Effectiveness of a combined treatment of dry needling with an exercise program in patients with tennis elbow.

INTERVENTION: Dry needling combined with an isometric exercise program. The intervention will be 4‐week intervention program with 2 weekly treatment sessions. ‐Dry needling will be performed once a week on the 1st weekly session using sterilized surgical steel disposable needles (0.3x40mm; APS (Registered Trademark), AGU‐PUNT, S.L., Barcelona, Spain). The technique described by Hong will be used, which consist on fast in and out movements with the needle. The technique will be performed on the muscles of the lateral epicondyle. It will be performed by a physiotherapist with more than 10 years of clinical experience and knowledge on the technique. The duration of this part of the treatment is 10 minutes approximately. ‐The isometric exercise program will be done twice a week. It consists of 3 series of 10 hand‐grip isometric contractions mantained 10 seconds each, and 10 rest seconds between contractions. The force of the hand‐grip will be performed 20% under the forced obtained on the pain free grip strenght test. For the treatment a Riester Minimus (Registered Trademark) II sphygmomanometer will be used. It will be supervised by a physiotherapist. The exercises will take approximately 20 minutes to be performed. ‐During the first weekly session dry needling will be performed first, followed by a 5 minutes rest, and then the exercise program will be performed. For monitoring the adherence of patients to the study an attendance sheet in which they will have to sign each session will be done. ‐Intervention will be performed at Universidad de Alcala. CONDITION: Lateral epicondylalgia PRIMARY OUTCOME: Pain measured with a 100mm visual analogue scale SECONDARY OUTCOME: 1st stretch sensation during writst flexion using a goniometer Elbow muscle activation, assesed by using surface electromyography of elbow Pain free grip strength test using a dynamometer Patient Rated Tennis Elbow Evaluation (PRTEE) Pressure pain threshold using an algometer (Wagner Force DialTM FDK 20) INCLUSION CRITERIA: ‐Lateral epicondylalgia symptoms confirmed with at least 2 of the 4 following test: a) pain during palpation of lateral epicondyle, b) pain on resisted wrist extension, c) pain on resisted middle finger extension, d) pain during hand‐grip. ‐Lateral epicondylalgia symptoms for more than 3 months