Management of lateral epicondylitis: current concepts

Tennis elbow: associated psychological factors

BACKGROUND

The etiology of tennis elbow is multifactorial. Overuse of the wrist extensors along with anatomic factors, such as flexibility problems, aging, and poor blood circulation, may play a role. This study investigated whether patients with tennis elbow have a different psychological profile compared with healthy controls.

METHODS

Patients with clinical signs of tennis elbow, consulting at the Ghent University Hospital between September 2015 and January 2017, were offered a paper-and-pencil questionnaire about Big Five personality traits, perfectionism, anxiety, depression, work satisfaction, and working conditions. Healthy controls in the same risk group were offered the same questionnaires.

RESULTS

We recruited 69 patients (35 men, 34 women) and 100 controls (44 men, 56 women). Tennis elbow patients scored significantly lower on the personality traits extraversion and agreeableness. Men, in particular, scored significantly higher on perfectionism and were more likely to develop an anxiety disorder or a depression. Concerning work, patients indicated a significantly higher workload (especially men) and a significantly lower autonomy (especially women). Female patients also indicated less contact with colleagues. However, work satisfaction was relatively high in both groups.

CONCLUSION

The results suggest that there is a relationship between complaints related to tennis elbow and psychological characteristics.

Ultrasonic Percutaneous Tenotomy of Common Extensor Tendons for Recalcitrant Lateral Epicondylitis

Tennis elbow is a common musculoskeletal condition affecting middle-aged patients with symptoms usually lasting from 6 months to 2 years. The vast majority of individuals will respond to conservative therapy; however, some will require surgical intervention. A new treatment system has been developed for use with ultrasound guidance in the ultrasonic microresection of tendinopathic tissue. This technology has been implemented in the TX1 Tissue Removal System and is used to treat various tendinopathies by debridement using targeted ultrasonic energy. We describe the surgical technique for the TX1 system as well as provide pain and functional outcome scores for a series of patients with recalcitrant lateral epicondylitis treated with percutaneous tenotomy with ultrasonic energy utilizing ultrasound guidance.

Epidemiology and Disease Burden of Lateral Epicondylitis in the USA: Analysis of 85,318 Patients

BACKGROUND

National rates of lateral epicondylitis and surgical treatment are poorly defined. Disease burden of lateral epicondylitis (LE) continues to increase annually. Further study is necessary to optimize treatment algorithms to reduce associated health-care expenditures.

QUESTIONS/PURPOSES

The purpose of this study is to review the annual incidence of LE, surgical rates, and associated health-care costs in a population setting.

METHODS

A national database was queried for LE from 2007 to 2014. Surgical cases were identified and annual rates were recorded. Demographic and epidemiologic data were reported with descriptive statistics, while trends over time were analyzed using linear regression.

RESULTS

Eighty-five thousand three hundred eighteen cases of LE were identified. The annual incidence per 10,000 patients remained constant (p = 0.304). The proportion of diagnoses in patients <65 years decreased (p ≤ 0.002) and ≥65 years increased (p < 0.001) over the study period. One thousand six hundred ninety-four patients (2%) required operative treatment. The annual rate of surgical intervention remained constant (p = 0.623). The proportion of patients <40 years requiring surgery decreased (p < 0.001) as the proportion of patients ≥65 years needing surgery increased (p = 0.003). Total reimbursement for LE procedures during the study period was $7,220,912. Average per-patient reimbursement was $4263. Both annual total reimbursement (p = 0.006) and per-patient reimbursement rates (p = 0.002) significantly increased.

CONCLUSION

The annual incidence of LE and rate of surgical intervention have remained constant from 2007 to 2014. The proportion of patients over >65 years diagnosed with, and receiving surgical treatment for, LE has significantly increased in recent years. Total reimbursement and average per-patient reimbursement have steadily risen, demonstrating the increasing burden of cost on the health-care system.

Efficacy of peloid therapy in patients with chronic lateral epicondylitis: a randomized, controlled, single blind study

The aim of this study was to assess the effect of peloid on pain, functionality, daily life activities, and quality of life of lateral epicondylitis (LE) patients. In this randomized, controlled, single-blind study, 75 patients who were diagnosed with chronic LE were enrolled to the study. Patients were randomized into two groups using the random number table. The patients in the first group (group 1) (n = 33), were given lateral epicondylitis band (LEB) (during the day for 6 weeks) + peloid therapy (five consecutive days a week for 2 weeks), and the second group (group 2) (n = 32), received LEB treatment alone. The patients were assessed by using Patient Rated Tennis Elbow Evaluation (PRTEE) and Nottingham Health Profile (NHP). The data were obtained before treatment (W0), immediately after treatment (W2), and 1 month after treatment (W6). In analysis of the collected data, the Wilcoxon signed rank test for intra-group comparisons and Mann-Whitney U test for comparisons between groups were used. Both in groups 1 and 2, there was a statistically significant improvement in all the evaluation parameters at W2 and W6 when compared to W0 (p < 0.05). In comparison of difference scores between groups, although there was no statistically significant difference between the two groups at W2 when compared to W0 (p > 0.05), a statistically significant difference was found in favor of group 1 for all the evaluation parameters at W6 (p < 0.05). Our results have shown that peloid treatment could be effective in providing improvement in pain relief, function, daily life activities, and quality of life in LE patients.

Lateral epicondylitis: Associations of MR imaging and clinical assessments with treatment options in patients receiving conservative and arthroscopic managements

OBJECTIVES

We assessed the implications of MR imaging with clinical history in lateral epicondylitis management by evaluating imaging and clinical features in patients with lateral epicondylitis treated conservatively or operatively.

METHODS

Sixty patients with lateral epicondylitis treated conservatively (n = 38) or operatively (n = 22) from 2011-2015 were included. MR imaging findings of common extensor tendon (CET), lateral collateral ligament (LCL) complex, muscle oedema, ulnar nerve and elbow joint were reviewed. Clinical data recorded were frequency, duration and intensity of pain, history of trauma and injection therapy, range of motion.

RESULTS

MRI-assessed CET and LCL complex abnormalities, muscle oedema, radiocapitellar joint widening, joint effusion/synovitis, pain frequency and intensity differed significantly between the two groups (p < .05) with increased severity in operative group. Persistent pain (OR 12.2, p < .01), CET abnormality on longitudinal plane (OR 7.5, p = .03 for grade 2; OR 22.4, p < .01 for grade 3) and muscle oedema (OR 6.7, p = .03) were major factors associated with operative treatment. Area under the ROC curve of predicted probabilities for combination of these factors was 0.83.

CONCLUSION

MR imaging, combined with clinical assessment, could facilitate appropriate management planning for patients with lateral epicondylitis.

KEY POINTS

• MRI can reflect different disease severity between patients treated conservatively/operatively. • CET abnormality, muscle oedema were major MRI findings with operative treatment. • Patients in operative group were more likely to experience persistent pain. • MRI plus clinical symptoms could facilitate appropriate management for lateral epicondylitis.

Trends in Surgical Practices for Lateral Epicondylitis Among Newly Trained Orthopaedic Surgeons

Background:

Much controversy exists regarding the optimal surgical intervention for lateral epicondylitis because of a multitude of options available and the lack of comparative studies. Knowledge of the current practice trends would help guide the design of comparative studies needed to determine which surgical technique results in the best outcome.

Purpose:

To review the latest practice trends for the surgical treatment of lateral epicondylitis among newly trained surgeons in the United States utilizing the American Board of Orthopaedic Surgery (ABOS) database.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

The ABOS database was utilized to identify surgical cases for lateral epicondylitis submitted by Part II board certification examination candidates from 2004 through 2013. Inclusion criteria were predetermined using a combination of International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Cases were organized by open and arthroscopic treatment groups and by fellowship training and were analyzed to determine differences in surgical techniques, complication rates, and concomitant procedures.

Results:

In total, 1150 surgeons submitted 2106 surgical cases for the treatment of lateral epicondylitis. The number of surgical cases for lateral epicondylitis performed per 10,000 submitted cases significantly decreased from 26.7 in 2004 to 21.1 in 2013 (P = .002). Among all cases, 92.2% were open and 7.8% were arthroscopic, with no change in the incidence of arthroscopic surgeries over the study period. Shoulder and elbow (18.1%) and sports medicine (11.4%) surgeons were more likely to perform surgery arthroscopically compared with hand surgeons (6.1%) (P < .001). There was no difference in overall self-reported complication rates between open (4.4%) and arthroscopic (5.5%) procedures (P = .666). Percutaneous tenotomy, debridement only, and debridement with tendon repair comprised 6.4%, 46.3%, and 47.3% of open treatment, respectively. Sports medicine, hand, and shoulder and elbow surgeons were more likely to repair the tendon after debridement compared with other surgeons, who were more likely to perform debridement alone (P < .001). Hand surgeons were most likely to perform concomitant procedures, of which the majority were neuroplasties.

Conclusion:

Although comparative studies are ultimately necessary for determining the optimal surgical technique, researchers should be mindful of the differences in practices according to training and the extent to which concomitant procedures are being performed, as both these factors may confound any future results.

Effect of Metabolic Syndrome on the Functional Outcome of Corticosteroid Injection for Lateral Epicondylitis: Retrospective Matched Case-Control Study

Both obesity and diabetes mellitus are well-known risk factors for tendinopathies. We retrospectively compared the efficacy of single corticosteroid injections in treating lateral epicondylitis in patients with and without metabolic syndrome (MetS). Fifty-one patients with lateral epicondylitis and MetS were age- and sex-matched with 51 controls without MetS. Pain severity, Disability of the Arm, Shoulder, and Hand score, and grip strength were assessed at base line and at 6, 12 and 24 weeks post-injection. The pain scores in the MetS group were greater than those in the control group at 6 and 12 weeks. The disability scores and grip strength in the MetS group were significantly worse than those of the control group at 6 weeks. However, there were no significant differences at 24 weeks between the groups in terms of pain, disability scores and grip strengths. After 24 weeks, three patients (6%) in the control group and five patients (10%) in the MetS group had surgical decompression (p = 0.46). Patients with MetS are at risk for poor functional outcome after corticosteroid injection for lateral epicondylitis in the short term, but in the long term there was no difference in outcomes of steroid injection in patients with and without MetS.

Lateral Epicondylitis and Physical Exposure at Work? A Review of Prospective Studies and Meta-Analysis

OBJECTIVE

In view of recent published studies, a meta-analysis was undertaken on prospective studies in order to assess any association between lateral epicondylitis and physical exposure at work.

METHODS

Using the key words "lateral epicondylitis" AND "occupational" AND ("cohort" OR "longitudinal," OR "incidence") without limitations on the language or year of publication, original prospective studies were selected from 4 databases (PubMed, Scopus, Web of Science, and Base de Données de Santé Publique) after 2 rounds (valid design, valid association reported, and valid work exposure). Relevant associations between physical exposure at work and incident lateral epicondylitis were extracted from the articles, and a meta-risk was calculated using the generic variance approach (meta-odds ratios [meta-ORs]).

RESULTS

From 2001 to 2014, 5 prospective studies were included. Among 6,922 included subjects (and 3,449 who were followed), 256 cases of incident lateral epicondylitis were diagnosed 2.5-6 years after baseline. All the published studies found a significant estimation of relative risk for a positive association between combined biomechanic exposure involving the wrist and/or elbow and incidence of lateral epicondylitis. The overall meta-OR was 2.6 (95% confidence interval 1.9-3.5), with a low heterogeneity (Q = 1.4, P > 0.05). Funnel plots and Egger's test did not suggest major publication bias.

CONCLUSION

The results of this meta-analysis strongly support the hypothesis of an association between biomechanic exposure involving the wrist and/or elbow at work and incidence of lateral epicondylitis.

Autologous Blood and Platelet-Rich Plasma Injections for Treatment of Lateral Epicondylitis

Lateral epicondylitis (tennis elbow) is a frequent cause of elbow pain; most patients (80%-90%) are successfully treated with standard nonoperative methods (rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy). Autologous blood injections and platelet-rich plasma injections are the two most frequently used orthobiologic techniques in the treatment of lateral epicondylitis. Studies of the effectiveness of autologous blood injections and platelet-rich plasma report varying outcomes, some citing significant clinical relief and others reporting no beneficial effect. More research is needed to determine how to best use orthobiologics in the treatment of lateral epicondylitis.

Radiographic and Clinical Analysis of Lateral Epicondylitis

PURPOSE

The literature suggests that radiographs may be unnecessary in the initial evaluation of lateral epicondylitis because treatment is rarely altered as a result of the radiographic findings. The most commonly reported radiographic finding is calcification at the lateral epicondyle. Our goal was to perform a quantitative and qualitative analysis of this finding to determine its importance and possible relationship with various clinical factors and patient-reported measures.

METHODS

All patients diagnosed with lateral epicondylitis by a single surgeon during a 5-year period were retrospectively reviewed. Age, sex, laterality, hand dominance, pain visual analog scale, duration of symptoms, Quick-Disability of the Arm, Shoulder, and Hand questionnaire score, and history of steroid injection were recorded. Calcifications on standard elbow radiographs, acquired digitally and viewed at 200% magnification on a 24-inch monitor, were characterized by size and relationship with the lateral epicondyle.

RESULTS

We reviewed 245 patients diagnosed with lateral epicondylitis. A total of 115 elbows (47%) demonstrated lateral epicondyle calcifications. Patients with and without calcifications were similar with regard to clinical factors, as were patients with larger or smaller lesions. Eighty-five elbows (35%) had additional radiographic findings. Treatment was not altered by the radiographic findings in any case.

CONCLUSIONS

Lateral epicondyle calcifications are much more common in lateral epicondylitis than previously reported, possibly owing to modern digital radiography and magnification, although they do not appear to be related to clinical factors including patient-reported measures. Thus, patients and surgeons should be careful to avoid overinterpretation of such findings. Although radiographs may be helpful in ruling out additional pathology, we did not find other clinically important contributions to the initial evaluation and management of this condition, and thus we do not recommend their routine use.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

USG-guided injection of corticosteroid for lateral epicondylitis does not improve clinical outcomes: a prospective randomised study

BACKGROUND

Corticosteroid injection used to be the treatment of choice for lateral epicondylitis. Most injections are performed blindly. In the blinded technique, it could be difficult to determine the exact pathological localisation. The purpose of this single-blinded, randomised controlled clinical study was to compare the clinical therapeutic effects of blinded and USG-guided corticosteroid injection therapy in lateral epicondylitis.

PATIENTS AND METHODS

Forty patients with chronic lateral epicondylitis were included in this clinical trial. The patients were randomly allocated to blinded group or USG-guided injection group according to a computer-generated randomisation list. All blinded injections were administered by an orthopaedic surgeon and all ultrasound-guided injections were made by a radiologist experienced in this technique. All patients were injected under aseptic conditions using 40 mg/2 mL methylprednisolone acetate. The outcomes of both treatments were assessed by an independent assessor at pre-injection, then at 6-week and 3- and 6-month follow-up assessments. The assessor evaluated the q-DASH, VAS, and grip strength scores.

RESULTS

No statistically significant difference was determined between the groups in respect of the Q-DASH and grip strength scores preoperatively and at 6 weeks and 3 and 6 months post-injection. No statistically significant difference was determined between the groups in respect of the VAS scores preoperatively and at 6 weeks and 6 months. No systemic or local complications were reported during the treatment.

CONCLUSION

There was no statistically significant difference compared to the blinded injection technique, and the mean score differences between the groups are of no clinical relevance.

Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis: an analysis of 3863 patients

BACKGROUND

This study was conducted to identify the rate of failure of operative treatment of lateral epicondylitis, defined as progression to ipsilateral revision surgery, and associated patient-specific risk factors for failure.

METHODS

A national database was used to identify patients undergoing surgical treatment of lateral epicondylitis from 2005 to 2012. Patients undergoing concomitant procedures were excluded. Patients who then required subsequent ipsilateral extensor carpi radialis brevis débridement or release within 2 years were identified using similar methods. A multivariate binomial logistic regression analysis was used to evaluate patient-related risk factors for revision surgery. In addition, the number of preoperative injections (1, 2, or ≥3) in the ipsilateral elbow was identified and included in the regression analysis. Adjusted odds ratios (OR) and 95% confidence intervals were calculated for each risk factor.

RESULTS

Of 3863 patients who underwent operative treatment of lateral epicondylitis, 58 (1.5%) required ipsilateral revision surgery. Risk factors for revision surgery included age <65 years (OR, 2.95; P = .003), male gender (OR, 1.53; P = .017), morbid obesity (OR, 2.13; P = .002), tobacco use (OR, 1.87; P < .001), and inflammatory arthritis (OR, 1.79; P = .009). Having ≥3 ipsilateral preoperative injections was the most significant risk factor (OR, 3.55; P < .001), whereas having 2 (OR, 1.44; P = .135) or 1 (OR, 1.15; P = .495) was not significant.

CONCLUSIONS

The incidence of failure requiring revision surgery for lateral epicondylitis in the studied population is low (1.5%). Risk factors for revision surgery include younger age, male gender, morbid obesity, tobacco use, and inflammatory arthritis. The most significant risk factor for revision surgery is having ≥3 ipsilateral preoperative injections.

Comparison of treatment effects on lateral epicondylitis between acupuncture and extracorporeal shockwave therapy

Background

Lateral epicondylitis is one of the most common overuse injuries, and has been reported to reduce function and affect daily activities. There is no standard therapy for lateral epicondylitis. In Hong Kong, acupuncture and extracorporeal shockwave therapy (ESWT) have been popular in treating lateral epicondylitis in recent years.

Objective

This study is to compare the treatment effects of acupuncture and ESWT on lateral epicondylitis.

Methods

In this study, we evaluated 34 patients (34 elbows) with lateral epicondylitis. Seventeen patients were treated by 3-week ESWT, one session per week. Another 17 were treated by 3-week acupuncture therapy, two sessions per week. The outcome measures included pain score by visual analogue scale, maximum grip strength by Jamar dynamometer, and level of functional impairment by disability of arms, shoulders, and hands questionnaire. Participants were assessed at three time points: baseline; after treatment; and 2-week follow-up.

Results

The two treatments showed no significant difference at any assessment time-point. Both treatment groups had significant improvement in pain score in longitudinal comparisons. No significant difference was found in maximum grip strength and functional impairment in either treatment group, but a trend of improvement could be observed. In addition, improvement in pain relief stopped when treatment ended for either groups.

Conclusions

The treatment effects of acupuncture and ESWT on lateral epicondylitis were similar. The pain relief persisted for at least two weeks after treatment.

Efficacy of betamethasone valerate medicated plaster on painful chronic elbow tendinopathy: a double-blind, randomized, placebo-controlled trial

OBJECTIVE

to investigate the efficacy and safety of a medicated plaster containing betamethasone valerate (BMV) 2.25 mg in patients with chronic elbow tendinopathy.

METHODS

randomized, double-blind, placebo-controlled study with assignment 2:2:1:1 to BMV medicated plaster applied daily for 12 hours, daily for 24 hours or matched placebo. 62 patients aged ≥18 years with chronic lateral elbow tendinopathy were randomized. The primary efficacy variable was pain reduction (VAS) at day 28. Secondary objectives included summed pain intensity differences (SPID), overall treatment efficacy and tolerability.

RESULTS

mean reduction in VAS pain score at day 28 was greater in both BMV medicated plaster groups, -39.35±27.69 mm for BMV12-h and -36.91±32.50 mm for BMV24-h, than with placebo, -20.20±27.32 mm. Considering the adjusted mean decreases, there was a statistically significant difference between BMV12-h and placebo (p=0.0110). Global pain relief (SPID) and overall treatment efficacy were significantly better with BMV. BMV and placebo plasters had similar local tolerability and there were few treatment-related adverse events.

CONCLUSIONS

BMV plaster was significantly more effective than placebo at reducing pain in patients with chronic elbow tendinopathies. The BMV plaster was safe and well tolerated.

Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years

BACKGROUND

A previously published study found positive outcomes for a novel technique for ultrasound-guided percutaneous ultrasonic tenotomy, showing good tolerability, safety, and early efficacy within an office setting.

PURPOSE

In this follow-up study, all 20 members of the original cohort were contacted after 3 years to explore the sustainability of symptomatic relief, functional improvement, and sonographic soft tissue response for percutaneous ultrasonic tenotomy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All 20 subjects of the clinical trial that was performed from June to November 2011 were further assessed at 36 months after the procedure in terms of visual analog scale for pain, Disabilities of the Arm, Shoulder and Hand (DASH)-Compulsory/Work scores, need for adjunct procedures, and overall satisfaction. Importantly, all 20 were reassessed with ultrasound imaging at 36 months, and evidence of the common extensor tendon response was assessed in terms of tendon hypervascularity, tendon thickness, and the progress of the hypoechoic scar tissue.

RESULTS

A 100% clinical follow-up was achieved, inclusive of ultrasonographic assessment. None of the subjects required further treatment procedures, and 100% expressed satisfaction. Previous improvements in visual analog scale (current median ± SD, 0 ± 0.9; range, 0-3) and DASH-Work scores (current median, 0 ± 0) were sustained with conformity to a linear pattern on polynomial measures. There was further reduction in DASH-Compulsory scores to a median of 0 ± 0.644 (range, 0-2) with a significant decrease on repeated measures (P = .008). Tendon hypervascularity was resolved in 94% of patients, and 100% had reduction in tendon thickness. Overall reduction in the hypoechoic scar tissue was observed in all subjects, with a 90% response achieved by 6 months. Between 6 and 36 months, further reduction in the scar was observed in around 60% of patients, with 20% of patients having complete resolution of the hypoechoic scar.

CONCLUSION

Minimally invasive percutaneous ultrasonic tenotomy provided sustained pain relief and functional improvement for recalcitrant tennis elbow at 3-year follow-up. It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy.

Factors associated with failure of nonoperative treatment in lateral epicondylitis

BACKGROUND

Lateral epicondylitis is a common cause of elbow pain that is treated with a variety of nonoperative measures and often improves with time. Minimal research is available on patients in whom these nonoperative treatments fail.

PURPOSE

To identify baseline patient and disease factors associated with the failure of nonoperative treatment of lateral epicondylitis, defined as surgery after a period of nonoperative treatment.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

A total of 580 patients treated for lateral epicondylitis at a tertiary center between 2007 and 2012 were analyzed. Disease-specific and patient demographic characteristics were compared between patient groups (nonoperative vs surgical treatment). A multivariable logistic regression model was created based on preliminary univariate testing to determine which characteristics were associated with failure of nonoperative treatment.

RESULTS

Of the 580 patients, 92 (16%) underwent surgical treatment at a mean of 6 months (range, 0-31 months) from their initial visit. Univariate analysis demonstrated a potential association (P < .10) between operative management and the following factors at initial diagnosis: increased age, body mass index, duration of symptoms, presence of radial tunnel syndrome, prior injection, physical therapy, splinting, smoking, workers' compensation, a labor occupation, use of narcotics, use of antidepressant medications, and previous orthopaedic surgery. In the final multivariable model, a workers' compensation claim (odds ratio [OR], 8.1), prior injection (OR, 5.6), the presence of radial tunnel syndrome (OR, 3.1), previous orthopaedic surgery (OR, 3.2), and duration of symptoms >12 months (OR, 2.5) remained significant independent predictors of surgical treatment.

CONCLUSION

This study identifies risk factors for surgical treatment for lateral epicondylitis. While these findings do not provide information regarding causal factors associated with surgery, these patient and disease-specific considerations may be helpful when counseling patients regarding treatment options and the likelihood of the success of continued nonoperative treatment.

New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis

Lateral epicondylitis is a common source of elbow pain. Though it is often a self-limited condition, refractory lateral epicondylitis can lead to problems with activities of daily living and sometimes requires sick leave from work. Therefore prompt treatment is essential. Histopathologic studies have suggested that lateral epicondylitis is a tendinopathy, associated with apoptosis and autophagy, rather than a tendonitis associated with inflammation. Although corticosteroids have been used for short-term treatment, recent studies have suggested that they are not helpful and may even be harmful and delay healing in the treatment of lateral epicondylitis. Researchers have recently begun to investigate the use of biologics as potential treatment options for lateral epicondylitis. Autologous blood preparations including platelet rich plasma (PRP) and autologous whole blood injections (ABIs) have been proposed in order to deliver growth factors and other nutrients to the diseased tendon. Stem cell therapies have also been suggested as a method of improving tendon healing. This review discusses the current evidence for the use of PRP, ABI, and stem cell therapies for treatment of lateral epicondylitis. We also review the evidence for nonbiologic treatments including corticosteroids, prolotherapy, botulinum toxin A, and nitric oxide.

The epidemiology and health care burden of tennis elbow: a population-based study

BACKGROUND

Lateral elbow tendinosis (epicondylitis) is a common condition both in primary care and specialty clinics.

PURPOSE

To evaluate the natural history (ie, incidence, recurrence, and progression to surgery) of lateral elbow tendinosis in a large population.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

The study population comprised a population-based incidence cohort of patients with new-onset lateral elbow tendinosis between January 1, 2000, and December 31, 2012. The medical records of a 10% random sample (n=576) were reviewed to ascertain information on patient and disease characteristics, treatment modalities, recurrence, and progression to surgery. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 US population.

RESULTS

The age- and sex-adjusted annual incidence of lateral elbow tendinosis decreased significantly over time from 4.5 per 1000 people in 2000 to 2.4 per 1000 in 2012 (P<.001). The recurrence rate within 2 years was 8.5% and remained constant over time. The proportion of surgically treated cases within 2 years of diagnosis tripled over time, from 1.1% during the 2000-2002 time period to 3.2% after 2009 (P<.00001). About 1 in 10 patients with persistent symptoms at 6 months required surgery.

CONCLUSION

The decrease in incidence of lateral elbow tendinosis may represent changes in diagnosis patterns or a true decrease in disease incidence. Natural history data can be used to help guide patients and providers in determining the most appropriate course at a given time in the disease process. The study data suggest that patients without resolution after 6 months of onset may have a prolonged disease course and may need surgical intervention.

Leukocyte-poor platelet-rich plasma versus bupivacaine for recalcitrant lateral epicondylar tendinopathy

PURPOSE

To compare a single leukocyte-poor (type-4B) platelet-rich plasma (PRP) injection versus bupivacaine injection for recalcitrant lateral epicondylar tendinopathy (LET).

METHODS

25 patients aged 27 to 50 years with painful and recalcitrant LET of the humerus were randomised to receive leukocyte-poor (type-4B) PRP (n=15) or bupivacaine (n=10) injection. Outcome measures included visual analogue scale (VAS) for pain, modified Mayo clinic performance index for elbow (MMCPIE) for elbow function, and Nirschl score for activity-related pain at 1, 3, 6, and 12 months by a single assessor.

RESULTS

At baseline, the PRP and bupivacaine groups were comparable in terms of age, sex, duration of symptoms, VAS for pain, MMCPIE score, and Nirschl score. After one month, the percentage of improvement was less in the PRP than bupivacaine group in terms of the VAS for pain (17.7% vs. 26.5%), MMCPIE score (24.0% vs. 27.6%), and Nirschl score (20.7% vs. 31.1%). Nonetheless, improvement in the respective scores was greater in the PRP than bupivacaine group after 3 months (42.5% vs. 30.9%, 34.1% vs. 27.2%, and 50.7% vs. 39.6%), 6 months (67.3% vs. 20.1%, 40.6% vs. 16.3%, and 71.4% vs. 31.1%), and one year (83.2% vs. 45.6%, 47.0% vs. 21.7%, and 76.6% vs. 56.3%). The differences in scores between groups were significant at 6 months and one year only (p<0.001).

CONCLUSION

Leukocyte-poor (type-4) PRP injection for recalcitrant LET enabled good improvement in pain and function.

Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no treatment? A meta-analysis

BACKGROUND

Lateral epicondylitis is a painful tendinopathy for which several nonsurgical treatment strategies are used. Superiority of these nonsurgical treatments over nontreatment has not been definitively established.

QUESTIONS/PURPOSES

We asked whether nonsurgical treatment of lateral epicondylitis compared with observation only or placebo provides (1) better overall improvement, (2) less need for escape interventions, (3) better outcome scores, and (4) improved grip strength at intermediate- to long-term followup.

METHODS

The English-language literature was searched using PubMed and the Cochrane Central Register of Controlled Trials. Randomized-controlled trials (RCTs) comparing any form of nonsurgical treatment with either observation only or placebo at followup of at least 6 months were included. Nonsurgical treatments included injections (corticosteroid, platelet-rich plasma, autologous blood, sodium hyaluronate, or glycosaminoglycan polysulfate), physiotherapy, shock wave therapy, laser, ultrasound, corticosteroid iontophoresis, topical glyceryl trinitrate, or oral naproxen. Methodologic quality was assessed with the Consolidated Standards of Reporting Trials (CONSORT) checklist, and 22 RCTs containing 2280 patients were included. Pooled analyses were performed to evaluate overall improvement; requirement for escape interventions (treatment of any kind, outside consultation, and surgery); outcome scores (Patient-Rated Tennis Elbow Evaluation [PRTEE]; DASH; Pain-Free Function Index [PFFI]; EuroQoL [EQ]-5D; and overall function); and maximum and pain-free grip strength. Sensitivity analyses were performed using only trials of excellent or good quality. Heterogeneity analyses were performed, and funnel plots were constructed to assess for publication bias.

RESULTS

Nonsurgical treatment was not favored over nontreatment based on overall improvement (risk ratio [RR] = 1.05 [0.96-1.15]; p = 0.32), need for escape treatment (RR = 1.50 [0.84-2.70]; p = 0.17), PRTEE scores (mean difference [MD] = 1.47, [0.68-2.26]; p < 0.001), DASH scores (MD = -2.69, [-15.80 to 10.42]; p = 0.69), PFFI scores (standardized mean difference [SMD] = 0.25, [-0.32 to 0.81]; p = 0.39), overall function using change-from-baseline data (SMD = 0.11, [-0.14 to 0.36]; p = 0.37) and final data (SMD = -0.16, [-0.79 to 0.47]; p = 0.61), EQ-5D scores (SMD = 0.08, [-0.52 to 0.67]; p = 0.80), maximum grip strength using change-from-baseline data (SMD = 0.12, [-0.11 to 0.35]; p = 0.31) and final data (SMD = 4.37, [-0.65 to 9.38]; p = 0.09), and pain-free grip strength using change-from-baseline data (SMD = -0.20, [-0.84 to 0.43]; p = 0.53) and final data (SMD = -0.03, [-0.61 to 0.54]; p = 0.91).

CONCLUSIONS

Pooled data from RCTs indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Systematic diagnosis and therapy of lateral elbow pain with emphasis on elbow instability

PURPOSE

In recalcitrant epicondylitis innumerable operative techniques have been published, nevertheless a certain percentage of patients remains symptomatic after operative treatment. We developed an individual, systematic diagnostic pathway including arthroscopic assessment of elbow stability to identify the optimal and respectively less invasive therapy.

METHODS

We so far included 40 patients with recalcitrant lateral epicondylitis (mean age 46 ± 11). 5 patients had previous surgery. In all patients, we did an elbow arthroscopy and a systematic arthroscopic stability testing. 25 patients were treated exclusively arthroscopically once instability was excluded. In 13 patients with slight instability, we did an open debridement of the lateral tendon complex and local refixation. Two patients with severe instability were treated with open debridement and additional stabilization of the LUCL with a trizeps graft. With a minimum follow-up of 1 year, we assessed the DASH score and subjective patient satisfaction.

RESULTS

Mean follow-up was 24 ± 12 months, mean duration of symptoms before surgery was 19 ± 18 months. The mean DASH score at follow-up was 22 ± 19.36 patients reported symptoms improvement, 34 patients would repeat surgery given the same situation; in 30 cases, patients expectations had been fulfilled. We did not observe any intraoperative complications or infections. One patient developed joint stiffness requiring reoperation.

CONCLUSION

Using a systematic diagnostic pathway including assessment of elbow stability and consecutive individualized, respectively, less invasive surgical procedure we acquired high patients satisfaction and good clinical outcome with a low complication rate.

LEVEL OF EVIDENCE

Level III.

Injection of autologous blood versus corticosteroid for lateral epicondylitis: a randomised controlled study

PURPOSE

To compare the efficacy of autologous blood injection versus corticosteroid injection for lateral epicondylitis.

METHODS

21 men and 59 women (mean age, 45.2 years) presenting with lateral epicondylitis were randomised to receive either autologous blood injection (2 ml of autologous venous blood mixed with 1 ml of 2% prilocaine hydrochloride) or corticosteroid injection (1 ml of 40 mg methylprednisolone acetate mixed with 1 ml of 2% prilocaine hydrochloride) given by a single physician. Patients were assessed before (day 0) and after (days 15, 30, and 90) treatment for elbow pain (using a visual analogue scale [VAS]), function (using the patient-rated tennis elbow evaluation [PRTEE] questionnaire), and grip strength (using a hydraulic hand dynamometer). Patients were followed up at 6 months by telephone to assess elbow pain using the VAS.

RESULTS

No complications (infection, skin atrophy, neurovascular damage, or tendon rupture) were noted. 10 patients reported increased pain for up to 2 days after autologous blood injection. In both groups, the VAS score for elbow pain, PRTEE score, and grip strength improved significantly after treatment (p=0.0001), but the pattern of improvement differed. Compared with autologous blood injection, corticosteroid injection improved all 3 scores at a faster rate over the first 15 days (p=0.0001), and then started to decline slightly until day 90. After autologous blood injection, all 3 scores improved steadily and were eventually better (p=0.0001). If a 37% decrease in PRTEE is defined as complete recovery, 38 (95%) of patients with autologous blood injection and 25 (62.5%) of patients with corticosteroid injection achieved complete recovery (p=0.0001).

CONCLUSION

Autologous blood injection was more effective over the follow-up period than corticosteroid injection in improving pain, function, and grip strength. It is recommended as a first-line injection treatment because it is simple, cheap, and effective.

Lateral epicondylitis treatment: international survey of surgeons' preferences and literature review

BACKGROUND

Lateral epicondylitis (LE) is a common cause of elbow pain. Despite a relatively high prevalence and morbidity, there is still no single effective ('gold standard') treatment for LE. We hypothesised that a surgeon's experience, country of origin and area of expertise would influence choices concerning patient management. The purpose of this survey was to describe the current trends and common practices in treating LE worldwide.

MATERIAL AND METHODS

A total of 291 orthopaedic surgeons of 12 subspecialties from 57 countries were surveyed on their choice of LE treatment modalities. Their preferences were analysed according to country of origin, field of expertise and seniority. The results were compared with current published level-1 evidence.

RESULTS

The most popular modalities of treatment among all of the surveyed orthopaedic surgeons were non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid (CS) injection (38% of recommendations each). The most popular Modalities of treatment among the hand surgeons was NSAIDs (48%) and CS injection (30%). There was no significant difference in recommendations based on geography, seniority or specialisation (i.e., hand surgeons among others).

CONCLUSIONS

Neither geography, seniority nor medical specialty affects surgeons' preferences in the treatment of LE. There appears to be little correlation between scientific evidence and therapeutic choices for managing LE.

LEVEL OF EVIDENCE

Level V, Study.

Long term results in refractory tennis elbow using autologous blood

Tennis elbow (TE) is one of the commonest myotendinosis. Different treatment options are available and autologous blood injection has emerged as the one of the acceptable modalities of treatment. Long term studies over a larger group of patients are however lacking. The purpose of this study was to evaluate these patients on longer durations. One-hundred and twenty patients of TE, who failed to respond to conventional treatment including local steroid injections were taken up for this prospective study over the period from year 2005 to 2011 and were followed up for the minimum of 3 years (range 3-9 years). Two mL of autologous blood was taken from the ipsilateral limb and injected into the lateral epicondyle. The effectiveness of the procedure was assessed by Pain Rating Sscale and Nirschl Staging, which was monitored before the procedure, at first week, monthly for first three months, at 6 months and then 3 monthly for first year, six monthly for next 2 years and then yearly. Statistical analysis was done and a P value of <0.05 was taken as significant. The patients (76 females and 44 males) were evaluated after procedure. The mean age group was 40.67±8.21. The mean follow up was 5.7±1.72 (range 3 to 9 years). The mean pain score and Nirschl stage before the procedure was 3.3±0.9 and 6.2±0.82 respectively. At final follow up the pain score and Nirschl were 1.1±0.9 and 1.5±0.91 respectively. Autologous blood injection was found to be one of the modalities for treatment of TE. Being cheap, available and easy method of treatment, it should be considered as a treatment modality before opting for the surgery. Universal guidelines for the management of tennis elbow should be made as there is lot of controversy regarding the treatment.

Lateral epicondylitis: review of injection therapies

Lateral epicondylitis has several different treatment methods, with no single agreed upon therapy. This article summarizes the current literature on injection therapies for lateral epicondylitis. Glucocorticoid, botulinum toxin, autologous blood, platelet-rich plasma, hyaluronic acid, polidocanol, glycosaminoglycan, and prolotherapy injections are discussed.

How to perform local soft-tissue glucocorticoid injections?

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae is the hallmark of many inflammatory rheumatic diseases, but inflammation or rather irritation of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in the literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

Isolation and characterization of human mesenchymal stem cells derived from shoulder tissues involved in rotator cuff tears

BACKGROUND

Recent studies report a relatively high failure rate for tendon-bone healing after rotator cuff repair. Several studies have investigated biologically augmented rotator cuff repair; however, none has shown the application of synovial mesenchymal stem cells for such repair.

PURPOSE

To demonstrate whether cells derived from shoulder tissues have mesenchymal stem cell properties and to identify which tissue is the best source of the mesenchymal stem cells.

STUDY DESIGN

Controlled laboratory study.

METHODS

Forty-two patients with a diagnosed rotator cuff tear preoperatively were enrolled in this study. Human mesenchymal tissues were obtained during arthroscopic surgery for rotator cuff tears from 19 donors who met the inclusion criteria and had investigable amounts of tissue. Colony-forming units, yield obtained, expandability, differentiation potential, epitope profile, and gene expression were compared among the cells from 4 shoulder tissues: synovium of the glenohumeral joint, subacromial bursa, margin of the ruptured supraspinatus tendon, and residual tendon stump on the greater tuberosity (enthesis).

RESULTS

The number of live passage 0 cells from whole tissue was significantly higher in cells derived from the subacromial bursa (P < .05). Subacromial bursa-derived cells retained their expandability even at passage 10. In adipogenesis experiments, the frequency of Oil Red O-positive colonies was significantly higher for synovium- and subacromial bursa-derived cells than for tendon- and enthesis-derived cells (P < .0001). In studies of osteogenesis, the rate of von Kossa- and alkaline phosphatase-positive colonies was highest in subacromial bursa-derived cells (P < .0001). The chondrogenic potential was highest in cells derived from the enthesis. For epitope profiling, 11 surface antigens were measured, and most had similar epitope profiles, irrespective of cell source.

CONCLUSION

The findings indicate that the subacromial bursa is a good candidate for the source of mesenchymal stem cells in rotator cuff tears.

CLINICAL RELEVANCE

Synovial cells from the subacromial bursa in patients with rotator cuff tears are a superior cell source in vitro, suggesting that mesenchymal stem cells from this tissue could be good candidates for biological augmentation of rotator cuff repair.

Acute radial ulno-humeral ligament injury in patients with chronic lateral epicondylitis: an observational report

PURPOSE

Lateral elbow pain has multiple etiologies; most common is lateral epicondylitis. Radio-capitellar arthritis, posterolateral rotatory instability (PLRI), plica and radial tunnel syndromes may produce similar pain. The purpose of this study is to report on a rare subset of patients who had an acute injury during treatment for chronic lateral epicondylitis, exacerbating symptoms and lessening function. Indications for surgery were a failure of another round of nonoperative management and diagnosis of a new injury to the lateral ligaments in addition to the lateral epicondylitis. Surgical intervention revealed the acute injury to the radial ulno-humeral ligament (RUHL) complex, superimposed on chronic lateral epicondylitis, which we believe caused worsening of symptoms. Surgical repair of both lesions provided satisfactory results.

MATERIALS AND METHODS

Seven patients (range, 29-46 years; mean, 40.7) being treated for chronic lateral epicondylitis each sustained an acute elbow injury resulting in PLRI. Study data, including Andrews-Carson Elbow Score (ACES) and Mayo Elbow Performance Score (MEPS), were collected in the initial evaluation and at regular postoperative intervals, with a follow-up period of 12-24 months. Indications for surgery were pain, functional impairment, and failure of other treatments. All surgeries were performed on an outpatient basis under general anesthesia in the prone position.

RESULTS

All patients showed arthroscopic evidence of chronic lateral epicondylitis and acute RUHL injury. All showed significant improvement in total ACES and MEPS after repair of both lesions, full range of motion, and objective improvement in strength and function, with no adverse effects or complications.

CONCLUSION

Patients with chronic lateral epicondylitis who sustain an acute injury may damage the RUHL complex. Early recognition of this additional injury may allow surgical repair of both injuries with satisfactory results.

Evaluation and management of elbow tendinopathy

Context:

Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations.

Evidence Acquisitions:

The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy.

Results:

Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments.

Conclusions:

Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.

Obstacles to obtaining optimal physiotherapy services in a rural community in southeastern Nigeria

Background. Many people continue to live with physical disabilities across the globe, especially in rural Africa despite expertise of Physiotherapists and available evidence of effectiveness of Physiotherapy. Objective. To determine the obstacles to obtaining Optimal Physiotherapy services in a rural community in Southeastern Nigeria. Methods. Population-based cross-sectional study of individuals and health facilities in a rural community in Southeastern Nigeria. Results. The obstacles to obtaining optimal physiotherapy services in this community were unavailability of physiotherapy services, poor knowledge of health workers and community dwellers of the roles and scope of physiotherapy, poor health care seeking behavior of community dwellers, patronage of traditional health workers, and poor referral practices by health workers. Conclusion. Rural health workers in Nkanu West Local Government and other rural communities in Nigeria and Africa should be educated on the roles and scope of physiotherapy. There is a need for raising awareness of the management options for movement/functional problems for rural indigenous communities in Nigeria in particular and Africa in general. Physiotherapists should be made aware of the growing need for physiotherapy in rural areas of Nigeria and Africa largely comprising of the elderly.

Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis

BACKGROUND

In patients with lateral epicondylitis recalcitrant to nonsurgical treatments, surgical intervention is considered. Despite the numerous therapies reported, the current trend of treatment places particular emphasis on minimally invasive techniques.

PURPOSE

The authors present a newly developed minimally invasive procedure, ultrasonographically guided percutaneous radiofrequency thermal lesioning (RTL), and its clinical efficacy in treating recalcitrant lateral epicondylitis.

CASE SERIES

Level of evidence, 4.

METHODS

Thirty-four patients (35 elbows), with a mean age of 52.1 years (range, 35-65 years), suffered from symptomatic lateral epicondylitis for more than 6 months and had exhausted nonoperative therapies. They were treated with ultrasonographically guided RTL. Patients were followed up at least 6 months by physical examination and 12 months by interview. The intensity of pain was recorded with a visual analog scale (VAS) score. The functional outcome was evaluated using grip strength, the upper limb Disability of Arm, Shoulder and Hand (QuickDASH) outcome measure, and the Modified Mayo Clinic Performance Index (MMCPI) for the elbow. The ultrasonographic findings regarding the extensor tendon origin were recorded, as were the complications.

RESULTS

At the time of the 6-month follow-up, the average VAS score in resting (from 4.9 to 0.9), palpation (from 7.6 to 2.5), and grip (from 8.2 to 2.9) had improved significantly compared with the preoperative condition (P < .01). The grip strength (from 20.6 to 27.0 kg) and QuickDASH score (from 54.3 to 21.0) had also improved significantly (P < .01). The MMCPI score improved from "poor" to "excellent." The ultrasonographic finding revealed that the thickness of the common extensor tendon origin did not change significantly. At the final follow-up (mean, 14.3 months; range, 12-21 months), the patients reported a 78% reduction in pain compared with the preoperative status. No major complications were noted in any patient.

CONCLUSION

Ultrasonographically guided RTL for recalcitrant lateral epicondylitis was found to be a minimally invasive treatment with satisfactory results in this pilot investigation. This innovative method can be considered as an alternative treatment of recalcitrant lateral epicondylitis before further surgical intervention.

Magnetic resonance imaging of the elbow in athletes

Acute and chronic elbow pain is common, particularly in athletes. Although plain radiographs, ultrasound, and computed tomography all have a role to play in the investigation of elbow pain, magnetic resonance imaging (MRI) has emerged as the imaging modality of choice for diagnosis of soft tissue disease and osteochondral injury around the elbow. The high spatial resolution, excellent soft-tissue contrast, and multiplanar imaging capabilities of MRI make it ideal for evaluating the complex joint anatomy of the elbow. This article reviews imaging of common disease conditions occurring around the elbow in athletes, with an emphasis on MRI.

Partial-thickness tears of the gluteus medius: rationale and technique for trans-tendinous endoscopic repair

Tears in the gluteus medius and minimus tendons, often misdiagnosed as trochanteric bursitis, have recently emerged as an important cause of recalcitrant greater trochanter pain syndrome. Advances in endoscopic surgery of the hip have created opportunities to better evaluate and treat pathology in the peritrochanteric compartment. We reviewed the literature on trochanteric pain syndrome and gluteus medius tendon injuries. Existing techniques for endoscopic and open gluteus tendon repair and potential challenges in restoration of abductor function were analyzed. Partial-thickness undersurface tears of the gluteus medius were identified as a common pathologic entity. Although these tears are otherwise analogous to partial-thickness tears of the rotator cuff, the lack of arthroscopic access to the deep side of the gluteus medius tendon represents a unique technical challenge. To address the difficulty in visualizing and thus repairing undersurface tears of the gluteus medius, a novel endoscopic trans-tendinous repair technique was developed. The purposes of this article are to review the anatomy, pathology, and existing repair techniques of gluteus medius tendon tears and to describe the rationale and surgical steps for endoscopic trans-tendinous repair.

Evidence supporting the use of physical modalities in the treatment of upper extremity musculoskeletal conditions

PURPOSE OF REVIEW

To evaluate recent trials and reviews of physical modalities and conservative treatments for selected upper extremity musculoskeletal conditions for evidence supporting their use.

RECENT FINDINGS

Recent evidence suggests that many localized tendinopathies are related more to degenerative than inflammatory processes. With this realization, there is increased emphasis on finding new modalities to treat tendinopathies and other localized musculoskeletal conditions that rely on other than anti-inflammatory mechanisms. Although there is good evidence to support the short-term benefits of corticosteroid injections, convincing evidence in support of other conservative treatments and modalities is generally lacking. Extracorpal shock wave therapy may have significant clinical benefit for calcific tendinitis; however, it requires intravenous sedation in most cases and does not appear to be effective in lateral epicondylitis. The most consistent positive treatment effects for rotator cuff tendinitis were achieved by ultrasound-guided subacromial corticosteroid injection as well as manual therapy in conjunction with therapeutic exercise.

SUMMARY

Although there is evidence supporting the use of several different physical modalities and conservative treatments for upper extremity musculoskeletal conditions, there is a strong need for larger, higher quality randomized controlled trials. Although most studies are able to demonstrate short-term benefits, there is a lack of high-quality data demonstrating that these conservative treatments have long-term benefits, particularly, with regard to functional outcomes.

Surgical treatment for lateral epicondylitis: a long-term follow-up of results

HYPOTHESIS

Since its first description, the pathology, natural history, and treatment of lateral epicondylitis have remained controversial. For patients in who conservative management fails, surgery remains an option. The optimal method of surgery remains debatable and is further confounded by a relative lack of long-term follow-up studies.

MATERIALS AND METHODS

This study describes a modification of the Nirschl surgical technique and presents its long-term results. Patients undergoing this open technique were reviewed by use of the Hospital for Special Surgery and Mayo elbow performance assessment tools, as well as having grip strength and subjective outcome recorded.

RESULTS

From June 1986 to December 2001, 158 consecutive patients (171 elbows) underwent surgery in a single-surgeon series. Of these patients, 137 (86.7%) were available for follow-up at a mean of 9.8 years. The mean age of the group was 42 years. Subjectively, the results were good to excellent in 94.6% of patients and in 92.6% to 94.0% of patients by use of the Hospital for Special Surgery and Mayo scores, respectively. No differences were noted in grip strength. No patient required revision surgery.

CONCLUSIONS

This repeatable open technique offers excellent results with a low rate of complications at a mean follow-up of 9.8 years. These results compare favorably in terms of numbers followed up, length of follow-up, and outcome and offer strong evidence of its efficacy.

Finding evidence: evidence-based practice

Best practice treatment decisions require the integration of external information, internal information, and patient factors. This article provides a tested methodology for formulating a structured question from a clinical dilemma and then transforming that question into a query appropriate for searching online evidence-based resources. Listed are some of the preeminent online databases for searching for evidence pertinent to clinicians specializing in hand surgery. Also discussed are various online methods for continuously delivering pertinent evidence to the clinician as it becomes available. The conclusion is a practical example of a literature search as it applies to a problem commonly encountered in surgical care of the upper extremity.

Are "knife and fork" good enough for day case surgery of resistant tennis elbow?

This observational retrospective study was performed on 22 consecutive patients treated surgically in a day surgery unit for resistant tennis elbow to ascertain the effectiveness of the "knife and fork" procedure. All patients had an unfavourable response to nonsurgical treatment lasting at least six months. A simple and inexpensive "knife and fork" technique yielded excellent results in 90.5% of patients and a high percentage (95.2%) of satisfied patients at an average follow-up of two years. There were no fair or poor results and no complications. We conclude that the "knife and fork" technique is a simple and dependable day case procedure. In the present National Health Service (NHS) era of tariff and "payment by results", this approach is more cost effective than an arthroscopic alternative.