Guidelines
Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

https://doi.org/10.1016/j.jos.2021.09.003Get rights and content

Abstract

Background

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

Methods

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the “Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014”, which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

Results

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

Conclusions

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

Introduction

The first edition of the lateral epicondylitis clinical practice guidelines was published in 2006; the second edition was revised based on the concept of evidence-based medicine (EBM) issued by the Japan Council for Quality Health Care and was implemented as per the “Handbook for Clinical Practice Guideline Development 2014 (MINDS 2014)” [1]. During the creation of clinical practice guidelines, evidence, such as that from research treatises, is collected in a systematic manner using an established method called systematic review, and all the evidence adopted is evaluated and integrated as a whole. Further, the guidelines emphasize the importance of “balance between benefit and harm”. The clinical practice guidelines compare multiple intervention methods (diagnosis, treatment, prevention, etc.) that may be selected in a clinical situation and recommend the method that is considered to be the most effective. However, the intervention is equivalent to the effectiveness of the intervention. Attention should also be paid to the harmful aspects. MINDS 2014 proposed preferred methods of guideline preparation in Japan based on The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, Cochrane Collaboration, Agency for Healthcare Research and Quality (AHRQ), and the Oxford EBM center. In the MINDS 2014, the preparation procedures of the guidelines have been defined precisely; in particular, the importance of a viable body of evidence was emphasized. For clinical questions (CQ), study reports were collected using a systematic method and were evaluated as per the outcome data and study design. The results were evaluated in light of a viable body of evidence and were required to emphasize the balance between risk and benefit. Clinical and epidemiological characteristics, natural history, pathology, and diagnosis were not incorporated into the CQ; therefore, a commentary on these characteristics was added as background question (BQ). With respect to the treatment methods that are not covered by Japanese National Health Insurance (insurance), we do not present any recommendations at present and have listed them as future research questions, trusting that in the future, more extensive research will be conducted on this subject. The guidelines are designed to assist the clinician in easily identifying areas of concern and allow him/her to quickly select appropriate treatments for lateral epicondylitis.

The diagnostic criteria for lateral epicondylitis of the humerus followed the diagnostic criteria in the first edition of the guidelines.

  • 1

    Most tenderness is experienced at the origin of the extensor muscles of the lateral epicondyle.

  • 2

    Resisted wrist dorsiflexion causes pain on the outside of the elbow.

  • 3

    Exclude cases wherein the condition is attributable to disorders at sites other than the origin of the extensor muscles, such as disorders of the humero-radial joint.

This disorder is regarded as a disorder of the origin of the extensor muscle group among the disease groups presenting lateral elbow pain and is regarded as an enthesopathy among the disorders of the origin of the extensor muscle group. It is not possible to completely exclude lesions of the humero-radial joint that continuously affect enthesis, such as the annular ligament; however, at least radial tunnel syndrome that is considered entrapment neuropathy of the posterior interosseous nerve is excluded. Since the publication of the first edition, there have been remarkable advances in the treatment of refractory patients who do not respond to conservative therapy, and research is ongoing on the pathophysiology. This edition of the guidelines is applicable to cases of lateral epicondylitis refractory to conservative therapy, synovitis in the elbow joint, synovitis of the humero-radial joint, synovitis fold disorder, degeneration of the humero-radial joint, etc. We also examined lateral humero-radial joint degeneration in a lecture that included periarticular disorders.

Section snippets

Results of the literature search

In preparation for the second edition revision, the authors performed a MEDLINE search of the literature to identify papers published from January 2008 to May 2016. In this search, we used the search formula presented in Table 1 and extracted 414 papers. In addition, a Japanese Igaku-Chuo Zasshi search was performed to identify articles published from 2008 to 2016. This search was performed using the search formula presented in Table 2 and yielded 370 articles. In the initial screening,

Preparation of structured abstract and evaluation of the articles

The authors selected 102 clinicians who are experts in the treatment of elbow joints from the Japan Elbow Society Board of Trustees. These individuals constituted a systematic review (SR) team. The SR team performed a secondary screening for the full text of 402 articles and prepared structured abstracts from the articles selected in the secondary screening. Moreover, the SR team performed evaluations for the individual reports. The structured abstracts were based on the MINDS 2014

Strength of evidence and recommendations

The selected articles were evaluated as per the outcome data. Factors, such as risk, lack of direction, inconsistencies, inadequacies, and publication bias, were evaluated to formulate a viable body of evidence. The evaluation and definition of the strength of the body of evidence were determined as described in Table 3. The recommended text was created for each CQ, and the strength of the recommendation was determined by the committee members using a GRADE grid as described in Table 4. The

Caution

For the second edition, each selected article was evaluated as per the CQ, outcome data, and final body of evidence. Unlike in the previous edition, we did not evaluate the evidence level of each article. When formulating the body of evidence, the strength of the outcome data of studies, such as randomized controlled trials (RCT), was considered from the initial evaluation (A). The strength of the outcome data from observational studies was evaluated from the initial evaluation (C). Appropriate

BQ-1 What is the natural history (epidemiology) of lateral epicondylitis?

Lateral epicondylitis is common among individuals in their late 30s and 50s, with no sex-based differences. The onset is not associated with labor or the dominant hand side; however, it is associated with the performance of sports activities wherein rackets are used, such as tennis and badminton.

Lateral epicondylitis is less common in young people in their 20s, with most of the affected subjects being in their late 30s–50s [2]. To the best of our knowledge, no studies have described in detail

Declaration of competing interest

Conflicts of interest (2015–2017) were confirmed via self-reporting by all the members of the Lateral Epicondylitis Guideline Committee. No company was directly involved in the guideline recommendations and the systematic review team. The Executive Director and members declared that no company was directly involved in the recommended text for the clinical questions. To minimize bias and conflict of interest in the text, all the members voted on the recommended decisions, excluding the persons

Acknowledgement

We appreciate Masahiro Yoshida, MD, PhD for a great advice of this guidelines. We would like to express our deep gratitude to Fuminori Kanaya, MD, PhD for his contribution as an advisor to the committee. We would like to thank systematic review team for preparation of structured abstract, and NAI Inc. (www.nai.co.jp) for English language editing. We also thanks to Ms. Misako Kaji, and Ms. Mariko Henmi, International Medical Information Center, for their clerical support. Funds required to

References (163)

  • M.J. Walton et al.

    The reliability and validity of magnetic resonance imaging in the assessment of chronic lateral epicondylitis

    J Hand Surg Am

    (2011 Mar)
  • T. Wada et al.

    Functional outcomes after arthroscopic treatment of lateral epicondylitis

    J Orthop Sci

    (2009 Mar)
  • S.K. Latham et al.

    The diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis: a systematic review and meta-analysis

    Orthop Traumatol Surg Res

    (2014 May)
  • R. Garg et al.

    A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis

    J Shoulder Elbow Surg

    (2010 Jun)
  • M.S. Ajimsha et al.

    Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals

    Arch Phys Med Rehabil

    (2012 Apr)
  • S. Küçükşen et al.

    Muscle energy technique versus corticosteroid injection for management of chronic lateral epicondylitis: randomized controlled trial with 1-year follow-up

    Arch Phys Med Rehabil

    (2013 Nov)
  • S. Barr et al.

    Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review

    Physiotherapy

    (2009 Dec)
  • A. Mehra et al.

    The use of a mobile lithotripter in the treatment of tennis elbow and plantar fasciitis

    Surgeon

    (2003 Oct)
  • T. Morizane et al.

    Medical information network distribution service (MINDS) handbook for clinical practice guideline development 2014

    (2014 April)
  • T. Tajika et al.

    Prevalence and risk factors of lateral epicondylitis in a mountain village in Japan

    J Orthop Surg

    (2014 Aug)
  • L. Bisset et al.

    Conservative treatments for tennis elbow do subgroups of patients respond differently?

    Rheumatology

    (2007 Oct)
  • K. Walker-Bone et al.

    Prevalence and impact of musculoskeletal disorders of the upper limb in the general population

    Arthritis Rheum

    (2004 Aug 15)
  • R.A. Werner et al.

    Predictors of persistent elbow tendonitis among auto assembly workers

    J Occup Rehabil

    (2005 Sep)
  • J.P. Haahr et al.

    Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice

    Rheumatology

    (2003 Oct)
  • A. Descatha et al.

    Self-reported physical exposure association with medial and lateral epicondylitis incidence in a large longitudinal study

    Occup Environ Med

    (2013 Sep)
  • Z.J. Fan et al.

    The association between combination of hand force and forearm posture and incidence of lateral epicondylitis in a working population

    Hum Factors

    (2014 Feb)
  • R.M. van Rijn et al.

    Associations between work-related factors and specific disorders at the elbow: a systematic literature review

    Rheumatology

    (2009 May)
  • A.M. Lucado et al.

    Upper extremity strength characteristics in female recreational tennis players with and without lateral epicondylalgia

    J Orthop Sports Phys Ther

    (2012 Dec)
  • A. Descatha et al.

    Study Group on Repetitive Work. Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors

    J Occup Environ Med

    (2003 Sep)
  • O.N. Schipper et al.

    Nirschl surgical technique for concomitant lateral and medial elbow tendinosis: a retrospective review of 53 elbows with a mean follow-up of 11.7 years

    Am J Sports Med

    (2011 May)
  • V.S. Kumar et al.

    Tennis elbow--outcome following the Garden procedure: a retrospective study

    J Orthop Surg

    (2004 Dec)
  • E. Zeisig et al.

    Extensor origin vascularity related to pain in patients with Tennis elbow

    Knee Surg Sports Traumatol Arthrosc

    (2006 Jul)
  • K.H. Noh et al.

    Sonographic probe induced tenderness for lateral epicondylitis: an accurate technique to confirm the location of the lesion

    Knee Surg Sports Traumatol Arthrosc

    (2010 Jun)
  • E. Oskarsson et al.

    Improved intramuscular blood flow and normalized metabolism in lateral epicondylitis after botulinum toxin treatment

    Scand J Med Sci Sports

    (2009 Jun)
  • A.W. Clarke et al.

    Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability

    Am J Sports Med

    (2010 Jun)
  • C. Spang et al.

    Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow - implication for treatment?

    J Musculoskelet Neuronal Interact

    (2017 Jun 1)
  • C. Spang et al.

    Marked expression of TNF receptors in human peritendinous tissues including in nerve fascicles with axonal damage - studies on tendinopathy and tennis elbow

    J Musculoskelet Neuronal Interact

    (2017 Sep 1)
  • H. Mullett et al.

    Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies

    Clin Orthop Relat Res

    (2005 Oct)
  • A.F. Steinert et al.

    Snapping elbow caused by hypertrophic synovial plica in the radiohumeral joint: a report of three cases and review of literature

    Arch Orthop Trauma Surg

    (2010 Mar)
  • I.H. Rhyou et al.

    Is posterior synovial plica excision necessary for refractory lateral epicondylitis of the elbow?

    Clin Orthop Relat Res

    (2013 Jan)
  • M. Peterson et al.

    PET-scan shows peripherally increased neurokinin 1 receptor availability in chronic tennis elbow: visualizing neurogenic inflammation?

    PLoS One

    (2013 Oct 14)
  • G.F. Hatch et al.

    The effect of tennis racket grip size on forearm muscle firing patterns

    Am J Sports Med

    (2006 Dec)
  • E.J. Waugh et al.

    Computer use associated with poor long-term prognosis of conservatively managed lateral epicondylalgia

    J Orthop Sports Phys Ther

    (2004 Dec)
  • K.E. Ozturan et al.

    Autologous blood and corticosteroid injection and extracoporeal shock wave therapy in the treatment of lateral epicondylitis

    Orthopedics

    (2010 Feb)
  • M.J. Zehtab et al.

    The predictive value of extensor grip test for the effectiveness of treatment for tennis elbow

    Saudi Med J

    (2008 Sep)
  • P.A. Struijs et al.

    The predictive value of the extensor grip test for the effectiveness of bracing for tennis elbow

    Am J Sports Med

    (2005 Dec)
  • J. Fernández-Carnero et al.

    Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia

    Clin J Pain

    (2007 May)
  • N. Rosenberg et al.

    Comparison of two methods for the evaluation of treatment in medial epicondylitis: pain estimation vs grip strength measurements

    Arch Orthop Trauma Surg

    (2004 Jul)
  • I. Pasternack et al.

    MR findings in humeral epicondylitis. A systematic review

    Acta Radiol

    (2001 Sep)
  • L. Qi et al.

    Magnetic resonance imaging of patients with chronic lateral epicondylitis: is there a relationship between magnetic resonance imaging abnormalities of the common extensor tendon and the patient's clinical symptom?

    Medicine (Baltim)

    (2016 Feb)
  • View full text