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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

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A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

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Review published: .

CRD summary

This review assessed physical interventions for lateral epicondylitis. The authors concluded that there was little evidence about the long-term effects of physical therapies, and that further research is required. However, the evidence suggested that extracorporeal shock wave therapy is not effective. The review had some methodological limitations but, overall, the authors' conclusions reflect the limited data.

Authors' objectives

To assess the effectiveness of physical interventions for lateral epicondylitis (LE).


MEDLINE, CINAHL, EMBASE, Web of Science, AMED, PEDro, SPORTDiscus and the Cochrane Controlled Trials Register were searched in September 2003 for studies reported in any language. References in retrieved papers and systematic reviews were screened.

Study selection

Study designs of evaluations included in the review

Randomised controlled trials (RCTs) were eligible for inclusion if they scored 50% or more (at least 8 out of 15 points) for quality (see 'Validity' section for details of criteria).

Specific interventions included in the review

Studies that included a physical intervention (defined as not solely a pharmaceutical or surgical intervention) were eligible for inclusion. Studies that used corticosteroid injections or non-steroidal anti-inflammatory drugs (NSAIDs) as the control were included, whereas studies with a surgical control group were excluded, as were those using the same physical intervention in both treatment groups. The included studies used exercise, manipulation, orthotics, taping, acupuncture, laser, extracorporeal shock wave therapy (ESWT), electromagnetic field therapy and ionisation, ultrasound (US), phonophoresis and combined interventions.

Participants included in the review

Studies of patients diagnosed with tennis elbow or LE (defined as lateral elbow pain that increased on palpation and/or during resisted wrist dorsiflexion) were eligible for inclusion.

Outcomes assessed in the review

Studies that assessed a clinically relevant outcome such as pain, grip strength or global improvement were eligible for inclusion. Most of the included studies assessed pain using either a continuous visual analogue scale (PVAS) or using an ordinal points method, and assessed grip strength as the maximum grip strength (MGS) or pain-free grip strength (PFGS). Most studies assessed a dichotomous outcome of success using global improvement or a patient satisfaction scale. The studies assessed outcomes from immediately post-intervention to more than 6 months. The review also assessed effects.

How were decisions on the relevance of primary studies made?

One reviewer selected studies. Any uncertainties were resolved by this reviewer and two other reviewers.

Assessment of study quality

Studies were assessed and scored using the following criteria modified from the PEDro rating scale: eligibility criteria specified; justification of sample size; ethical clearance and consent; randomisation; allocation concealment; baseline similarity of the treatment groups; blinding of the patient, therapist and outcome assessors; outcome measures valid; outcomes measured for more than 85% of those randomised; data analysed on an intention-to-treat basis; statistical comparison between treatments; and the reporting of point estimate and variability of outcome measures and side-effects. The maximum possible quality score was 15 points. Two qualified PEDro raters assessed validity and resolved any disagreements through discussion, with the help of a third independent reviewer if required. Inter-rater agreement was assessed using the kappa (k) statistic.

Data extraction

One reviewer extracted the data using a standardised form, which was then checked by a second reviewer. Where possible, for each study, the standardised mean difference (SMD) with 95% confidence interval (CI) was calculated for continuous data (using post-intervention mean scores if necessary) and the relative risk (RR) with 95% CI calculated for dichotomous data. Authors of studies with missing data were contacted for further information.

Methods of synthesis

How were the studies combined?

The studies were grouped by intervention and combined in a narrative. Where studies compared similar treatments using similar outcomes after similar periods of follow-up, pooled SMDs with 95% CI were calculated for continuous data and pooled RRs with 95% CI were calculated for dichotomous data.

How were differences between studies investigated?

Differences between the studies were discussed in the text, with additional information presented in tabular format. The robustness of using a quality score of 50% as the cut-off point for inclusion was explored by re-examining all studies scoring more than 40% for quality.

Results of the review

Twenty-eight RCTs were included. It was not possible to calculate the total number of patients because of potential double-counting in studies with more than one treatment group.

In terms of study quality, the most common methodological flaws were absence of allocation concealment and the lack of intention-to-treat analysis.

Twenty-four RCT assessed only short-term outcomes (less than 6 weeks). Only 8 RCTs followed up patients beyond 6 months.

Exercise (1 RCT): the study found that exercises may improve pain, but not MGS, compared with US.

Manipulation (3 RCTs): a meta-analysis of 2 RCTs showed that manipulation improved PFGS (SMD 1.28, 95% CI: 0.84, 1.73) and pressure pain threshold (SMD 0.49, 95% CI: 0.08, 0.90) post-intervention in comparison with placebo, but there was no longer term follow-up. The other RCT showed no significant difference between a combination treatment that included exercise and control for global improvement, PVAS, MGS or pressure pain threshold.

Orthotics and taping (3 RCTs): the studies used different control groups and assessed outcomes at different times. One RCT found taping significantly improved PFGS and pressure pain threshold post-treatment. Other studies found no significant difference between an orthotic and corticosteroid injection (1 RCT) or between an off-the-shelf orthotic, two placebo braces and control (1 RCT).

Acupuncture (4 RCTs): 2 of 3 RCTs comparing acupuncture with placebo found a significant improvement with acupuncture post-treatment, but no significant different between treatments at 2 months; the other placebo-controlled RCT found acupuncture significantly increased the duration of pain relief and improved success. The fourth RCT found no significant difference between acupuncture and US post-treatment or at 1 month.

Laser (6 RCTs): the short-term results for laser versus placebo were mixed. Four RCTs found no significant difference between treatments, while 1 RCT found a significant improvement with laser. The meta-analysis showed no statistically significant difference between laser and placebo for PVAS, PFGS and global improvement at 3 months, 6 months or 1 year (the results were reported).

ESWT (2 RCTs): the meta-analysis showed no statistically significant difference between ESWT and placebo for PVAS (SMD 0.02, 95% CI: -0.19, 0.24) or global improvement (RR 1.01, 95% CI: 0.78, 1.57) at 4 to 6 weeks. One high-quality RCT found that ESWT significantly increased side-effects (RR 2.64, 95% CI: 1.98, 3.53).

Electromagnetic field therapy and ionisation (4 RCTs): a meta-analysis of the 2 placebo-controlled RCTs of ionisation showed no significant difference between treatments for patient-rated global improvement at 1 to 3 months (RR 1.03, 95% CI: 0.83, 1.28). One RCT found that ionisation with high- or low-dose NSAID significantly improved PVAS compared with sham ionisation. The one electromagnetic study presented insufficient data to calculate an effect size.

US and phonophoresis (5 RCTs): a meta-analysis of the 2 detuned placebo-controlled RCTs of US ionisation showed no significant difference between treatments for global improvement at 3 months (RR 1.01, 95% CI: 0.62, 1.65). Other RCTs found no significant difference between US and acupuncture at 4 weeks (1 RCT) or for US plus either transverse friction massage or hydrocortisone coupling compared with US alone post-treatment (1 RCT). The fifth RCT compared US with exercise (see 'Exercise' above for details). Combined physical interventions (2 RCTs): one RCT used manipulation as the control (see 'Manipulation' above for details). The other RCT found corticosteroid injection improved outcomes at 6 weeks in comparison with combined treatment (massage, US and exercise), but the physical intervention significantly improved outcomes at 6 and 12 months. It found no significant difference between combined treatment and a no treatment control.

Authors' conclusions

Overall, there was a lack of evidence about the long-term effects of physical therapies. Further research is required. The evidence suggested that ESWT is not effective for tennis elbow.

CRD commentary

The review addressed a clear question that was defined in terms of the participants, intervention, outcomes and study design. The search was comprehensive and attempts were made to minimise language and publication bias. The lack of duplication in the study selection and data extraction processes might have led to errors and bias; the authors acknowledged these weaknesses. Validity was assessed using specified established criteria and only studies meeting the minimum quality criteria were included. Methods were used to minimise errors and bias in the validity assessment.

The studies were combined in a narrative that considered the timing of the outcome assessment and methodological limitations of the studies. Meta-analysis was used only for clinically homogeneous studies but statistical heterogeneity was not assessed. Overall, the authors' conclusions correctly reflect the limitations of the evidence and the lack of support for ESWT.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that further research into the long-term effects of manipulation and exercise for LE is required. The authors also stated that there is a need for studies with higher quality designs, implementation and reporting of the results.


University of Queensland Research Development Scheme; National Health and Medical Research Council Project, grant number 252710.

Bibliographic details

Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine 2005; 39(7): 411-422. [PMC free article: PMC1725258] [PubMed: 15976161]

Indexing Status

Subject indexing assigned by NLM


Acupuncture Therapy /methods; Exercise Therapy /methods; High-Energy Shock Waves /therapeutic use; Humans; Iontophoresis /methods; Laser Therapy; Massage /methods; Musculoskeletal Manipulations /methods; Pain /etiology; Physical Therapy Modalities; Randomized Controlled Trials as Topic; Tennis Elbow /therapy; Treatment Outcome



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

Copyright © 2014 University of York.
Bookshelf ID: NBK71911


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