Effects of Prolotherapy Injections and an Exercise Program Used Singly and In Combination for Refractory Tennis Elbow.

Group 1- Physiotherapy and Therapeutic Exercise: a multimodal program comprising education, manual therapy and therapeutic exercise, and a home exercise program. Four, 30 minute physiotherapy sessions will be provided by a qualified physiotherapist over a 4-week period. Specific manual therapy techniques known as Mobilisation with Movement (MWM) will be applied. In addition, three main groups of exercises will be pragmatically prescribed: (a) Sensorimotor retraining of gripping and forearm movements and posture correction will be commenced early in the physiotherapy intervention; (b) progressive resistance exercise for the wrist extensors will be prescribed based on identified strength deficits in LE; (c) exercises geared towards general arm strengthening. Physiotherapists will prescribe exercises based on the participant's capabilities at any given session to allow for optimal exercise volume and load setting without exacerbating pain. The overriding rule for all exercise is that pain should not be provoked during or after exercise, including avoidance of delayed onset muscle soreness. Exercises will be performed in a slow manner with sufficient rest between sets to allow recovery, and correct form and posture emphasised throughout. Supervision of the home program at the commencement of every session and monitoring of exercise diaries by the treating practitioners will be used to facilitate program adherence and emphasise the importance of the exercise and self-treatment program. Group 2- Prolotherapy injection - the injection solution contains 20% glucose and 0.4% lignocaine. Injection sites will be determined by palpation for tenderness over the lateral epicondyle, the supracondylar ridge, the radial head, the common extensor insertion and the lateral collateral and annular ligaments. Each tender area will receive 0.5 to 1.0 ml using a peppering technique with a 25 gauge needle to a total of 2.0 ml. Injections will be given by a Musculoskeletal Medicine practitioner and will be repeated at 4, 8 and 12 weeks after the initial injections, giving a total of 4 treatments, each lasting approximately 30 minutes. Group 3- Combination of 1) Physiotherapy and Therapeutic Exercise and 2) Prolotherapy injection.