Upper limb muscle imbalance in tennis elbow: a functional and electromyographic assessment

The effect of lateral epicondylosis on upper limb mechanical parameters

BACKGROUND

Lateral epicondylosis is a prevalent and costly musculoskeletal disorder characterized by degeneration of the common extensor tendon origin at the lateral epicondyle. Grip strength is commonly affected due to lateral epicondylosis. However, less is known about the effect of lateral epicondylosis on other functional parameters such as ability to react to rapid loading.

METHODS

Twenty-nine lateral epicondylosis participants and ten controls participated in a case-control study comparing mechanical parameters (mass, stiffness and damping), magnetic resonance imaging signal intensity and grip strength of injured and uninjured limbs. A mixed effects model was used to assess the effect of dominance and injury on mechanical parameters and grip strength.

FINDINGS

Significant effect of injury and dominance was observed on stiffness, damping and grip strength. An injured upper limb had, on average, 18% less stiffness (P<0.01, 95% CI [9.8%, 26%]), 21% less damping (P<0.01, 95% CI [11%, 31%]) and 50% less grip strength (P<0.01, 95% CI [37%, 61%]) than an uninjured upper limb. The dominant limb had on average 15% more stiffness (P<0.01, 95% CI [8.0%, 23%], 33% more damping (P<0.01, 95% CI [22%, 45%]), and 24% more grip strength (P<0.01, 95% CI [6.6%, 44%]) than the non-dominant limb.

INTERPRETATION

Lower mechanical parameters are indicative of a lower capacity to oppose rapidly rising forces and quantify an important aspect of upper limb function. For individuals engaged in manual or repetitive activities involving the upper limb, a reduction in ability to oppose these forces may result in increased risk for injury or recurrence.

Normal shoulder muscular activation and co-ordination during a shoulder elevation task based on activities of daily living: an electromyographic study

Studies of normal shoulder function have often failed to consider the inter-relationship between different muscle groups in activities relevant to daily life. Upper limb functional status was assessed in 12 healthy male volunteers using the Functional Impairment Test-Hand, Neck, Shoulder and Arm test (FIT-HaNSA). Electromyography was then used to study the activity and coordination of 13 muscles (10 by surface electrodes, 3 by fine-wire intramuscular electrodes) around the shoulder during a dynamic movement task based on the shelf-lifting task in FIT-HaNSA. Muscles were grouped for analysis into deltoid (anterior, middle, and posterior divisions), adductors (latissimus dorsi and teres major), rotator cuff (supraspinatus, infraspinatus, and subscapularis), and elbow flexor (brachioradialis, biceps brachii) groups. There were no significant inter-session effects. Using cross-correlation analysis to investigate the whole time-course of activation, there were highly significant positive correlations (p < 0.001) between the deltoid and rotator cuff, the deltoid and adductor and the adductor and rotator cuff groups, and a significant negative correlation between the deltoid and elbow flexor groups (p = 0.031). We conclude that the deltoid, adductor, and rotator cuff muscles all contribute to the muscular component of glenohumeral joint stability. Muscular stability can be adapted as required to meet task-specific demands.

Effect of lateral epicondylosis on grip force development

STUDY DESIGN

Case-Control.

INTRODUCTION

Although it is well known that grip strength is adversely affected by lateral epicondylosis (LE), the effect of LE on rapid grip force generation is unclear.

PURPOSE OF THE STUDY

To evaluate the effect of LE on the ability to rapidly generate grip force.

METHODS

Twenty-eight participants with LE (13 unilateral and 15 bilateral LE) and 13 healthy controls participated in this study. A multiaxis profile dynamometer was used to evaluate grip strength and rapid grip force generation. The ability to rapidly produce force is composed of the electromechanical delay and rate of force development. Electromechanical delay is defined as the time between the onset of electrical activity and the onset of muscle force production. The Patient-rated Tennis Elbow Evaluation (PRTEE) questionnaire was used to assess pain and functional disability. Magnetic resonance imaging was used to evaluate tendon degeneration.

RESULTS

LE-injured upper extremities had lower rate of force development (50 lb/sec, confidence interval [CI]: 17, 84) and less grip strength (7.8 lb, CI: 3.3, 12.4) than nonnjured extremities. Participants in the LE group had a longer electromechanical delay (- 59% , CI: 29, 97) than controls. Peak rate of force development had a higher correlation (r = 0.56; p<0.05) with PRTEE function than grip strength (r = 0.47; p<0.05) and electromechanical delay (r = 0.30; p>0.05) for participants with LE. In addition to a reduction in grip strength, those with LE had a reduction in rate of force development and an increase in electromechanical delay.

CONCLUSIONS

Collectively, these changes may contribute to an increase in reaction time, which may affect risk for recurrent symptoms. These findings suggest that therapists may need to address both strength and rapid force development deficits in patients with LE.

LEVEL OF EVIDENCE

3B.

Virtual Exertions: a user interface combining visual information, kinesthetics and biofeedback for virtual object manipulation

Virtual Reality environments have the ability to present users with rich visual representations of simulated environments. However, means to interact with these types of illusions are generally unnatural in the sense that they do not match the methods humans use to grasp and move objects in the physical world. We demonstrate a system that enables users to interact with virtual objects with natural body movements by combining visual information, kinesthetics and biofeedback from electromyograms (EMG). Our method allows virtual objects to be grasped, moved and dropped through muscle exertion classification based on physical world masses. We show that users can consistently reproduce these calibrated exertions, allowing them to interface with objects in a novel way.

Interactive effects of acute experimental pain in trapezius and sored wrist extensor on the electromyography of the forearm muscles during computer work

We investigated the interactive effects of shoulder pain and wrist extensor muscle soreness on surface electromyography (EMG) during computer mouse work. On day one, subjects (N = 12) performed computer work with/without acute muscle pain induced in the trapezius muscle. Subsequently, eccentric exercise was performed to induce delayed onset muscle soreness (DOMS) in wrist extensor muscles. In presence of DOMS on day two, computer work recordings with/without pain were repeated. EMG signals were recorded from the descending part of trapezius bilaterally, flexor carpi ulnaris and extensor carpi radialis brevis. Experimental muscle pain in trapezius led to a decrease in the muscular activity of the wrist extensor (P < 0.02) and decreased the relative rest time in the wrist flexor even in presence of DOMS (P < 0.01). The present result suggests that shoulder pain plays a role in the coordination of wrist flexors and extensors during computer work.

Força de preensão manual de atletas tenistas avaliada por diferentes recomendações de teste

A avaliação da força de preensão manual (FPM) em tenistas competitivos deve ser realizada devido à assimetria que o jogador pode desenvolver. Para avaliar a FPM, profissionais utilizam dois protocolos diferentes (das Sociedades Americana e Europeia). Os objetivos deste estudo foram comparar a FPM usando a técnica do European Test of Physical Fitness Handbook (Eurofit) e da American Society of Hand Therapists (ASHT), bem como verificar a FPM entre o lado dominante/contralateral e comparar a FPM entre as idades em atletas de tênis da categoria infanto-juvenil. Participaram do estudo 137 tenistas do gênero masculino e 45 do feminino, todos com idade entre oito e 18 anos. Para avaliar a FPM, segundo as recomendações da Eurofit e ASHT, foi utilizado um dinamômetro manual (Jamar). Nenhum dos sujeitos avaliados apresentava qualquer lesão que pudesse comprometer o teste. Os resultados mostram que não há diferença na FPM entre os posicionamentos recomendados pela Eurofit e ASHT para medir a FPM independente do gênero. A curva sigmoide foi a que melhor se adequou para regressão da FPM e idade em ambos os gêneros sendo que para o masculino a FPM tem maior inclinação aos 11 anos, já para o feminino a maior inclinação é aos 10 anos. Além disso, a partir dos 14 anos, o lado dominante dos atletas masculinos apresentou maior FPM que o lado não dominante; contudo, essa assimetria não ocorreu no feminino em qualquer idade até os 18 anos.

New Assessment of Forearm Strength: Reliability and Validity

OBJECTIVE. The objective was to determine the reliability of a portable forearm strength hydraulic dynamometer with a doorknob handle and assess its validity compared with a Cybex 6000 (Cybex International, Inc., Medway, MA) isometric torque assessment.

METHOD. Eighteen volunteers (with a total of 30 forearms) participated in this one-session methodological study to determine the intra- and interrater reliability and criterion validity of a forearm dynamometer.

RESULTS. Intrarater reliability for both assessors for pronation was (intraclass correlation coefficient [ICC]3,1 = .937–.961) and for supination was (ICC3,1 = .923–.968). Interrater reliability for pronation was ICC3,2 = .927 and for supination was ICC3,2 = .847. Criterion validity of the Baseline hydraulic dynamometer (Fabrication Enterprises Inc., White Plains, NY) compared with the Cybex 6000 was .574–.664 for pronation and .749–.750 for supination.

CONCLUSION. The Baseline hydraulic dynamometer with a more functional doorknob handle had good intra- and interrater reliability and demonstrated moderate validity compared with Cybex 6000 strength testing.

Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: a protocol for a randomised control trial with placebo comparison

Background

Corticosteroid injection and physiotherapy are two commonly prescribed interventions for management of lateral epicondylalgia. Corticosteroid injections are the most clinically efficacious in the short term but are associated with high recurrence rates and delayed recovery, while physiotherapy is similar to injections at 6 weeks but with significantly lower recurrence rates. Whilst practitioners frequently recommend combining physiotherapy and injection to overcome harmful effects and improve outcomes, study of the benefits of this combination of treatments is lacking. Clinicians are also faced with the paradox that the powerful anti-inflammatory corticosteroid injections work well, albeit in the short term, for a non-inflammatory condition like lateral epicondylalgia. Surprisingly, these injections have not been rigorously tested against placebo injections. This study primarily addresses both of these issues.

Methods

A randomised placebo-controlled clinical trial with a 2 × 2 factorial design will evaluate the clinical efficacy, cost-effectiveness and recurrence rates of adding physiotherapy to an injection. In addition, the clinical efficacy and adverse effects of corticosteroid injection beyond that of a placebo saline injection will be studied. 132 participants with a diagnosis of lateral epicondylalgia will be randomly assigned by concealed allocation to one of four treatment groups – corticosteroid injection, saline injection, corticosteroid injection with physiotherapy or saline injection with physiotherapy. Physiotherapy will comprise 8 sessions of elbow manipulation and exercise over an 8 week period. Blinded follow-up assessments will be conducted at baseline, 4, 8, 12, 26 and 52 weeks after randomisation. The primary outcome will be a participant rating of global improvement, from which measures of success and recurrence will be derived. Analyses will be conducted on an intention-to-treat basis using linear mixed and logistic regression models. Healthcare costs will be collected from a societal perspective, and along with willingness-to-pay and quality of life data will facilitate cost-effectiveness and cost-benefit analyses.

Conclusion

This trial will utilise high quality trial methodologies in accordance with CONSORT guidelines. Findings from this study will assist in the development of evidence based practice recommendations and potentially the optimisation of resource allocation for rehabilitating lateral epicondylalgia.

Trial registration

Australian New Zealand Clinical Trials Register ACTRN12609000051246