General Guideline Principles for Epicondylitis
(Epicondylalgia) for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Epicondylitis (Epicondylalgia).

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Lateral Epicondylitis Diagnostic Criteria

Pain or discomfort on the outer (lateral) side of the upper arm close to the elbow is a symptom of lateral epicondylitis, also known as tennis elbow. The diagnosis of lateral epicondylitis is made on the basis of lateral elbow pain along with palpable soreness over the lateral epicondyle or tenderness a few cm distal to the epicondyle.

Most patients don’t need any more tests as long as there are no warning signs. Additional testing could be necessary for patients whose symptoms have not subsided after receiving treatment for at least four weeks.

Other potential explanatory illnesses like elbow arthrosis, fibromyalgia, or cervical radiculopathy (particularly C-6) shouldn’t exist in patients. Although this is not necessary to obtain a diagnosis, some individuals will experience onset following a stressful event, typically a relatively minor mishap like hitting the elbow on a hard surface.

Medial Epicondylitis Diagnostic Criteria

The medial or inner aspect of the elbow is far less frequently affected by medial epicondylitis. Sometimes it’s hypothesized that ulnar neuropathy in the elbow occurs together with medial epicondylalgia. Similar to lateral epicondylitis, medial epicondylitis can be treated.

Special Studies and Diagnostic and Treatment Considerations of Epicondylitis

Most patients don’t need any more tests as long as there are no warning signs. Additional testing could be necessary for patients whose symptoms have not subsided after receiving treatment for at least four weeks.

For certain patients, testing is necessary to rule out potential alternative diagnoses including arthrosis or C-6 cervical radiculopathy (usually via MRI) (x-ray of the elbow).

Cervical radiculopathy may be treated using electromyography (EMG), although it is advised to wait at least six weeks following the onset of symptoms so that the EMG changes can become apparent (need at least three weeks).

Medications of Epicondylitis

For the majority of individuals, older NSAIDs like ibuprofen, naproxen, or endorsed as first-choice treatments. Acetaminophen or an equivalent For patients who are not candidates for NSAIDs, paracetamol (acetaminophen) may be a viable alternative to NSAIDs, despite the fact that the majority of research indicates that it is just marginally less effective.

There is proof that NSAIDs are less dangerous and just as good in relieving pain as opioids, such as tramadol.

1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) NSAIDs for Treatment of Acute, Subacute, Chronic, or Postoperative Epicondylalgia

   Non-Steroidal Anti-inflammatory Drugs (NSAIDs) NSAIDs for Treatment of Acute, Subacute, Chronic, or Postoperative Epicondylalgia are recommended for the treatment of postoperative, chronic, or acute epicondylalgia

   Indications – NSAIDs are advised as a treatment for acute, subacute, chronic, or post-operative epicondylalgia. First, try over-the-counter (OTC) medications to see whether they work.

   Frequency/Duration –- For many patients, as required, use may be suitable.

   Indications for Discontinuation – The easing of elbow pain, a lack of effectiveness, or the appearance of side effects that require stopping the treatment.

    

2. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

   NSAIDs for Patients at High Risk of Gastrointestinal Bleeding are recommended Misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors are commonly used together by individuals who are at high risk of gastrointestinal bleeding.

   Indications – For patients who additionally have a high-risk factor profile, the use of NSAIDs and cytoprotective drugs should be taken into account, especially if longer-term treatment is being discussed. At-risk Patients having a background of previous gastrointestinal bleeding, older people, people with diabetes, and smokers.

   Frequency/Dose/Duration – H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.

   Indications for Discontinuation – Intolerance, the emergence of negative effects, or the stopping of NSAIDs.

    

3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

   NSAIDs for Patients at Risk for Cardiovascular Adverse Effects are recommended Acetaminophen or aspirin tend to be the safest medications for cardiovascular side effects when used as first-line therapy.If necessary, non-selective NSAIDs are preferred to COX-2-specific medications.

   To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in individuals receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.

    

4. Acetaminophen for Treatment of Elbow Pain

   Acetaminophen for Treatment of Elbow Pain is recommended for treatment of elbow discomfort, particularly in patients \with contraindications for NSAIDs.

   Indications – All patients, including those with acute, subacute, chronic, and post-operative elbow pain.

   Dose/Frequency – As per the manufacturer’s recommendations; can be used as required. When more than four gm/day is consumed, there is evidence of liver toxicity.

   Indications for Discontinuation –- The disappearance of discomfort, side effects, or intolerance.

    

5. Topical NSAIDs of Epicondylitis (Epicondylalgia)

   Topical NSAIDs for Treatment of Acute, Subacute, Chronic, or Post-Operative Epicondylalgia

   Topical NSAIDs for Treatment of Acute, Subacute, Chronic, or Post-Operative Epicondylalgia are recommended for lateral epicondylalgia that is acute, subacute, chronic, or post-operative

   indications – Oral drugs are advised for the majority of individuals. Topical NSAIDs, however, might be a good substitute for people who cannot take oral NSAIDs or who are intolerant to them.

   Frequency/Dose/Duration – as per the advice of the manufacturer.

   Indications for Discontinuation – The easing of elbow pain, a lack of effectiveness, or the appearance of side effects that require stopping the treatment.

   There is Support for Topical NSAIDs and Other Agents in the Treatment of Lateral Epicondylalgia

    

6. Opioids of Epicondylitis (Epicondylalgia)

   Patients with epicondylalgia are hardly ever treated with opioids. They are more typically utilised for limited periods right after surgery.

    

   • Opioids for Select Patients with Post-Operative Epicondylalgia

     Opioids for Select Patients with Post-Operative Epicondylalgia are recommended for the selective management of post-operative epicondylalgia patients.

     Indications – A brief opioid regimen of a few days to no more than one week is advised for the treatment of post-operative epicondylalgia. Following surgery, a small nocturnal dose of opioids may be beneficial. Opioids are not advised for people with various forms of epicondylalgia.

     Prior to using opioids, the majority of patients should try NSAIDs and acetaminophen for pain relief. It is advised to stop using opioids as soon as possible.

     Frequency/Dose/Duration – For most epicondylar surgeries, patients typically need no more than a few days to a week of opioid treatment.

     Indications for Discontinuation – Elimination of elbow pain, adequate control with additional drugs, ineffectiveness, or emergence of side effects that need discontinuation.

      

   • Opioids for Acute, Subacute, or Chronic Epicondylalgia

     Opioids for Acute, Subacute, or Chronic Epicondylalgia are not recommended for chronic epicondylalgia or acute, subacute, or both. Rationale for Recommendations Opioids have not been adequately studied when used to treat epicondylalgia.Opioids have serious side effects, including poor tolerance, constipation, sleepiness, impaired judgement, memory loss, and the potential for overuse or dependency, which has been observed in up to 35% of patients.

     Patients should be warned against using machinery or motor vehicles and aware of these possible side effects prior to receiving an opioid prescription. The majority of musculoskeletal complaints can be treated with safer analgesics, and opioids should only be taken in extreme cases of pain or for a brief period of time (no longer than one week) after surgery.

     Patients with epicondylalgia are not advised to take opioids, unless it is a brief postoperative course. There is Support for Opioid Use in Lateral Epicondylalgia.

Rehabilitation: Devices / Therapy of Epicondylitis

In the event that rehabilitation is necessary as a result of a job-related injury, the main goal should be to help the patient regain the functional ability needed to carry out daily tasks and return to work, with the goal of returning them as closely as possible to their pre-injury condition.

Active therapy calls for the patient to put in an internal effort to finish a particular activity or assignment. This type of therapy necessitates therapist supervision, such as verbal, visual, and/or tactile guidance (s).

The majority of the energy needed to perform the job is executed by the patient, while the therapist may occasionally assist in stabilizing the patient or directing the movement pattern. In order to maintain improvement levels, the patient should be advised to continue active therapy at home as an extension of the treatment process.

Over passive interventions, active initiatives should be prioritized. Passive interventions are those that rely on modalities administered by a therapist rather than requiring the patient to expend any effort.

Passive therapies are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains.

To facilitate functional gains, assistive devices may be used as an adjuvant measure in the rehabilitation strategy.

1. Tennis Elbow Bands, Straps, and Braces for Acute, Subacute, and Chronic Epicondylalgia

   Tennis Elbow Bands, Straps, and Braces for Acute, Subacute, and Chronic Epicondylalgia are recommended to handle acute, subacute, or long-term epicondylalgia.

   Devices are typically worn everyday, but not at night or just when more strenuous activity is required (discontinue for less strenuous tasks during daily routine).

   The dorsum of the hand may become numb or there may be pain radiating down the dorsum of the forearm into the hand as a result of treatment that has not resolved elbow pain, intolerance, or lack of effectiveness.

    

2. Cock-up Wrist Braces for Acute, Subacute, or Chronic Epicondylalgia

   Cock-up Wrist Braces for Acute, Subacute, or Chronic Epicondylalgia are recommended to manage acute, subacute, or chronic epicondylalgia.

   Indications – Devices are typically worn every day (but not at night) or only when necessary for more strenuous activities. They are discontinued for less strenuous activities performed as part of daily routine.

   Frequency/Dose/Duration – Devices are typically worn throughout the day (but not at night) or only when more strenuous activity is required (discarding for less strenuous activities during daily routine).

   Indications for Discontinuation – – The disappearance of elbow discomfort, intolerance, or ineffectiveness.

Therapy (Active and Passive) of Epicondylitis (Epicondylalgia)

Rehab (supervised formal therapy) needed after a work-related injury should be concentrated on regaining the functional ability needed to meet the patient’s daily and work obligations and enable them to return to work, with the goal of returning the injured worker to their pre-injury status to the extent that is practical.

Active therapy calls for the patient to put in an internal effort to finish a particular activity or assignment. The procedures known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their side.

Passive therapies are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Interventions that are active should be prioritized over those that are passive.

To sustain improvement levels, the patient should be advised to continue both active and passive therapies at home as an extension of the therapeutic process.

To facilitate functional gains, assistive devices may be used as an adjuvant measure in the rehabilitation strategy.

Active Therapy of Epicondylitis (Epicondylalgia)

Physical / Occupational Therapy Physical or Occupational Therapy for Acute, Subacute, Chronic, or Post-operative Epicondylalgia

Physical / Occupational Therapy Physical or Occupational Therapy for Acute, Subacute, Chronic, or Post-operative Epicondylalgia are recommended for the management of postoperative, chronic, or acute epicondylalgia.

Frequency/Dose/Duration – Patients with moderate functional deficits may require as few as two to three visits overall; patients with more severe deficits may require 12 to 15 appointments with documentation of continued objective functional improvement.

If there is evidence of functional improvement toward particular objective functional goals (e.g., enhanced grip strength, key pinch strength, range of motion, or improving capacity to execute work activities), more than 12 to 15 visits may be necessary to address persistent functional impairments.

A home exercise regimen should be created as part of the rehabilitation strategy and carried out alongside the therapy.

Indications for Discontinuation – Resolution of elbow discomfort, intolerance, lack of effectiveness, or non-compliance, including failure to perform the recommended at-home exercises.

Passive Therapy of Epicondylitis (Epicondylalgia)

1. Heat or Cold Packs

   Heat or Cold Packs are recommended for the management of postoperative or chronic or subacute acute epicondylalgia

   Frequency/Dose/Duration – Three to five times each day, self-applications of heat or ice may be reasonable therapies.

   Indications for Discontinuation – Elimination of elbow discomfort, intolerance, or ineffectiveness.

    

2. Iontophoresis

   Iontophoresis is recommended Iontophoresis for the treatment of acute, subacute, or chronic epicondylalgia in combination with glucocorticoids or NSAIDs

   Indications – For patients with acute, subacute, or chronic epicondylalgia; people who are unable to take oral NSAIDs or who don’t respond to alternative treatments (such as inadequate pain alleviation from elbow straps and exercise may make for the best candidates. In most cases, mild Patients who are badly harmed are viewed as better candidates.

   Frequency/Dose/Duration – A variety of drugs were employed in the quality studies. Dexamethasone, naproxen, and ketorolac are a few of these.

   Indications for Discontinuation – Pain, intolerance, lack of effectiveness, or non-compliance are all resolved.

    

3. Ultrasound of Epicondylitis (Epicondylalgia)

   Ultrasound of Epicondylitis (Epicondylalgia) is recommended to manage acute, subacute, or chronic epicondylalgia.

   Indications – Ideal candidates may include people with acute, subacute, or chronic epicondylalgia, those who cannot tolerate oral NSAIDs and exercise, as well as those who have not responded to conventional treatments (such as inadequate pain alleviation with elbow straps and activity adjustment).

   Patients who are moderately to severely impaired are typically considered to be better candidates. Ultrasound’s overall impact seems small, therefore additional interventions particularly exercise are advised before it.

   Frequency/Dose/Duration – The quality studies have made use of a variety of regimens. Ten to twelve treatments spread over four to six weeks were used in the two trials demonstrating the greatest benefit

   Indications for Discontinuation – Pain, intolerance, lack of effectiveness, or non-compliance are all resolved.

Other Therapies of Epicondylitis (Epicondylalgia)

1. Manipulation and Mobilization Soft Tissue Mobilization for Acute, Subacute, or Chronic Epicondylalgia

   Manipulation and Mobilization Soft Tissue Mobilization for Acute, Subacute, or Chronic Epicondylalgia are not recommended to manage acute, subacute, or chronic epicondylalgia.

    

2. Manipulation and Mobilization for Acute, Subacute, or Chronic Epicondylalgia

   Manipulation and Mobilization for Acute, Subacute, or Chronic Epicondylalgia are not recommended – for the treatment of acute, subacute, or chronic epicondylalgia.

    

3. Massage, Including Friction Massage, for Acute, Subacute, or Chronic Epicondylalgia

   Massage, Including Friction Massage, for Acute, Subacute, or Chronic Epicondylalgia not recommended: Massage techniques such as friction massage

    

4. Magnets and Pulsed Electromagnetic Field for Acute, Subacute, or Chronic Epicondylalgia

   Magnets and Pulsed Electromagnetic Field for Acute, Subacute, or Chronic Epicondylalgia are not recommended: to handle acute, subacute, or long-term epicondylalgia.

    

5. Extracorporeal Shockwave Therapy for Acute, Subacute, or Chronic Epicondylalgia

   Extracorporeal Shockwave Therapy for Acute, Subacute, or Chronic Epicondylalgia not recommended: to handle acute, subacute, or long-term epicondylalgia.

    

6. Phonophoresis for Acute, Subacute, or Chronic Epicondylalgia

   Phonophoresis for Acute, Subacute, or Chronic Epicondylalgia are not recommended: to handle acute, subacute, or long-term epicondylalgia.

    

7. Low-Level Laser Therapy for Acute, Subacute, or Chronic Epicondylalgia

   Low-Level Laser Therapy for Acute, Subacute, or Chronic Epicondylalgia are not recommended: to handle acute, subacute, or long-term epicondylalgia.

    

8. Acupuncture of Epicondylitis (Epicondylalgia)

   Acupuncture for Select Chronic Epicondylalgia are recommended to treat a select number of patients with long-lasting epicondylalgia

   Indications – Patients with chronic epicondylalgia; those not sufficiently responding to oral NSAID treatment and/or topical), activity, or individuals who don’t respond to treatments therapies (such as inadequate pain alleviation with elbow restraints and activity adjustment) can be the best options.

   Injections of glucocorticosteroids are also acceptable. Other interventions to try before acupuncture. Generally, moderately to severely impacted people are thought to be superior applicants. Acupuncture appears to have moderate overall advantages and seems to lose its effectiveness quickly. a few weeks afterwards.

   Frequency/Dose/Duration – Two to three treatments per week for eight to ten sessions per regimen. Patients must show improvement after four to five appointments; otherwise, the technique needs to be changed or acupuncture should be stopped.

   Indications for Discontinuation – Getting rid of pain, intolerance, ineffectiveness, or non-compliance.

    

9. Acupuncture for Acute, Subacute, or Post-Operative Epicondylalgia

   Acupuncture for Acute, Subacute, or Post-Operative Epicondylalgia are not recommended for the treatment of post-operative or acute, subacute, or acute epicondylalgia.

   Biofeedback, Electrical Nerve Stimulation, and Diathermy for Acute, Subacute, or Chronic Epicondylalgia

   Biofeedback, Electrical Nerve Stimulation, and Diathermy for Acute, Subacute, or Chronic Epicondylalgia are not recommended in order to treat acute, subacute, or persistent epicondylalgia.

Injections of Epicondylitis

1. Glucocorticosteroid Injections

    

   • Glucocorticosteroid Injections for Subacute or Chronic Epicondylalgia

     Glucocorticosteroid Injections for Subacute or Chronic Epicondylalgia are recommended for the management of very specific chronic or subacute epicondylalgia.

     Indications – patients with persistent or subacute epicondylalgia. Patients should not have responded well enough to several NSAIDs (oral and/or topical), exercise, elbow straps, and activity adjustment during NYS WCB MTG – Elbow Injuries 38 treatment.

     Patients should be informed that following an injection, symptoms frequently return. Patients who are moderately to severely affected are regarded to be better candidates, especially those who are thought to be surgical candidates but are delaying treatment in the hopes that the pain will go away.

     Frequency/Dose/Duration – All high-quality trials have only administered one injection and have checked the outcomes for a successful outcome before administering more.

     Indications for Discontinuation – Pain, intolerance, lack of effectiveness, or non-compliance are all resolved. The diagnosis should be reevaluated if there is no response.

      

   • Glucocorticosteroid Injections for Acute Epicondylalgia

     Glucocorticosteroid Injections for Acute Epicondylalgia are not recommended to alleviate acute epicondylalgia.

      

   • Glucocorticosteroid Injections Using Bupivacaine for Subacute

     Glucocorticosteroid Injections Using Bupivacaine for Subacute or Chronic Epicondylalgia are not recommended – as a supplement to the treatment of chronic or subacute epicondylalgia.

      

2. Botulinum Injections for Acute, Subacute, or Chronic Lateral Epicondylalgia

   Botulinum Injections for Acute, Subacute, or Chronic Lateral Epicondylalgia are not recommended for the treatment of lateral epicondylalgia that is acute, subacute, or persistent.

    

3. Platelet Rich Plasma Injections

   Platelet Rich Plasma Injections are recommended pertaining to Chronic Lateral Epicondylalgia

   Indications – Unresponsive to various therapies such as NSAIDs, straps, stretching and strengthening exercises, and at least one glucocorticosteroid injection. Lateral epicondylalgia persisting at least 6 months.

   Dose/Duration – Approximately 3mL of platelet-rich plasma, buffered with NS, 8.4% sodium bicarbonate, 0.5% bupivacaine, and epinephrine, were administered in one injection (1:200,000).

    

4. Autologous Blood Injections

   Autologous Blood Injections are recommended pertaining to Chronic Lateral Epicondylalgia

   Indications – Unresponsive to various therapies such as NSAIDs, straps, stretching and strengthening exercises, and at least one glucocorticosteroid injection. Lateral epicondylalgia persisting at least 6 months.

   Dose/Frequency – 2 millilitres of autologous blood are drawn from a peripheral vein, then are injected into the area that is most sensitive (s).

    

5. Platelet-rich Plasma or Autologous Blood Injections for Acute or Subacute Epicondylalgia

   Platelet-rich Plasma or Autologous Blood Injections for Acute or Subacute Epicondylalgia are not recommended as a remedy for subacute or acute epicondylalgia.

    

6. Polidocanol Injections for Acute, Subacute, or Chronic Epicondylalgia

   Polidocanol Injections for Acute, Subacute, or Chronic Epicondylalgia are not recommended to treat acute, subacute, or chronic conditions epicondylalgia.

    

7. Periarticular Viscosupplementation (Hyaluronate and Glycosaminoglycan) Injections for Chronic Epicondylalgia

   Periarticular Viscosupplementation (Hyaluronate and Glycosaminoglycan) Injections for Chronic Epicondylalgia are not Recommended in order to manage chronic epicondylalgia.

    

8. Other Injections of Epicondylitis (Epicondylalgia)

    

   • Prolotherapy or Sonographically Guided Percutaneous Tenotomy Injections for Acute, Subacute, or Chronic Epicondylalgia

     Prolotherapy or Sonographically Guided Percutaneous Tenotomy Injections for Acute, Subacute, or Chronic Epicondylalgia are not recommended to handle acute, subacute, or long-term epicondylalgia.

      

   • Dry Needling or Multi Puncture Technique (‘peppering”) May Be Effective for Treatment of Subacute or Chronic Epicondylalgia

     Dry Needling or Multi Puncture Technique (‘peppering”) May Be Effective for Treatment of Subacute or Chronic Epicondylalgia are recommended to treat subacute or persistent epicondylalgia

     Rationale for Recommendations – There is some preliminary evidence that the numerous puncture approach (sometimes known as “peppering”) or dry needling may be useful.

Surgical Considerations of Epicondylitis

When lateral epicondylalgia does not improve with nonsurgical methods, adequate nonoperative care trials. The three primary surgical methods for arthroscopic, percutaneous, and open lateral epicondylalgia.

A review discovered no proof that one method was superior to another and came to the conclusion that The surgeon should be free to make their own decision.

1. Lateral Epicondylar Release for Chronic Lateral Epicondylalgia

   Lateral Epicondylar Release for Chronic Lateral Epicondylalgia are recommended for the treatment of lateral epicondylalgia that is persistent.

   Indications – Surgery should be scheduled according to the degree of functional impairment, as well as the progression and seriousness of objective findings.

   Contrary to severe entrapment neuropathies, lateral epicondylalgia typically does not result in unmistakably objective proof of impairment or severe dysfunction; for this reason, it is especially necessary to document adequate non-operative management trials notwithstanding adherence to therapy.

   Although there are a few rare exceptions, most patients should experience pain for at least 6 months before considering surgery. In some cases, however, only 3 months of non-operative treatment may be required.

   In order to increase the range of motion and strength of the musculature around the elbow, there should typically be considerable restrictions, failure to improve with NSAIDs, elbow bands or straps, activity adjustment, and exercise programmes.

   Ideally, patients should have verified short-term alleviation from injection after failing glucocorticosteroid injection(s) (s). Any of the three primary surgical techniques is suitable.

    

2. Radiofrequency Microtenotomy for Chronic Lateral Epicondylalgia

   Radiofrequency Microtenotomy for Chronic Lateral Epicondylalgia are recommended to treat lateral epicondylalgia that is persistent.

   Indications – the same as before.

What our office can do if you have Epicondylitis (Epicondylalgia)

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.