Letter to the editor regarding “Nonoperative treatment of lateral epicondylitis: a systematic review and meta-analysis”

Abstract

To the Editor, I read with great interest and would like to congratulate Lapner et al 2 for their interesting systematic review and meta-analysis that contributes to the understanding of the conservative treatment effect in lateral epicondylitis (LE). I would like to emphasize the importance of the article since the consequences are still unclear in terms of adopting the ideal conservative treatment approach for dealing with LE management. The findings of this study aid in the decision-making of clinicians, researchers, academics, policy makers, and ultimately patients. Precisely because of the significant influence that these findings may have on clinical practice and especially in physiotherapy practice, Ι would like to raise some topics that Ι believe might complement the discussions provided by the authors and enhance the interpretation of the study results. Specifically, I would like to report the following: 1. The authors used the term LE. However, lateral elbow tendinopathy (LET) seems to be the most appropriate term to use in clinical practice because terms such as LE make reference to inappropriate etiological, anatomical, and pathophysiological terms. 4 Moreover, the term lateral elbow pain syndrome seems to be an appropriate diagnostic clinical term for persistent LET. 5 2. The study design of Chesterton et al (2011) article [reference 7 in the article] is not a systematic review. 3. The authors wrote in the article “A meta-analysis by Weber et al concluded that there was insufficient evidence to support physiotherapy for the treatment of tennis elbow (39).” However, this article concluded that some electrophysical agents are not effective treatment approaches for the management of LET. The most commonly used and effective physiotherapy approach for LET patients is an exercise program, supervised or in the clinic. The electrophysical agents should not be used as a substitute for exercise but as a supplement to exercise programs for LET management. 4. The authors state “passive treatment such as stretching.” However, stretching is not a passive approach. 5. I suggest using “soft tissue techniques” or “soft tissue manipulation” instead of “massage.” 6. Only studies that compared physiotherapy with a strengthening program compared with no active treatment were included in this meta-analysis article. Can the authors clarify why an active treatment is compared with no active treatment? In the article, the authors wrote “The strict inclusion criteria allowed us to confidently interpret the treatment effect of these individual modalities in isolation.” However, I wonder if the authors believe that LET is a self-limiting condition. LET is not self-limiting and is associated with ongoing pain and disability in a substantial proportion of sufferers. 1 7. Five studies were included in this article on physiotherapy (strengthening) [references 4, 22, 23, 34, 35 in the article]. Patients followed a home exercise program in all included studies. Stasinopoulos and colleagues found that a supervised in-clinic program is a better physiotherapy approach than an in-home exercise program in LET management, even if it is more expensive. 6 Patients fail to comply with the regimen of home exercise programs. 6 8. The study of McQueen et al (2020) [reference 23 in the article] is not a randomized controlled trial. 9. Patients followed not only strengthening exercises but also stretching exercises in 5 included trials [references 4, 22, 23, 34, 35 in the article]. The authors state in the article that stretching was excluded. 10. Patients received deep friction massage in 2 studies (references 35 and 36 in the article). The authors report in the article that massage was excluded. 11. Finally, 4 out of the 5 included trials [references 4, 22, 34, 35 in the article] were conducted before 2010. The study of McQueen et al (2020) [reference 23 in the article] was conducted in 2020 but it is not a randomized controlled trial, as mentioned above. This study should be excluded from the present meta-analysis. The exercise program for the management of LET has been changed in the last decade. Components such as proprioception and neuroplastic training have been added to the recommended exercise protocol for the management of LET. 3 Overall, I trust that the topics raised in this letter might help interpret the findings of the present systematic review and meta-analysis. I acknowledge the difficulties in performing this review study and once again congratulate the authors for their hard work. Disclaimers Funding: No funding was disclosed by the author. Conflicts of interest: The author, his immediate family, and any research foundation with which he is affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.