[Elbow pain]

Pain and disability in the elbow are not as common as in the neck, shoulder or wrist, for example. The elbow may, however, present disorders that may in a prolonged state be difficult and cause significant loss of working capacity. These include epicondylitis, osteoarthritis and entrapment of the ulnar nerve.

Steroid injection in lateral epicondylar pain

What is the evidence for using steroid injection to treat lateral epicondylar pain in the general practice setting? In reviewing four randomised controlled trials, this article concludes that steroid injection is indicated if rapid pain relief is desired in the short term. The evidence for steroid injection in the long term is less clear.

[Tennis elbow (lateral epicondylitis)--assessment and treatment]

Tennis elbow typically presents as pain and localized tenderness at the lateral aspect of the elbow. It is the most common diagnosis related to the elbow. Microtrauma at the vicinity of the Extensor Carpi Radialis Brevis muscle is postulated to be the cause of this clinical entity. Initial treatment should be conservative and is successful in up to 90% of cases. Modalities such as patient education, physiotherapy, use of splints, anti-inflammatory medication, complementary medicine and eventually local injections are all acceptable treatment methods. Surgical treatment of tennis elbow should be used only as a last resort. Both open and arthroscopic methods are acceptable and their results are considered to be excellent.

[The current state of knowledge about pathomechanism of tennis elbow]

The term tennis elbow applies to the state in which the patient feels pain in the area of lateral epicondyle and concomitantly suffers from strength disorders together with diminished capability of the upper limb. Even a very brief look at the specialist literature reveals that there is a number of terms for this particular pain unit. Throughout many years this pain was linked with the inflammation of the common extensors tendon. Presently there is a widespread agreement that this painful condition is connected with the degeneration in the area of common extensors tendon, in particular the extensor carpi radialis brevis. A closer consideration of the pathomechanism of the tennis elbow points to the fact that this seemingly simple pain unity is a complex problem. Moreover, it shows how important the nuances in patients opinion are and how such details can influence not only the diagnose but also the treatment.

[Industrial manufacturing of the wool: pathology secondary to the biomechanical involvement of the upper limbs and the course in relation to work tasks]

In years 2003-2005, 1248 laborers of Zegna Baruffa - Lane Borgosesia Company (establishment of Borgosesia and Vallemosso) have been visited and we selected 102 cases of pathology from upper extremity work-related musculoskeletal disorders in the units with working risk. Subsequently from April 2005 to May 2006 we have controlled the clinical evolution of the enlisted laborers and we noted that in 54% of the cases the clinical symptomatology has been resolved with a rest works and a correct therapy. The diagnosis, the treatment and the change of working duty can resolve a meaningful number of clinical cases.

Lateral epicondylitis: review and current concepts

Lateral epicondylitis is a painful and functionally limiting entity affecting the upper extremity and is frequently treated by hand surgeons. The anatomic basis of the injury to the extensor carpi radialis brevis origin appears to be multifaceted, involving hypovascular zones, eccentric tendon stresses, and a microscopic degenerative response. Although many treatments have been advocated, there is little clear consensus on which modality works best, for both conservative and operative options. In this article, we present an overview of this difficult problem and an evidence-based review of treatment choices.

Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment

Lateral epicondylitis (tennis elbow) is the most frequent type of myotendinosis and can be responsible for substantial pain and loss of function of the affected limb. Tennis biomechanics, player characteristics and equipment are important in preventing the condition. This article presents an overview of the current knowledge on lateral epicondylitis, and focuses on treatment strategies. Conservative and surgical treatment options are discussed, and recent techniques are outlined.

Effect of elbow position on grip strength in the evaluation of lateral epicondylitis

PURPOSE

This study evaluated the maximum grip strength in a position of elbow extension versus flexion as a diagnostic tool in the assessment of a patient with suspected lateral epicondylitis (LE).

METHODS

From our database we identified 81 patients with grip strength measurements and the diagnosis of LE. From these patient records we collected grip strength measurements with the elbow in full extension and with the elbow in 90 degrees of flexion for the affected and the healthy extremity. We then compared 2 values: the pretreatment grip strength in flexion and extension for the affected extremity and the pretreatment grip strengths of the nonaffected extremity compared with the affected extremity. Grip strengths were compared with paired and unpaired 2-tailed t tests.

RESULTS

Grip strength was no different in flexion and extension for the healthy extremity and 29% stronger in flexion than in extension for the affected extremity. The affected arm averaged 50% of the strength of the healthy arm in extension and 69% of the strength of the healthy arm in flexion. These differences were statistically significant. An 8% difference in grip strength between flexion and extension was found to be 83% accurate in distinguishing the affected from the unaffected extremities.

CONCLUSIONS

The measurement of extension grip strength is a useful objective tool to aid in the diagnosis of LE. In patients with LE, the grip strength decreases as one moves from a position of flexion to a position of extension.

The role of physical examinations in studies of musculoskeletal disorders of the elbow

OBJECTIVES

To present data on pain and physical findings from the elbow region, and to discuss the role of diagnostic criteria in epidemiological studies of epicondylitis.

METHODS

From a cohort of computer workers a subgroup of 1369 participants, who reported at least moderate pain in the neck and upper extremities, were invited to a standardised physical examination. Two independent physical examinations were performed-one blinded and one not blinded to the medical history. Information concerning musculoskeletal symptoms was obtained by a baseline questionnaire and a similar questionnaire completed on the day of examination.

RESULTS

349 participants met the authors' criteria for being an arm case and 249 were elbow cases. Among the 1369 participants the prevalence of at least mild palpation tenderness and indirect tenderness at the lateral epicondyle was 5.8%. The occurrence of physical findings increased markedly by level of pain score. Only about one half with physical findings fulfilled the authors' pain criteria for having lateral epicondylitis. A large part with physical findings reported no pain at all in the elbow in any of the two questionnaires, 28% and 22%, respectively. Inter-examiner reliability between blinded and not blinded examination was found to be low (kappa value (0.34-0.40)).

CONCLUSION

Very few with at least moderate pain in the elbow region met common specific criteria for lateral epicondylitis. The occurrence of physical findings increased markedly by level of pain score and the associations were strongest with pain intensity scores given just before the examination. Physical signs were commonly found in subjects with no pain complaints. No further impact was achieved if the physical examination was not blinded to the medical history. Furthermore, the authors propose that pain, clinical signs and disability are studied as separate outcomes, and that the diagnoses of lateral epicondylitis should be used only for cases with classical signs of inflammation reflected by severe pain, which for example conveys some disability.

Validation of the Patient-rated Tennis Elbow Evaluation Questionnaire

The aim of this study was to determine the reliability, validity, and sensitivity of the Patient-rated Tennis Elbow Evaluation (PRTEE) Questionnaire in 78 tennis playing subjects who had chronic, unilateral, MRI-confirmed lateral elbow tendinopathy and who concomitantly participated in an outcome study. The PRTEE results were compared with results of the Visual Analog Scale (VAS); the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire; the Roles and Maudsley score; and the Upper Extremity Function Scale. Questionnaires were completed at baseline and 12 weeks. Reliability and internal consistency were excellent (PRTEE pain subscale, 0.94; PRTEE specific activities subscale, 0.93; PRTEE usual activities, 0.85). Correlations were good between the PRTEE subscales and total scale and the VAS and DASH. Standardized response means (SRM) were higher in the PRTEE (SRM=2.1) than in the other outcome measures (SRM, 1.5-1.7). The PRTEE was a reliable, reproducible, and sensitive instrument for assessment of chronic lateral elbow tendinopathy in a tennis playing cohort. It was at least as sensitive to change as the other outcome tools tested. The PRTEE may become the standard primary outcome measure in research of tennis elbow.

Tennis elbow: blending basic science with clinical practice

Tennis elbow defines a condition of varying degrees of pain or point tenderness on or near the lateral epicondyle. It is prevalent in individuals who perform a combination of forceful and repetitive activities including athletes and wheelchair users. The most common work-related disorder at the elbow is tennis elbow. Histopathological findings indicate that tennis elbow is a degenerative condition, called tendinosis, of the common extensor tendon, with the extensor carpi radialis brevis tendon more commonly implicated as the primary location of tendinosis. Despite the absence of inflammation, patients with tennis elbow still present with pain. Neurochemicals including glutamate, substance P, and calcitonin gene-related peptide have been identified in patients with chronic tennis elbow and in animal models of tendinopathy. Their presence provides an alternative mechanism for pain mediation. Based on what is known about tissue changes within chronic tendinopathies, implications for therapy including examination and interventions are discussed.

A unified approach to radial tunnel syndrome and lateral tendinosis

Two of the most common diagnoses assigned to patients presenting with lateral elbow and proximal forearm pain are lateral tendinosis and radial tunnel syndrome. Traditionally, these 2 conditions have been treated as distinct and separate entities with most patients being diagnosed with either one or the other, but not both. The extensor carpi radialis brevis (ECRB) and, to a lesser the degree, a portion of the extensor digitorum communis that form the conjoined lateral extensor tendon are thought to be primarily responsible for the excessive traction that induces lateral tendinosis (a degenerative process of microtears in the tendon with impaired healing), but the supinator blends with these same fibers and shares a role in the pathology. The supinator, primarily the arcade of Frohse, has been thought to play the majority role in compressing the posterior interosseous nerve in radial tunnel syndrome, but the undersurface thick tendon of the ECRB may also cause substantial nerve compression. Reduction of the linear tension transmitted by the ECRB is the common element in the various surgical treatments for lateral tendinosis, performed anywhere from directly at the lateral epicondyle to the distal myotendinous junction. Nerve decompression by division of fascial bands is the goal in surgery for radial tunnel syndrome. These 2 surgical approaches need not be mutually exclusive. In fact, this separation of the 2 clinical entities may play a role in the unpredictable results reported in the literature. This article presents a unified approach to treating both pathologies simultaneously including short-term clinical results.

Musculoskeletal injuries in tennis

Tennis is popular in the United States, with millions participating in the sport. Unlike many other sports, young, middle-aged, and elderly persons are actively playing tennis. Most injuries that are seen are secondary to overuse. Faulty stroke mechanics are often involved in the development of specific injuries seen in tennis players. Fortunately, most injuries respond to conservative treatment and do not require surgery. Most players are able to return to their previous level of activity after appropriate treatment.

Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening

The objective of this study was to evaluate the effectiveness of eccentric strengthening. Ninety-four subjects (50 men) with chronic lateral epicondylitis were allocated randomly into three groups: stretching, concentric strengthening with stretching, and eccentric strengthening with stretching. Subjects performed an exercise program for six weeks. All three groups received instruction on icing, stretching, and avoidance of aggravating activities. The strengthening groups received instruction on isolated concentric and eccentric wrist extensor strengthening, respectively. At six weeks, significant gains were made in all three groups as assessed with pain-free grip strength, Patient-rated Forearm Evaluation Questionnaire, Disabilities of the Arm, Shoulder, and Hand questionnaire, Short Form 36, and visual analog pain scale. No significant differences in outcome measures were noted among the three groups. Although there were no significant differences in outcome among the groups, eccentric strengthening did not cause subjects to worsen. Further studies are needed to assess the unique effects of a more intense or longer eccentric strengthening program for patients with lateral epicondylitis.