Other treatment modalities to be considered include corticosteroid injections, acupuncture, autologous blood and other injection therapies, botulinum injection, topical nitrates, laser therapy, and surgery.
Corticosteroid Injections Versus Physical Therapy
In a randomized controlled trial contrasting the use of corticosteroid injections, physical therapy, and a wait-and-see approach for patients with lateral epicondylitis, corticosteroid injections were found superior in the short term (defined as six weeks after treatment initiation). In the long term, however (ie, at 52 weeks), physical therapy was found more effective than either of the alternative approaches. Outcome measures included general improvement, reduction in severity of the main complaint, alleviation of pain, improved elbow function, and patient satisfaction.13
A less invasive alternative to steroid injections for patients with lateral epicondylitis, though not yet FDA approved, has yielded promising results: administration of transdermal dexamethasone by way of iontophoresis.14,15 This delivery method (in which administration of ionic, water-soluble agents is facilitated using a weak electric current23) was recently studied by Stefanou et al14 in the form of a transdermal patch, activated by a 24-hour battery.
In the short term (ie, upon completion of therapy), patients who received iontophoretic dexamethasone had significantly better grip strength and were better able to return to work than those treated with injections of dexamethasone or triamcinolone. By six months, outcome measures were comparable among the three groups.14 However, possible advantages to iontophoresis are that it is painless, noninvasive, and less likely to cause adverse effects.15,23
Acupuncture
While few sources support the use of complementary modalities to treat lateral epicondylitis,24 findings from one randomized controlled trial offered modest support for acupuncture use. Compared with a sham procedure (in which nonspecific points were targeted), “real” acupuncture—selection and stimulation of specific acupuncture points—provided reductions in pain intensity and improvements in function and strength. Evidence of these improvements became even more robust at two-week follow-up. At two months, however, only improvements in function remained significant.16
Four Injection Therapies
Injections of autologous whole blood or platelet-rich plasma, prolotherapy (injections with hyperosmolar dextrose and sodium morrhuate25), and polidocanol injections were examined in a systematic literature review of treatment strategies for lateral epicondylosis published in 2009 by Rabago et al.3
Although most of the study cohorts involved were small, significant improvements were reported for all modalities and outcome measures, particularly pain: reduction in pain scores by as much as 88% among patients injected with autologous whole blood17; a 55% improvement at eight months in patients treated with the sclerosing agent polidocanol26; improvement as great as 90%, 16 weeks after treatment with prolotherapy (compared with 22% in controls)25; and, in a nonrandomized trial, pain reduction of 93% in patients who had received platelet-rich plasma injections about 26 months earlier.27 Nevertheless, the researchers note, further study is required in larger trials examining specified biomarkers in addition to clinical, biomechanical, and radiologic means of measurement to assure the long-term safety and effectiveness of each of these modalities.3
Botulinum Toxin
Injecting botulinum toxin is another treatment strategy that may be considered when results of more traditional approaches are unsatisfactory. In two double-blind, placebo-controlled, randomized studies, patients injected once with botulinum toxin A experienced significant reductions in pain within four to six weeks, compared with those given placebo.18,28 A notable but expected complication of this treatment reported by Placzek et al18 was weakness of the third finger of the treated hand, two weeks after treatment. However, normal strength was regained in all affected patients by week 18 of follow-up.
Nitrates
Use of topical nitric oxide showed promising results in a 2003 study by Australian researchers.19 Eighty-six patients with chronic extensor tendinosis, all of whom underwent a standard tendon rehabilitation program (ie, rest and stretching and strengthening exercises) and used a forearm counterforce brace, were randomized to receive glyceryl trinitrate transdermal patches or sham patches. One-quarter of a patch was applied just distal to the lateral epicondyle of the humerus for 24 hours, then replaced by another in a rotating fashion around the target spot.
Treated patients reported significant reduction in elbow pain within two weeks. At six months, 81% of patients with active patches were able to perform activities of daily living with no symptoms (versus 60% of controls, with the rehabilitation program and brace use alone).19
Laser Therapy
After completing a 2010 study of low-energy gallium-arsenide (GaAs) laser therapy for the treatment of lateral epicondylitis, researchers found no short-term advantages of laser therapy, compared with a sham procedure—but long-term results were more promising.20 Study participants underwent 15 sessions of treatment (application of a laser probe to the two most sensitive points, with a specified dose given) over a three-week period. Shortly after the treatment period ended, patients in both groups had significant improvements.