Prolotherapy injections and physiotherapy used singly and in combination for lateral epicondylalgia: a single-blinded randomised clinical trial.

BACKGROUND: Lateral epicondylalgia (tennis elbow) is a common, debilitating and often treatment-resistant condition. Two treatments thought to address the pathology of lateral epicondylalgia are hypertonic glucose plus lignocaine injections (prolotherapy) and a physiotherapist guided manual therapy/exercise program (physiotherapy). This trial aimed to compare the short- and long-term clinical effectiveness, cost effectiveness, and safety of prolotherapy used singly and in combination with physiotherapy. METHODS: Using a single-blinded randomised clinical trial design, 120 participants with lateral epicondylalgia of at least 6 weeks' duration were randomly assigned to prolotherapy (4 sessions, monthly intervals), physiotherapy (weekly for 4 sessions) or combined (prolotherapy+physiotherapy). The Patient-Rated Tennis Elbow Evaluation (PRTEE) and participant global impression of change scores were assessed by blinded evaluators at baseline, 6, 12, 26 and 52 weeks. Success rate was defined as the percentage of participants indicating elbow condition was either 'much improved' or 'completely recovered.' Analysis was by intention-to-treat. RESULTS: Eighty-eight percent completed the 12-month assessment. At 52 weeks, there were substantial, significant improvements compared with baseline status for all outcomes and groups, but no significant differences between groups. The physiotherapy group exhibited greater reductions in PRTEE at 12 weeks than the prolotherapy group (p = 0.014). CONCLUSION: There were no significant differences amongst the Physiotherapy, Prolotherapy and Combined groups in PRTEE and global impression of change measures over the course of the 12-month trial. TRIAL REGISTRATION: ACTRN12612000993897 .

Does Kinesiotaping improve pain and functionality in patients with newly diagnosed lateral epicondylitis?

PURPOSE: This study aimed to compare the short-term effects of kinesiotaping and extracorporeal shock wave therapy (ESWT) along with physiotherapy on pain, functionality, and grip strength in patients with newly diagnosed lateral epicondylitis undergoing rehabilitation. METHODS: Forty-five voluntary patients (mean age 48 years) were randomly assigned to three groups. Patients in all groups received physiotherapy consisting of a cold pack and transcutaneous electrical nerve stimulation five times per week for a total of 15 sessions and a home exercise programme including stretching and eccentric strength exercises. In the second group, patients received kinesiotaping 5 days a week for 3 weeks. In the third group, ESWT was applied three times for 3 weeks. Patients were assessed by visual analogue scale for pain intensity, pain-free grip strength using a hand dynamometer, Cyriax Resisted Muscle Test, and Patient-Rated Tennis Elbow Evaluation Scale. All measurements were collected at baseline and after treatment. RESULTS: There were no significant differences in the demographic characteristics of the patients in all groups at baseline. Intra-group analysis revealed that pain intensity decreased, whereas maximum grip strength and functionality increased in all groups at the end of the treatment (p < 0.05). Inter-group analysis revealed that the kinesiotaping group yielded better results in decreasing pain intensity than the other groups (p < 0.05). The kinesiotaping group (p < 0.001) and ESWT group (p = 0.002) yielded better results in improving functionality than the physiotherapy group. There were significant differences in recovering pain-free grip strength in the kinesiotaping group (p < 0.05). CONCLUSION: Kinesiotaping was found to be effective for decreasing pain intensity, recovering grip strength, and improving functionality in patients with lateral epicondylitis undergoing rehabilitation. LEVEL OF EVIDENCE: Therapeutic study, Level II.

Pattern Differentiation of Lateral Elbow Pain in Traditional Chinese Medicine: A Systematic Review.

BACKGROUND: Traditional Chinese Medicine (TCM) uses a sophisticated diagnostic system called pattern differentiation, which allows for the tailor-made treatment of individuals. OBJECTIVE: This study aimed to identify the commonly used TCM patterns for lateral elbow pain (LEP), as well as the clinical features associated with these patterns. METHOD: Journal literature in 15 major Chinese and English databases and textbooks from five medical libraries as well as Chinamaxx were reviewed. RESULTS: Five hundred and fifty-five full-text journal articles, as well as 465 textbooks, were retrieved for further assessment, but only eight studies and seven books that mentioned LEP patterns could be identified and included in this study. The top four patterns that were identified were the wind-cold-dampness pattern, the qi stagnation and blood stasis pattern, the dual deficiency of qi and blood pattern, and the retained dampness-heat pattern, each of which was associated with unique features that were made up of distinct signs and symptoms. CONCLUSIONS: The unique features identified for each of the major patterns might be the key to understanding TCM individualized treatment based on pattern differentiation. Furthermore, the approach taken in studying TCM pattern of LEP may also be useful for studying the TCM patterns of other musculoskeletal conditions.

Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial.

BACKGROUND: Lateral epicondylitis of the elbow is a frequent condition with long-lasting symptoms. Corticosteroid injection is increasingly discouraged and there is little knowledge on the combined effect of corticosteroid injection and physiotherapy for acute conditions. We wanted to investigate the efficacy of physiotherapy alone and combined with corticosteroid injection for acute lateral epicondylitis. METHODS: A randomized, controlled study with one-year follow-up was conducted in a general practice setting in Sarpsborg, Norway. We included 177 men and women aged 18 to 70 with clinically diagnosed lateral epicondylitis of recent onset (2 weeks to 3 months). They were randomly assigned to one of three treatments: physiotherapy with two corticosteroid injections, physiotherapy with two placebo injections or wait-and-see (control). Physiotherapy consisted of deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises. We used double blind injection of corticosteroid and single blind assessments. The main outcome measure was treatment success defined as patients rating themselves completely recovered or much better on a six-point scale. RESULTS: One hundred fifty-seven patients (89 %) completed the trial. Placebo injection with physiotherapy showed no significant difference compared to control or to corticosteroid injection with physiotherapy at any follow-up. Corticosteroid injection with physiotherapy had a 10.6 times larger odds for success at six weeks (odds ratio 10.60, p < 0.01) compared to control (NNT = 3, 99 % CI 1.5 to 4.2). At 12 weeks there was no significant difference between these groups, but at 26 weeks the odds for success were 91 % lower (OR 0.09, p < 0.01) compared to control, showing a large negative effect (NNT = 5, 99 % CI 2.1 to 67.4). At 52 weeks there was no significant difference. Both control and placebo injection with physiotherapy showed a gradual increase in success. CONCLUSIONS: Acute lateral epicondylitis is a self-limiting condition where 3/4 of patients recover within 52 weeks. Physiotherapy with deep transverse friction massage, Mills manipulation, stretching, and eccentric exercises showed no clear benefit, and corticosteroid injection gave no added effect. Corticosteroid injections combined with physiotherapy might be considered for patients needing a quick improvement, but intermediate (12 to 26 weeks) worsening of symptoms makes the treatment difficult to recommend. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00826462.

Lateral epicondylalgia: midlife crisis of a tendon.

The pathogenesis and management of lateral epicondylalgia, or tennis elbow, a common ailment affecting middle-aged subjects of both genders continue to provoke controversy. Currently it is thought to be due to local tendon pathology, pain system changes, and motor system impairment. Its diagnosis is usually clinical, based on a classical history, as well as symptoms and signs. In selected cases, additional imaging (X-rays, ultrasound, and magnetic resonance imaging) can help to confirm the diagnosis. Different treatment modalities have been described, including the use of orthotics, non-steroidal anti-inflammatory drugs, steroid injections, topical glyceryl trinitrate, exercise therapy, manual therapy, ultrasound therapy, laser therapy, extracorporeal shockwave therapy, acupuncture, taping, platelet-rich plasma injections, hyaluronan gel injections, botulinum toxin injections, and surgery. Nevertheless, evidence to select the best treatment is lacking and the choice of therapy depends on the experience of the management team, availability of the equipment and expertise, and patient response. This article provides a snapshot of current medical practice for lateral epicondylalgia management.

Lateral epicondylitis: a review of pathology and management.

Lateral epicondylitis, or 'tennis elbow', is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments.

Do blood growth factors offer additional benefit in refractory lateral epicondylitis? A prospective, randomized pilot trial of dry needling as a stand-alone procedure versus dry needling and autologous conditioned plasma.

OBJECTIVE: To evaluate whether autologous conditioned plasma offers any therapeutic advantage over ultrasound-guided dry needling as a stand-alone procedure in the treatment of refractory lateral epicondylitis. MATERIALS AND METHODS: Prospective, randomized pilot study of 28 patients (11 men, 17 women, mean age, 49.1  years) with refractory lateral epicondylitis (mean symptom duration, 19.1 months) who underwent either dry needling (n = 13) or dry needling combined with autologous conditioned plasma (ACP) injection (n = 15). Each patient received two separate injections (0 weeks and 1 month) and analysis of visual analogue pain scores (VAS) and Nirschl scores were performed pre-procedure, at 2 months and final evaluation at 6 months. Successful treatment was defined as more than a 25 % reduction in pain scores without re-intervention. Data was analyzed using the Mann-Whitney test and local research ethics committee approval was obtained. RESULTS: At 2 months, the mean VAS improvement was 0.85 (12.3 %) in the dry needling group compared to 2.19 (27.1 %) in the ACP group (p = 0.76) and there was a 5.83-point and 20.3-point Nirschl score improvement respectively (p = 0.72). At the final follow-up of 6 months, the mean VAS improvement was 2.37 (34 %) in the dry needling group compared to 3.92 (48.5 %) in the ACP group (p = 0.74) and there was a 22.5-point and 40-point Nirschl score improvement, respectively (p = 0.82). CONCLUSIONS: There is a trend to greater clinical improvement in the short term for patients treated with additional ACP, however no significant difference between the two treatment groups was demonstrated at each follow-up interval. A larger, multicenter, randomized controlled trial is required to corroborate the results of this pilot study.

Acupuncture for lateral epicondylitis (tennis elbow): study protocol for a randomized, practitioner-assessor blinded, controlled pilot clinical trial.

BACKGROUND: Lateral epicondylitis is the most frequent cause of pain around the elbow joint. It causes pain in the region of the elbow joint and results in dysfunction of the elbow and deterioration of the quality of life. The purpose of this study is to compare the effects of ipsilateral acupuncture, contralateral acupuncture and sham acupuncture on lateral epicondylitis. METHODS/DESIGN: Forty-five subjects with lateral epicondylitis will be randomized into three groups: the ipsilateral acupuncture group, contralateral acupuncture group and the sham acupuncture group. The inclusion criteria will be as follows: (1) age between 19 and 65 years with pain due to one-sided lateral epicondylitis that persisted for at least four weeks, (2) with tenderness on pressure limited to regions around the elbow joint, (3) complaining of pain during resistive extension of the middle finger or the wrist, (4) with average pain of NRS 4 or higher during the last one week at a screening visit and (5) voluntarily agree to this study and sign a written consent. Acupuncture treatment will be given 10 times in total for 4 weeks to all groups. Follow up observations will be conducted after the completion of the treatment, 8 weeks and 12 weeks after the random assignment. Ipsilateral acupuncture group and contralateral acupuncture group will receive acupuncture on LI4, TE5, LI10, LI11, LU5, LI12 and two Ashi points. The sham acupuncture group will receive treatment on acupuncture points not related to the lateral epicondylitis using a non-invasive method. The needles will be maintained for 20 minutes. The primary outcome will be differences in the visual analogue scale (VAS) for elbow pain between the groups. The secondary outcome will be differences in patient-rated tennis elbow evaluation (PRTEE), pain-free/maximum grip strength (Dynamometer), pressure pain threshold, clinically relevant improvement, patient global assessment, and the EQ-5D. The data will be analyzed with the paired t-test and ANCOVA (P <0.05). DISCUSSION: The results of this study will allow evaluation of contralateral acupuncture from two aspects. First, if the contralateral acupuncture shows the effects similar to ipsilateral acupuncture, this will establish clinical basis for contralateral acupuncture. Second, if the effects of contralateral acupuncture are not comparable to the effects of ipsilateral acupuncture, but are shown to be similar to the effects of the sham acupuncture, we can establish the basis for using the same acupoints of the unaffected side as a control in acupuncture clinical studies. TRIAL REGISTRATION: This trial has been registered with the 'Clinical Research Information Service (CRIS)', Republic of Korea: KCT0000628.

Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial.

OBJECTIVE: To compare the effectiveness of supervised exercise program and Cyriax physiotherapy in the treatment of tennis elbow (lateral epicondylitis). DESIGN: Randomized clinical trial. SETTING: Physiotherapy and rehabilitation centre. SUBJECTS: This study was carried out with 20 patients, who had tennis elbow (lateral epicondylitis). INTERVENTION: Group A (n = 10) had received supervised exercise program. Group B (n = 10) was treated with Cyriax physiotherapy. All patients received three treatment sessions per week for four weeks (12 treatment sessions). OUTCOME MEASURES: Pain was evaluated using a visual analogue scale (VAS), and functional status was evaluated by completion of the Tennis Elbow Function Scale (TEFS) which were recorded at base line and at the end of fourth week. RESULTS: Both the supervised exercise program and Cyriax physiotherapy were found to be significantly effective in reduction of pain and in the improvement of functional status. The supervised exercise programme resulted in greater improvement in comparison to those who received Cyriax physiotherapy. CONCLUSION: The results of this clinical trial demonstrate that the supervised exercise program may be the first treatment choice for therapist in managing tennis elbow.

Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical and ultrasonographical comparison.

The aim of this study was to compare--clinically and ultrasonographically--the therapeutic effects of physical therapy modalities (hot pack, ultrasound therapy, and friction massage), local corticosteroid injection, and extracorporeal shock wave treatment (ESWT) in lateral epicondylitis (LE). Fifty-nine elbows of 59 patients with LE were randomized into three treatment groups receiving either physical therapy, a single corticosteroid injection, or ESWT. Visual analogue scale (VAS) was used to assess pain intensity, Jamar hydraulic dynamometer for grip strength, finger dynamometer for pinch strength (before treatment, on the first, third, and sixth months of treatment). All subjects were also evaluated with ultrasonography before and 6 months after treatment. In all groups, VAS scores of the patients were found to decrease significantly on the first, third, and sixth months of treatment. With respect to grip strength evaluations, the increase after treatment was significant only on the first month in group II; on the first and third months in group I; and on the first, third, and sixth months of treatment in group III. Pinch strength and ultrasonographical findings did not change during follow-up in any group. We imply that physical therapy modalities, corticosteroid injection, and ESWT have favorable effects on pain and grip strength in the early period of LE treatment. The increase in grip strength lasts longer with ESWT. On the other hand, ultrasonographic findings do not change in the first six months of these treatment methods.

Tennis elbow.

INTRODUCTION: Lateral pain in the elbow affects up to 3% of the population, and is considered an overload injury of the extensor tendons of the forearm where they attach at the lateral epicondyle. Although usually self-limiting, symptoms may persist for over 1 year in up to 20% of people. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for tennis elbow? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, autologous whole blood injections, corticosteroid injections, combination physical therapies, exercise, extracorporeal shock wave therapy, iontophoresis, low-level laser therapy, manipulation, non-steroidal anti-inflammatory drugs (oral and topical), orthoses (bracing), platelet-rich plasma injections, pulsed electromagnetic field treatment, surgery, and ultrasound.

Effectiveness of leech therapy in chronic lateral epicondylitis: a randomized controlled trial.

OBJECTIVES: Leech therapy has been found to be effective in osteoarthritis of the knee and hand in previous trials. Chronic epicondylitis is a prevalent pain syndrome with limited treatment options. In this study, we tested whether leech therapy would be beneficial in the symptomatic treatment of chronic lateral epicondylitis. METHODS: Forty patients with manifestation of epicondylitis of at least 1-month duration were randomized to a single treatment with 2 to 4 locally applied leeches or a 30-day course with topical diclofenac. The primary outcome was change of pain sum score on day 7 calculated from 3 visual analog scales for pain during motion, grip, and rest. Secondary outcomes included disability (Disability of the Arm, Shoulder, Hand questionnaire), physical quality of life (Short Form-36), and grip strength. Outcomes and safety were assessed on days -3, 0, 7, and 45. RESULTS: Leeches induced a significantly stronger decrease of the pain score (143.7±36.9 to 95.3±45.1) compared with topical diclofenac (131.6±29.6 to 134.7±70.7; mean difference -49.0; 95% confidence interval,-82.9--15.1; P=0.0075) after 7 days. On day 45, this group difference was reduced (-27.5; confidence interval, -60.8-5.8; P=0.110) due to delayed pain relief with diclofenac. Functional disability showed a stronger decrease in the leech group, which was most prominent after 45 days (P=0.0007). Quality of life increased nonsignificantly in the leech group. Results were not affected by outcome expectation. DISCUSSION: A single course of leech therapy was effective in relieving pain in the short-term and improved disability in intermediate-term. Leeches might be considered as an additional option in the therapeutic approach to lateral epicondylitis.

Augmented soft tissue mobilization vs natural history in the treatment of lateral epicondylitis: a pilot study.

OBJECTIVE: The purpose of this study was to evaluate the effect of augmented soft tissue mobilization (ASTM) on the treatment of lateral epicondylitis. METHODS: This randomized clinical study assessed 27 subjects (12 men and 15 women) with lateral epicondylitis and were divided randomly into 2 groups. The experimental group (n = 15) received ASTM twice a week for 5 weeks. The subjects of the control group (n = 12) received advice on the natural evolution of lateral epicondylitis, computer ergonomics, and stretching exercises. Patient-rated outcome was assessed at baseline and after 6 weeks and 3 months using a visual analog scale and the Patient-Rated Tennis Elbow Evaluation. The function was assessed using the pain-free grip strength at baseline and after 6 weeks. RESULTS: Both groups showed improvements in pain-free grip strength, visual analog scale, and Patient-Rated Tennis Elbow Evaluation. Sample size for larger future randomized clinical trial was 116 participants. CONCLUSION: A larger study investigating the same hypothesis is warranted to detect difference in the effects of these treatments strategies. The study design is feasible, and minor improvements will help to minimize the potential bias.

[Treatment of epicondylitis - a current review]. / Die Therapie der Epicondylitis - eine aktuelle Übersicht.

Lateral epicondylitis or tennis elbow is a common injury, which affects not only people who play tennis but occurs with many different activities. It reflects overuse of the extensor muscles of the forearm. There are some other pathologies which have to be separated from epicondylitis. The choice of different treatments is hard to overlook and there are only a few good clinical trials which support one treatment option by means of evidence based medicine. During the acute phase topical NSAIR, steroid injections, ultrasound and acupuncture are helpful. There is no consensus about the effectiveness of physiotherapy, orthoses, laser, electrotherapy or botulinumtoxininjections. During the chronic phase none of the different treatment modalities is effective according to criterias of evidence based medicine. By now, it has not been proven whether patients profit during that time of physiotherapy, orthoses, extracorporeal shock wave therapy or an operation. Whether orthobiological treatment options may play a role in the future is presently uncertain.

Osteopoiquilosis: a propósito de un caso / No disponible

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

Lateral epicondylitis is a common disorder characterized by pain and tenderness over the lateral epicondyle. It occurs most frequently as a result of minor, unrecognized trauma during sports activities and occupation-related physical activities. The goal of this study was to evaluate the short-, medium-, and long-term effects of corticosteroid injection, autologous blood injection, and extracorporeal shock wave therapy in the treatment of lateral epicondylitis.Sixty patients (32 women, 28 men) with lateral epicondylitis were randomly divided into 3 groups: group 1 received a corticosteroid injection; group 2, an autologous blood injection, and group 3, extracorporeal shock wave therapy. Thomsen provocative testing, upper extremity functional scores, and maximal grip strength were used for evaluation. Outcomes were assessed at 4, 12, 26, and 52 weeks. Corticosteroid injection gave significantly better results for all outcome measures at 4 weeks; success rates in the 3 groups were 90%, 16.6%, and 42.1%, respectively. Autologous blood injection and extracorporeal shock wave therapy gave significantly better Thomsen provocative test results and upper extremity functional scores at 52 weeks; the success rate of corticosteroid injection was 50%, which was significantly lower than the success rates for autologous blood injection (83.3%) and extracorporeal shock wave therapy (89.9%). Corticosteroid injection provided a high success rate in the short term. However, autologous blood injection and extracorporeal shock wave therapy gave better long-term results, especially considering the high recurrence rate with corticosteroid injection. We suggest that the treatment of choice for lateral epicondylitis be autologous blood injection.

Combined multimodal therapies for chronic tennis elbow: pilot study to test protocols for a randomized clinical trial.

OBJECTIVE: The objective of this project was to develop and test protocols for a randomized clinical trial (RCT) of 2 multimodal package therapies for chronic lateral epicondylitis. METHODS: Six participants were enrolled after case review and randomized to 1 of 2 groups (4 in group A and 2 in group B). Group A had high-velocity low-amplitude manipulation, high-voltage pulse galvanic stimulation, counterforce bracing, ice, and exercises, whereas group B had ultrasound, counterforce bracing, and exercise. Both groups had 12 weeks of active care and instructed to restrict usage of the affected elbow. Participants filled out a visual analog scale and the Patient Rated Tennis Elbow Evaluation every week. The pain-free grip strength test was measured at baseline, and at the end of the third, sixth, ninth, and twelfth visits. RESULTS: One participant in group A dropped out before the end of care. Both groups demonstrated changes in all of the outcome variables from the baseline to the end point (12 weeks) of treatment. Sample size for a larger future randomized clinical trial was calculated as n = 246 participants. CONCLUSION: The pilot study demonstrated that the study design is feasible and that patients could be recruited for a 12-week trial of multimodal treatment. A larger trial is warranted in a multicenter setting to detect differences in the effects of these treatment strategies.

Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures.

Lateral and medial epicondylitis are common causes of elbow pain in the general population, with the lateral variety being more common than the medial by a ratio reportedly ranging from 4:1 to 7:1. Initially thought to be an inflammatory condition, epicondylitis has ultimately been shown to result from tendinous microtearing followed by an incomplete reparative response. Numerous nonoperative and operative treatment options have been employed in the treatment of epicondylitis, without the emergence of a single, consistent, universally accepted treatment protocol. Tendon ruptures about the elbow are much less frequent, but result in more significant disability and loss of function. Distal biceps tendon ruptures typically occur in middle-aged males as a result of an event that causes a sudden, eccentric contraction of the biceps. Triceps tendon ruptures are exceedingly rare but usually have a similar etiology with a forceful eccentric contraction of the triceps that causes avulsion of the tendon from the olecranon. The diagnosis of these injuries is not always readily made. Complete ruptures of the biceps or triceps tendons have traditionally been treated surgically with good results. With regard to biceps ruptures, there continues to be debate about the best surgical approach, as well as the best method of fixation of tendon to bone. This article is not meant to be an exhaustive review of the broad topics of elbow tendinopathy and tendon ruptures, but rather is a review of recently published information on the topics that will assist the clinician in diagnosis and management of these conditions.

Combination of manipulation, exercise, and physical therapy for the treatment of a 57-year-old woman with lateral epicondylitis.

OBJECTIVE: This case report presents a simple systematic approach consisting of a 10-week specific sequential multimodal conservative management approach to chronic lateral epicondylitis. CLINICAL FEATURES: A 57-year-old female science teacher experiencing elbow pain for 5 months presented to our multidisciplinary clinic complaining of whole-arm pain extending to the wrist. INTERVENTION AND OUTCOME: In the 10-week protocol, we used high-velocity and low-amplitude manipulation, high-voltage pulsed galvanic stimulation, a hard-padded elbow brace, ice, and exercise, along with restricted use of the affected elbow. The Patient-Rated Forearm Evaluation Questionnaire, currently named as the Patient-Rated Tennis Elbow Evaluation, was used for an outcome measurement. Overall, there was a systematic reduction of pain (92.86%), specific activity (100%), and usual activity (96.87%), and even after 3 weeks of follow-up, we did not notice significant changes in all of the data. CONCLUSIONS: This case study showed the possible beneficial effects of the specific sequential multimodal treatment approach in a patient with resistant chronic lateral epicondylitis.