This is the first study to assess how the Brazilian orthopedist diagnoses and treats lateral epicondylitis. This type of evaluation is important for mapping and comparing the results with the current evidence about diagnosis and treatment, in order to warn about possible discrepancies. In addition, it can serve as a reference for the development of comparative studies, especially when there is no definitive evidence about which are the best interventions, as in the case of LE treatment. Similar surveys have been conducted in other populations of professionals, on how the management of lateral epicondylitis is carried out, and they allow physicians to be aware of that, comparing the found results with the available evidences [23–25].
The diagnosis of lateral epicondylitis (LE) is clinical. Painful palpation of the lateral epicondyle is suggestive of the condition, and specific tests such as the Cozen test and Mill's test can be used, despite the lack of an accuracy study in this regard . The change in grip strength, measured with a dynamometer, with the wrist in flexion and extension, indicates the diagnosis, as normal individuals do not present a difference. A sensitivity of 78% and specificity of 90% were estimated for patients with a 10% loss of strength when extended .
Ultrasonography (US) has a sensitivity of 64.52%, specificity of 85.19%, and an accuracy of 72.73% in comparison to Magnetic resonance (MRI). MRI is the gold standard for diagnostic imaging of LE, associated lesions, and for excluding differential diagnoses, but its cost is still high compared to other methods. Its use is relevant, especially in refractory cases, and when it is desired to have a better assessment of the extent of the lesion in the common extensor tendon origin and associated lesion. Although It is suggested that there is a correlation between the severity of symptoms andchanges in the MRI, the values of those finds still have to be ore elucidated.
Many patients present impact on engaging in physical or work activities and require treatment. Because of the self-limiting nature of the pathology, with resolution of around 90% of the cases within one year , there is consensus that non-surgical treatment should be indicated as the treatment of choice, and our sample corroborated it.
In respect to the use of oral and topical NSAIDs, evidence is limited for drawing conclusions about the benefits or harm in the treatment of LE . Physical therapy treatment was the most commonly recommended modality in our series as well as in similar studies [23, 24]. In a meta-analysis , the benefit of using pain reduction physiotherapy has been demonstrated. Exercises are rarely used in an isolated way and can be done in a concentric, eccentric, or isometric way, with no differences amongst them .
As for the use of orthoses, there are several devices available, with no evidence of effectiveness, for medium and long term, by any. Despite this, its use is often indicated in treatment, more frequently for the Hand surgeons as we verified.
Our results shows that local infiltrations are a major therapeutic arsenal in the treatment of refractory LE. Notwithstanding the main substance chosen by our participants being corticosteroids (CS), there is evidence against the practice. Smidt et al.  concluded that CS infiltration presents improvement in the short term, but the result after one year is better with physiotherapy and a "wait-to-see policy". There is also evidence of improvement in the first month and no difference in the result when compared to placebo at 6 months .
Another study  suggests that even after the publication of high impact articles   contraindicating infiltration of corticosteroids (CS) for treatment, the practice has not yet been abandoned. These articles demonstrate that these infiltrations present improvement in the short term, but less effect, or even a worsening in the medium and long term, compared to other treatments. In the clinical and cost-effectiveness assessment, the use of CS for infiltrations is also contraindicated .
Another survey with orthopedists has shown the use of CS in infiltrations by around 71% of the professionals in the United States . In the United Kingdom, 21% use it routinely for most patients, and only 40% never use it . Whereas in a survey of surgeons from around the world, 38% recommended infiltration with CS as the first line therapy . The result of our work corroborated that despite the evidence, the practice is still vastly used in our country, even more frequently than in other populations.
As alternatives to corticosteroids in infiltrations, the following has been described: botulinum toxin (BT), hyaluronic acid (HA), prolotherapy (PL), local anesthetics, autologous blood (AB), platelet-rich plasma (PRPs). Some systematic reviews reinforce the evidence of improvement of symptoms in the short term with the use of CS infiltrations, but better results in the medium and long term with AB and PRPs , and even better with PL and AH [9, 41]. These same authors also suggest that further studies are needed to confirm the effectiveness of these substances.
Surgical treatment is an option for persistent cases, and has been estimated that around 2% of diagnosed patients will undergo surgical treatment. The study by Sanders et al.  concluded that those that do not get better within 6 months are more likely to be treated surgically. There is no acknowledge superiority between arthroscopic and open techniques in terms of improving function and reducing symptoms, despite a greater number of minor complications with the open technique . In our analysis, Hand specialists perform more open surgical procedures, then others orthopedists.
We can compare our results to those of other populations in the indication of surgical treatment. In the study carried out with upper limb specialists in the USA, 5% of the participants do not recommend surgery, and of those who do, 75% prefer the open technique . In the research with surgeons in the United Kingdom, 11% never recommend surgery, a result similar to that of our paper, with the majority waiting at least 12 months for this recommendation . In the survey of surgeons from all over the world, only 10% of them recommended surgical treatment , nonetheless the treatment time was not evaluated, nor was the first and second line treatment differentiated on those studies.
As limitations of this study, we have the evaluation only from participants of congresses and members of the SBOT. However, this form allows a representative sample of how the Brazilian orthopedist treats the pathology. We also did not include in the study other professionals who can treat LE, such as family doctors, occupational doctors, and rheumatologists. The questions were done in a generic way, as it is very difficult to administer a questionnaire that involves all possible treatment variables, such as patient requirements and symptom intensity.
As a strength of this work, we can relate the diagnosis and treatment options with the evidence in literature. This evaluation allows comparison of the more common practices with the available evidence, in the sense of making professionals aware about for an informed practice. Another positive point is the possibility of comparing the practices with those of other populations, although there are few studies about the subject, such as those already mentioned .