MR findings in humeral epicondylitis: A systematic review

Purpose: To highlight the importance of meta-analysis in diagnostic imaging by presenting a systematic search of the literature on the accuracy of MR imaging in epicondylitis.

Material and Methods: The literature was comprehensively reviewed to identify studies on MR findings in epicondylitis. Reviewers blind to the clinical diagnoses screened the data according to predetermined inclusion criteria. Data were collected and validity and relevance were assessed on structured forms.

Results: Seven studies including 148 patients with epicondylitis were accepted for the analysis. Eleven asymptomatic contralateral elbows and 29 elbows of healthy volunteers served as controls. The volunteers were distinctly younger than the patients. The MR technique was divergent, and the observed pathological changes also varied. The most frequent alteration was a change in the common extensor tendon signal (90%, 95% confidence interval 84-94%); 14% of the healthy volunteers and 50% of the contralateral elbows displayed the similar alteration.

Conclusion: Small sample size and methodological shortcomings in the original studies make the assessment of MR findings in epicondylitis questionable. There is a need for well-designed studies in which clinical features and occupational backgrounds as well as imaging parameters are carefully documented.

You're the Flight Surgeon: lateral epicondylitis

Wolf SJ. You're the flight surgeon: lateral epicondylitis. Aerosp Med Hum Perform. 2015; 86(12):1077-1080.

Posterolateral Rotatory Apprehension Test in Tennis Elbow

BACKGROUND

Tennis elbow is a syndrome that commonly diagnosed in patient who comes with lateral elbow pain. Instability pain in tennis elbow patient was observed and reported in many previous literatures. Posterolateral rotatory apprehension test was proposed for diagnosis of posterolateral rotatory instability of elbow. However, no review literatures that studied about posterolateral rotatory apprehensions test in tennis elbow.

OBJECTIVE

To find out the relationship between posterolateral rotatory apprehension test and tennis elbow.

MATERIAL AND METHOD

There were 44 patients that were recruited in this study. We examined the posterolateral rotatory apprehension test in tennis elbow patients. The examination was done in our outpatient clinic from March 2012 to April 2012. The data was collected to find out the ratio of negative test in tennis elbow patient.

RESULTS

The results from the posterolateral rotatory apprehension test were negative in 43 patients. The ratio of the negative test result was 98%.

CONCLUSION

A result from posterolateral rotatory apprehension test should be negative in general tennis elbow patients. If this test is used in a tennis elbow patients who are suspected with hidden instability and the result is positive, further evaluation is strongly suggested.

Epicondylitis and corticosteroid injection: fewer cures at one year

Corticosteroid injection provides short-term relief for patients with epicondylitis. However, in a trial lasting one year, corticosteroid injection resulted in a lower complete recovery rate and higher recurrence rate. Physiotherapy appears to improve symptoms in the short-term without affecting outcome at one year.

[Elbow tendinopathy]

The lateral and medial epicondylitis is often manifested in a professional or in a sport context leading to repetitive wrist movements. The diagnosis is primarily clinical. Additional tests are indicated in chronic evolution and in searching for differential diagnoses. Elbow X-ray can be completed with ultrasound or MRI, the most efficient but expensive diagnostic procedure. There is no consensus on treatment. After a period of rest, stretching then strengthening exercises are recommended. Corticosteroid injections may provide a short-term beneficial effect. Platelet-Rich Plasma injections have recently gained notoriety. In case of failure of treatment, surgery is possible, but only in a minority of patients.

Lateral Epicondylitis and Tobacco Use: A Case-Control Study

BACKGROUND

Although lateral epicondylitis (LE) is a very common tendinopathy, we understand little about the etiology of the disease. Tobacco use has been associated with other tendinopathies, and the purpose of this study is to determine if there is an association between the incidence of lateral epicondylitis and tobacco use.

METHODS

We performed a retrospective cohort study of adult patients diagnosed with lateral epicondylitis. Patients from a single orthopaedic surgeon's practice with LE were matched to control patients with other common upper extremity conditions based on age, gender, and occupation. A total of 65 case patients and 217 control patients were included in the study. The incidence of smoking in patients with lateral epicondylitis was compared to the incidence of smoking in the control group.

RESULTS

Of the LE patients, 30/65 (46.2%) were non-smokers, 23/65 (35.4%) were former smokers, and 12/65 (18.5%) were current smokers. Of the control patients, 121/217 (55.8%) were non-smokers, 45/217 (20.7%) were former smokers, and 51/217 (23.5%) were current smokers. The odds of LE patients being former or current smokers compared to control patients were 1.45 times higher, but this was not statistically significant. Among people who did not smoke at the time of presentation, the odds of being a former smoker were 2.28 times higher in LE patients than in controls, which was statistically significant.

CONCLUSIONS

The odds of being a former smoker were significantly higher in patients with lateral epicondylitis compared to patients with other upper extremity conditions. Although it did not reach statistical significance, the odds of being former or current smokers were also higher in the LE group. These results suggest a relationship between smoking history and incidence of lateral epicondylitis, though more research is needed to determine the exact nature of the relationship.

LEVEL OF EVIDENCE

Prognostic, Level III.

Effects of extracorporeal shock wave therapy on functional and strength recovery of handgrip in patients affected by epicondylitis

Extracorporeal shock wave therapy (ESWT) is effective in the treatment of tendinopathy. We designed a prospective observational clinical study to assess the correlation between clinical and functional measures and recovery of strength after ESWT for epicondylitis. We analyzed 26 patients. We measured progressive improvement in visual analogue scale values (p < 0.0005) and Mayo Elbow Performance Index scores (p = 0.004) for the pathologic limb. Monitoring of handgrip failed to reveal changes in values at any follow-up (p > 0.05). We found no correlation between degree of clinical function and muscle deficit during follow-up. After ESWT, there was a tendency toward a decrease in grip strength, especially in the dominant limb. This could be related to the effects of ESWT, which reduces spasticity in painful hypertonic muscles. These data may be useful in defining the expectations for function during ESWT for epicondylitis, particularly for elite athletes.

Elbow tendinopathy

Overuse injuries of the lateral and medial elbow are common in sport, recreational activities, and occupational endeavors. They are commonly diagnosed as lateral and medial epicondylitis; however, the pathophysiology of these disorders demonstrates a lack of inflammation. Instead, angiofibroblastic degeneration is present, referred to as tendinosis. As such, a more appropriate terminology for these conditions is epicondylosis. This is a clinical diagnosis, and further investigations are only performed to rule out other clinical entities after conventional therapy has failed. Yet, most patients respond to conservative measures with physical therapy and counterforce bracing. Corticosteroid injections are effective for short-term pain control but have not demonstrated long-term benefit.

Diagnostic confidence of sonoelastography as adjunct to greyscale ultrasonography in lateral elbow tendinopathy

BACKGROUND

Conventional ultrasonography or magnetic resonance (MR) imaging is commonly performed to obtain information about the severity of the disease, location of the injury, and differential diagnosis. The aim of this research was to investigate the diagnostic confidence of sonoelastography as an adjunct to greyscale ultrasonography in lateral elbow tendinopathy.

METHODS

A single experienced physiatrist performed greyscale ultrasonography and sonoelastography in 28 patients (9 men, 19 women; mean age, 48.5 years; age range, 36-67 years) with unilateral symptoms of lateral elbow tendinopathy; the asymptomatic elbows were used as controls. Greyscale images were described as normal, tendinosis, partial-thickness tear, and full-thickness tear. Sonoelastographic images of the common extensor tendon were analyzed qualitatively (scoring of the elastic spectrum) and quantitatively (based on a color histogram).

RESULTS

Both the imaging methods had high sensitivity, specificity, and accuracy for diagnosing lateral elbow tendinopathy. Considering the clinical diagnosis of lateral elbow tendinopathy, sonoelastography showed significantly higher diagnostic accuracy (96.4%) than ultrasonography (89.5%, P < 0.01). Quantitative analysis showed objective interpretation of the sonoelastographic images that revealed greater intensity of green and blue pixels in symptomatic elbows (P < 0.01).

CONCLUSION

Sonoelastography increases diagnostic confidence in tennis elbow pathology over greyscale ultrasonography alone and may be an additional powerful diagnostic tool in cases of lateral elbow tendinopathy with inconclusive greyscale ultrasonographic findings.

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.

[Treatment of refractory lateral epicondylitis with modified Nirschl surgical technique]

OBJECTIVE

To investigate the clinical effects of modified Nirschl surgical techniique in treating refractory lateral epicondylitis.

METHODS

From March 2009 to January 2011,21 patients (21 elbows) with refractory lateral epicondylitis were treated in our hospital. There were 8 males and 13 females,ranged in age from 25 to 59 years with an average of (48.3+/-13.4) years and the duration time from 8 to 33 months with an average of (17.1+/-7.7) months;affected position in dominant sides of 16 cases and non-dominant sides of 5 cases. The patients had already received multiple non-operative treatments. Modified Nirschl surgical technique was performed,and operative origination from origin of musculus extensor carpi radialis brevis to discard process with small incision, the process place of extensor digitorum communis would be removed. The incisions were nursed by ice compress for 2 days after operation. Range of motion (ROM) and strengthening exercise of elbow joints started at the 1 week after plaster slab fixation; ROM and strengthening exercise of wrist joints also started at the 2 week after fixation. The pain, power of gripping and patient staisfaction were recorded after operation. Verhaar scaling were used to estimate the recovery.

RESULTS

Seventeen patients were followed up from 13 to 22 months with an average of 16.3 months. According to Verhaar standard, 15 cases obtained excellent results and 2 good. No postoperative complication such as instability was found.

CONCLUSION

Modified Nirschl surgical technique is an effective method in treating refractory lateral epicondylitis but correct to diagnosis and exclusion the coexisting diseases,accurate removal the process are important guarantee.

Prevalence of epicondylitis, rotator cuff syndrome, and low back pain in Latino poultry workers and manual laborers

BACKGROUND

The goal of this study is to improve understanding of immigrant Latino manual workers' occupational health, focusing on upper body musculoskeletal injury.

METHODS

Physical exams were conducted with a representative sample of 516 Latino poultry workers and manual laborers in western North Carolina; outcome measures were prevalence of epicondylitis, rotator cuff syndrome, and low back pain.

RESULTS

Low back pain (n = 89; 17.2%) and rotator cuff syndrome (n = 76; 14.7%) indicated by physical exam was common. Epicondylitis was less common, but still frequent (n = 30; 5.8%). Prevalence of each outcome did not differ between poultry processing workers and other manual workers. Workers >40 years old had greater incidence of rotator cuff syndrome and epicondylitis.

CONCLUSIONS

Epicondylitis, rotator cuff syndrome, and low back pain are common in immigrant Latino workers, and may negatively impact long-term health and contribute to occupational health disparities.

[Update in Current Care guidelines: repetitive strain injuries of the hand and forearm]

Repetitive strain injuriesof the upper extremities refer to pain in the forearm, wrist and hand, caused by excessive strain. Diagnoses include tenosynovitis, epicondylitis and carpal tunnel syndrome. Treatment is aimed at alleviating pain, restoring normal physical functioning and maintain ability to work. Preventive interventions have shown some attenuation of discomfort but no effects on disease prevalance or sick leave days. Return to work interventions seem to decrease length of sickness absences. Part time work has hastened return to work and decreased sickness absences in musculoskeletal disorders.

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.

Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical-radiologic correlation

The diagnosis of lateral epicondylitis is often straightforward and can be made on the basis of clinical findings. However, radiological assessment is valuable where the clinical picture is less clear or where symptoms are refractory to treatment. Demographics, aspects of clinical history, or certain physical signs may suggest an alternate diagnosis. Knowledge of the typical clinical presentation and imaging findings of lateral epicondylitis, in addition to other potential causes of lateral elbow pain, is necessary. These include entrapment of the posterior interosseous and lateral antebrachial cutaneous nerves, posterolateral rotatory instability, posterolateral plica syndrome, Panner's disease, osteochondritis dissecans of the capitellum, radiocapitellar overload syndrome, occult fractures and chondral-osseous impaction injuries, and radiocapitellar arthritis. Knowledge of these potential masquerades of lateral epicondylitis and their characteristic clinical and imaging features is essential for accurate diagnosis. The goal of this review is to provide an approach to the imaging of lateral elbow pain, discussing the relevant anatomy, various causes, and discriminating factors, which will allow for an accurate diagnosis.

MRI and arthroscopy correlations of the elbow: a case-based approach

The number of elbow arthroscopies and indications for the procedure have increased significantly since the advent of modern elbow arthroscopy in the 1980s. In addition to the patient history, physical examination, and plain radiography, MRI is an important tool for the clinician in diagnosing several pathologies within and around the elbow. Understanding the pathophysiology and clinical presentation and being familiar with the MRI characteristics of a variety of elbow conditions will assist the physician in making an accurate diagnosis and help guide appropriate treatment.

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.

[Epicondylitis--diagnostics and treatment]

Shortcomings of tennis elbow treatment have raised medical interest in pathomechanics of this condition. In 2009, a new theoretic model was proposed, one that has integrated the current knowledge about tennis elbow pathophysiology, with aim to improve the effectiveness of therapeutic methods. It was suggested that tennis elbow patients should be grouped by severity of local tendon pathology, change in pain perception and degree of motor apparatus malfunction when deciding on the most suitable treatment method or when designing scientific research on the subject. It is believed that by employing detailed diagnostics of these lesions (either separate or clustered) in order to confirm or eliminate their presence, the effectiveness of their treatment should increase.

Elbow arthroscopy: setup, portal placement, and simple procedures

Elbow arthroscopy has become an accepted treatment for numerous elbow conditions, including loose bodies, lateral epicondylitis, contractures, painful osteophytes, synovitis, osteochondritis dissecans, synovial plica, and osteoarthritis. It is absolutely necessary that the treating surgeon have complete knowledge of elbow anatomy. Three options exist for patient positioning: supine, prone, and lateral decubitus. Standard arthroscopic probes, grasping forceps, punches, and motorized shavers and burrs are used in the procedure. Retractors are essential for visualizing, exposing, and protecting nerves. Specially designed capsular biters can be used to develop a plane between the capsule and the surrounding soft tissues to facilitate capsulotomy and capsulectomy. Among elbow arthroscopists, the sequence of portal placement varies; however, there is little variation in the exact location of portal placement because of neurovascular constraints. Loose body removal and extensor carpi radialis brevis release for lateral epicondylitis are common procedures suitable for the beginning arthroscopist. For beginning and advanced procedures, the surgeon's skill and competence must be at a level consistent with the procedure to avoid complications.