrotherapeutic or physical interventions.