An evaluation of treatment options for lateral epicondylitis



lateral elbow pain, peppering, eswt


Aim: Lateral pain in the elbow is a widespread problem in orthopedics and physiotherapy. There are different conservative treatment options available, but there is no consensus on their superiority to each other. The aim of this study was to evaluate the efficacy of three different treatment methods applied to patients followed up with a diagnosis of lateral epicondylitis. Methods: The study included a total of 105 patients who were diagnosed with lateral epicondylitis between 2010 and 2016 and treated conservatively. The patients were separated into three groups according to the treatment administered. In Group 1 (n:28), 1 ml betamethasone dipropionate (Diprospan®, Schering-Plough Corp., Kenilworth, NJ, ABD) was applied with the peppering method. In Group 2 (n:28), the same peppering method was used to apply 1 ml local anesthetic (prilocaine hydrochloride, Citanest®, AstraZeneca plc., London, UK). In Group 3 (n:49), extracorporeal shockwave therapy (ESWT) treatment was performed. Data were evaluated before and at one, three, and six months after treatment. Clinical scores were evaluated according to the Quick Dash (Q-DASH, Quick disabilities of arm, shoulder, and hand) scoring system and VAS (visual analog scale) scores during the daily activities of the patients. Quality of life and patient satisfaction levels were evaluated based on Quick Dash scores. Results: A significant improvement was observed in all three methods in the VAS and quality of life of the patients at one, three, and six months after treatment compared to pre-treatment values (P<0.001). A higher level of patient satisfaction was determined in Groups one and two compared to the ESWT group (P<0.001). Conclusion: Significant rates of satisfaction were determined in all three methods, and the corticosteroid treatment administered with the peppering method was not superior over local anesthetic applied with the same method. Although ESWT was beneficial, it was less effective than the other methods and cost higher.


Download data is not yet available.


Bill Vicenzino & Anthony Wright () Lateral epicondylalgia I: epidemiology, pathophysiology, aetiology and natural history, Physical Therapy Reviews, 1996;1(1):23-34. doi: 10.1179/ptr.1996.1.1.23

Allander E. Prevalence, incidence, and remission rates of some common rheumatic diseases or syndromes. Scand J Rheumatol. 1974;3(3):145-53. doi: 10.3109/03009747409097141. PMID: 4428194.

Gündüz R, Malas FÜ, Borman P, Kocaoğlu S, Özçakar L. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical and ultrasonographical comparison. Clin Rheumatol. 2012 May;31(5):807-12. doi: 10.1007/s10067-012-1939-y. Epub 2012 Jan 27. PMID: 22278162.

Kane SF, Lynch JH, Taylor JC. Evaluation of elbow pain in adults. Am Fam Physician. 2014 Apr 15;89(8):649-57. PMID: 24784124.

Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999 Feb;81(2):259-78. PMID: 10073590.

Hong QN, Durand MJ, Loisel P. Treatment of lateral epicondylitis: where is the evidence? Joint Bone Spine. 2004 Sep;71(5):369-73. doi: 10.1016/j.jbspin.2003.05.002. PMID: 15474386.

Barrington J, Hage W. Lateral epicondylitis (tennis elbow): nonoperative, open, or arthroscopic treatment?. Current Opinion in Orthopaedics. 2003;14:291–5. doi: 10.1097/00001433-200308000-00013.

Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard CH. Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. J Bone Joint Surg Br. 1992 Sep;74(5):646-51. doi: 10.1302/0301-620X.74B5.1388172. PMID: 1388172.

Buchbinder R, Green SE, Struijs P. Tennis elbow. BMJ Clin Evid. 2008 May 28;2008:1117. PMID: 19450309; PMCID: PMC2907994.

Shergill R, Choudur HN. Ultrasound-Guided Interventions in Lateral Epicondylitis. J Clin Rheumatol. 2019 Apr;25(3):e27-e34. doi: 10.1097/RHU.0000000000000879. PMID: 30074911.

Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed. 2000 May;28(5):38-48. doi: 10.3810/psm.2000.05.890. PMID: 20086639.

Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Nov 4;333(7575):939. doi: 10.1136/bmj.38961.584653.AE. Epub 2006 Sep 29. PMID: 17012266; PMCID: PMC1633771.

Price R, Sinclair H, Heinrich I, Gibson T. Local injection treatment of tennis elbow--hydrocortisone, triamcinolone and lignocaine compared. Br J Rheumatol. 1991 Feb;30(1):39-44. doi: 10.1093/rheumatology/30.1.39. PMID: 1991216.

Sölveborn SA, Buch F, Mallmin H, Adalberth G. Cortisone injection with anesthetic additives for radial epicondylalgia (tennis elbow). Clin Orthop Relat Res. 1995 Jul;(316):99-105. PMID: 7634730.

Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999 Oct 9;319(7215):964-8. doi: 10.1136/bmj.319.7215.964. PMID: 10514160; PMCID: PMC28251.

Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002 Feb 23;359(9307):657-62. doi: 10.1016/S0140-6736(02)07811-X. PMID: 11879861.

Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010 Nov 20;376(9754):1751-67. doi: 10.1016/S0140-6736(10)61160-9. Epub 2010 Oct 21. PMID: 20970844.

Yi R, Bratchenko WW, Tan V. Deep Friction Massage Versus Steroid Injection in the Treatment of Lateral Epicondylitis. Hand (N Y). 2018 Jan;13(1):56-59. doi: 10.1177/1558944717692088. Epub 2017 Feb 1. PMID: 28719982; PMCID: PMC5755866.

Orchard JW, Vicenzino B. Cortisone injections for tennis elbow should be an "avoid", rather than a recommended procedure. Med J Aust. 2017 Nov 20;207(10):453. doi: 10.5694/mja17.00445. PMID: 29129178.

Regan W, Wold LE, Coonrad R, Morrey BF. Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med. 1992 Nov-Dec;20(6):746-9. doi: 10.1177/036354659202000618. PMID: 1280910.

Okcu, G. & Yercan, H.S. & Öziç, U.. (2002). The comparison of single dose versus multi-dose local corticosteroid injections for tennis elbow. J Arthroplasty Arthroscopic Surg. 13. 158-163.

Okçu G, Erkan S, Sentürk M, Ozalp RT, Yercan HS. Evaluation of injection techniques in the treatment of lateral epicondylitis: a prospective randomized clinical trial. Acta Orthop Traumatol Turc. 2012;46(1):26-9. doi: 10.3944/aott.2012.2577. PMID: 22441448.

Dogramaci Y, Kalaci A, Savaş N, Duman IG, Yanat AN. Treatment of lateral epicondilitis using three different local injection modalities: a randomized prospective clinical trial. Arch Orthop Trauma Surg. 2009 Oct;129(10):1409-14. doi: 10.1007/s00402-009-0832-x. Epub 2009 Feb 14. PMID: 19219442.

Altay T, Günal I, Oztürk H. Local injection treatment for lateral epicondylitis. Clin Orthop Relat Res. 2002 May;(398):127-30. PMID: 11964641.

Stasinopoulos D, Johnson MI. Effectiveness of extracorporeal shock wave therapy for tennis elbow (lateral epicondylitis). Br J Sports Med. 2005 Mar;39(3):132-6. doi: 10.1136/bjsm.2004.015545. PMID: 15728688; PMCID: PMC1725150.

Trentini R, Mangano T, Repetto I, Cerruti P, Kuqi E, Trompetto C, Franchin F. Short- to mid-term follow-up effectiveness of US-guided focal extracorporeal shock wave therapy in the treatment of elbow lateral epicondylitis. Musculoskelet Surg. 2015 Sep;99 Suppl 1:S91-7. doi: 10.1007/s12306-015-0361-4. Epub 2015 May 10. PMID: 25957547.

Haake M, König IR, Decker T, Riedel C, Buch M, Müller HH; Extracorporeal Shock Wave Therapy Clinical Trial Group. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial. J Bone Joint Surg Am. 2002 Nov;84(11):1982-91. doi: 10.2106/00004623-200211000-00012. PMID: 12429759.

Yalvaç B, Mesci N, Geler Külcü D, Yurdakul OV. Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis. Acta Orthop Traumatol Turc. 2018 Sep;52(5):357-362. doi: 10.1016/j.aott.2018.06.004. Epub 2018 Jun 28. PMID: 30497658; PMCID: PMC6204478.

Stasinopoulos D. Can extracorporeal shock-wave therapy be used for the management of lateral elbow tendinopathy? World J Methodol. 2018 Nov 29;8(3):37-39. doi: 10.5662/wjm.v8.i3.37. PMID: 30519537; PMCID: PMC6275556.

Spacca G, Necozione S, Cacchio A. Radial shock wave therapy for lateral epicondylitis: a prospective randomised controlled single-blind study. Eura Medicophys. 2005 Mar;41(1):17-25. PMID: 16175767.

Ozkut AT, Kilinçoğlu V, Ozkan NK, Eren A, Ertaş M. Lateral epikondilitli olgularda ekstrakorporeal şok dalga tedavisi [Extracorporeal shock wave therapy in patients with lateral epicondylitis]. Acta Orthop Traumatol Turc. 2007;41(3):207-10. Turkish. PMID: 17876120.

Crowther MA, Bannister GC, Huma H, Rooker GD. A prospective, randomised study to compare extracorporeal shock-wave therapy and injection of steroid for the treatment of tennis elbow. J Bone Joint Surg Br. 2002 Jul;84(5):678-9. doi: 10.1302/0301-620x.84b5.12741. PMID: 12188483.

Buchbinder R, Green SE, Youd JM, Assendelft WJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003524. doi: 10.1002/14651858.CD003524.pub2. PMID: 16235324.

Capan N, Esmaeilzadeh S, Oral A, Basoglu C, Karan A, Sindel D. Radial Extracorporeal Shock Wave Therapy Is Not More Effective Than Placebo in the Management of Lateral Epicondylitis: A Double-Blind, Randomized, Placebo-Controlled Trial. Am J Phys Med Rehabil. 2016 Jul;95(7):495-506. doi: 10.1097/PHM.0000000000000407. PMID: 26544854.

Chung B, Wiley JP. Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial. Am J Sports Med. 2004 Oct-Nov;32(7):1660-7. doi: 10.1177/0363546503262806. PMID: 15494330.

Beyazal MS, Devrimsel G. Comparison of the effectiveness of local corticosteroid injection and extracorporeal shock wave therapy in patients with lateral epicondylitis. J Phys Ther Sci. 2015 Dec;27(12):3755-8. doi: 10.1589/jpts.27.3755. Epub 2015 Dec 28. PMID: 26834345; PMCID: PMC4713784.

Aydın A, Atiç R. Comparison of extracorporeal shock-wave therapy and wrist-extensor splint application in the treatment of lateral epicondylitis: a prospective randomized controlled study. J Pain Res. 2018 Aug 2;11:1459-67. doi: 10.2147/JPR.S166679. PMID: 30122976; PMCID: PMC6080668.






Research Article

How to Cite

Özcanyüz B, Oğur HU, Seyfettinoğlu F, Baydar M, Ozan F, Müjde S. An evaluation of treatment options for lateral epicondylitis. J Surg Med [Internet]. 2020 Dec. 1 [cited 2024 May 18];4(12):1182-5. Available from: