Radiographic and Clinical Analysis of Lateral Epicondylitis

Differences in Clinical Tests for Assessing Lateral Epicondylitis Elbow in Adults Concerning Their Physical Activity Level: Test Reliability, Accuracy of Ultrasound Imaging, and Relationship with Energy Expenditure

BACKGROUND

Physical activity (PA) can generate physical stress on the musculoskeletal system. Thus, the aim of the current study was to assess the influence of the level of physical activity on clinical tests used in the diagnosis of lateral epicondylitis in adults, intertest reliability and accuracy based on ultrasound imaging, and relationship with energy expenditure.

METHODS

102 adults with lateral epicondylitis were assessed via an International Physical Activity Questionnaire and divided according to PA level: low (n = 19) moderate (n = 42) or high (n = 41). Pain (visual analog scale), Cozen's and Mill's clinical tests and ultrasound exams were performed.

RESULTS

The Cozen's and Mill's tests differed among PA levels. Excellent reliability was found for Mill's test for PA levels and the ultrasound exam (low ICC = 1.0, moderate ICC = 0.82 and high ICC = 0.99). Good reliability was found for Cozen's test (low ICC = 0.80, moderate ICC = 0.74 and high ICC = 0.73), but with significant differences between the ultrasound exams. The Cozen's and Mill's clinical tests had no relationship to the level of energy expenditure for PA levels.

CONCLUSION

Mill's test was reliable and accurate for the PA levels. Intertest reliability was poor for the PA levels. Mill's test proved to be accurate based on the ultrasound exam. The pain caused by the tests was not related to the level of energy expenditure.

Radiologic evaluation and clinical effect of calcification in medial epicondylitis

BACKGROUND

Although most radiologic findings of medial epicondylitis (ME) are normal, up to 25% show calcification, and little is known about the clinical relevance of soft-tissue calcification in ME. The purposes of this study were to reveal the characteristics of calcification in ME and to identify their clinical relevance.

METHODS

This study included 187 patients (222 elbows) with a diagnosis of ME. We classified calcification according to its anatomic location and further evaluated its distribution. Logistic regression analysis was performed to calculate the odds ratios and 95% confidence intervals for possible factors that may affect calcification in ME: age, sex, laterality, hand dominance, visual analog scale (VAS) pain score, Mayo Elbow Performance Score, symptom duration, history of steroid injection, number of steroid injections, concomitant ulnar neuropathy, and treatment method in terms of conservative treatment or surgery.

RESULTS

Of a total of 222 elbows, 53% (118 of 222 elbows) showed calcification in radiologic findings. The VAS pain score, the number of steroid injections, and concomitant ulnar neuropathy were significantly associated with calcification in ME. Calcification was most commonly identified at the anatomic insertion site of the common flexor tendon (33%), followed by the pronator teres (18%) and the medial collateral ligament (10%). Of the total cases of calcification, 45% were distributed at multiple sites, and age was strongly associated with multiple-site distribution.

CONCLUSIONS

Calcification in ME was more commonly identified than previously reported and was distributed over a relatively broad area. Calcification was associated with a higher VAS pain score, a history of steroid injection, and combined ulnar neuropathy. The anatomic insertion site of the common flexor tendon most commonly showed calcification, and age was a strong indicator of a broad distribution of calcification.

Epicondylopathia humeri radialis

BACKGROUND

Lateral epicondylitis is a common orthopaedic condition often massively restricting the quality of life of the affected patients. There are a wide variety of treatment options - with varying levels of evidence.

METHOD

The following statements and recommendations are based on the current German S2k guideline Epicondylopathia radialis humeri (AWMF registry number: 033 - 2019). All major German specialist societies participated in this guideline, which is based on a systematic review of the literature and a structured consensus-building process.

OUTCOMES

Lateral epicondylitis should be diagnosed clinically and can be confirmed by imaging modalities. The Guidelines Commission issues recommendations on clinical and radiological diagnostic workup. The clinical condition results from the accumulated effect of mechanical overload, neurologic irritation and metabolic changes. Differentiating between acute and chronic disorder is helpful. Prognosis of non-surgical regimens is favourable in most cases. Most cases spontaneously resolve within 12 months. In case of unsuccessful attempted non-surgical management for at least six months, surgery may be considered as an alternative, if there is a corresponding structural morphology and clinical manifestation. At present, it is not possible to recommend a specific surgical procedure.

CONCLUSION

This paper provides a summary of the guideline with extracts of the recommendations and statements of its authors regarding the pathogenesis, prevention, diagnostic workup as well as non-surgical and surgical management.

Assessment of common extensor tendon elasticity in patients with lateral epicondylitis using shear wave elastography

Background

To investigate the role of shear wave elastography (SWE) in patients with lateral epicondylitis (LE) by assessing the common extensor tendon (CET) elasticity.

Methods

A total of 62 unilateral LE patients were enrolled. Shear wave speed (SWS) and the thickness of CET in both elbows, along with the involved elbows with pre- and post-treatment, were obtained by SWE. The differences between groups, inter- and intra-observer agreements, and diagnostic accuracy were analyzed with a paired t-test, intraclass correlation coefficients (ICCs), and receiver operator characteristic (ROC) curve, respectively.

Results

LE patients had significantly lower SWS on lesion sides compared to healthy elbows (P<0.05). The SWS of involved elbows were significantly higher after non-operation treatment than before treatment. The inter- and intra-observer agreements were excellent (ICCs: 0.900-0.993) for SWE measurements. Moreover, a 12.2 m/s cutoff value of mean SWS (C _mean) for discriminating LE patients from healthy subjects revealed a sensitivity and specificity of 93% and 93%, respectively.

Conclusions

SWE is a valid imaging technique for the diagnosis of LE and monitoring of the treatment effect. Future studies are essential for investigating the correlations among clinical examinations, conventional ultrasound, and SWE.

Association of steroid injection with soft-tissue calcification in lateral epicondylitis

BACKGROUND

Steroid injections are among the most commonly used conservative treatments for lateral epicondylitis (LE). Although soft-tissue calcification has been reported as a steroid injection complication in certain tendons, such an association in LE has not been established. This study's purpose was to determine any association of both a history of steroid injection and the number of steroid injections with the types of calcification found in LE.

METHODS

This study included 110 patients (110 elbows) with LE diagnosed from February 2016 to October 2017. We categorized calcifications seen on standard elbow radiographs as soft-tissue calcifications or enthesophytes using the classification of Shillito et al. Using logistic regression analyses, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) for various factors possibly affecting calcification in LE: age, sex, body mass index, dominant-side involvement, occupation, symptom duration, hand-grip power, pain score on a visual analog scale, and treatment methods. The evaluated treatments included stretching exercise, extracorporeal shockwave therapy, and steroid injections.

RESULTS

In the univariate analysis, the visual analog scale pain score, a history of steroid injection, and the number of steroid injections were significantly associated with soft-tissue calcification (P ≤ .020). In the multivariable analysis, a history of steroid injection (OR, 7.63; 95% CI, 1.63-35.72) and the number of steroid injections (OR, 1.18; 95% CI, 1.06-1.32) were significantly associated with soft-tissue calcification (P ≤ .010).

CONCLUSIONS

The significant association of steroid injections with soft-tissue calcification in LE suggests that this calcification is likely to be an iatrogenic complication of steroid injection.