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Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials
  1. Stefanos Karanasios1,
  2. Vasileios Korakakis2,
  3. Rod Whiteley2,3,
  4. Ioannis Vasilogeorgis4,
  5. Sarah Woodbridge5,
  6. Georgios Gioftsos1
  1. 1 Physiotherapy, University of West Attica, Egaleo, Greece
  2. 2 Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar
  3. 3 University of Sydney, Sydney, New South Wales, Australia
  4. 4 Hellenic OMT Diploma, Athens, Greece
  5. 5 Occupational Therapy, University of Derby, Derby, UK
  1. Correspondence to Stefanos Karanasios, Physiotherapy, University of West Attica, Egaleo 122 43, Greece; skaranasios{at}


Objective To evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function.

Design Systematic review and meta-analysis.

Methods We used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures.

Eligibility criteria RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET.

Results 30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident.

Conclusions Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small.

PROSPERO registration number CRD42018082703.

  • tendinopathy
  • elbow
  • tennis elbow
  • exercise

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  • Contributors SK contributed in planning, conduct, data analysis, synthesis and reporting of the work. VK contributed in planning, conduct, data analysis, synthesis and reporting of the work. RW contributed in data synthesis and revising of the work. IV contributed in data extraction. SW contributed in revising the work. GG contributed in revising the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.