Tennis elbow: conservative, surgical, and manipulative treatment

Is Low-Dose Dextrose Prolotherapy as Effective as High-Dose Dextrose Prolotherapy in the Treatment of Lateral Epicondylitis? A Double-Blind, Ultrasound Guided, Randomized Controlled Study

OBJECTIVES

To investigate the effects of prolotherapy (PrT) on pain, functionality, clinical improvement and to compare the 5% low and 15% high dose dextrose PrT in chronic lateral epicondylitis.

DESIGN

A double-blind, parallel groups, randomized controlled study.

SETTINGS

Outpatient Clinic.

PARTICIPANTS

Sixty patients (N=60), aged 44.30±10.31 years old, with chronic lateral epicondylitis were allocated randomly into 3 groups.

INTERVENTIONS

To Group 1 5% dextrose PrT, to Group 2 15% dextrose PrT, to Group 3 0.9% saline injections were done at 3 times (weeks 0, 3, 6), to the entheses of forearm extensors and annular ligament.

MAIN OUTCOME MEASURES

The primary outcomes were handgrip strength, visual analog scale-rest (VAS-R), visual analog scale-activity (VAS-A), pressure-pain threshold, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH). The secondary outcomes were clinical improvement (Disease Global Assessment Questionnaire), side effects, and complications. Primary outcomes were collected at baseline week 0, week 3, and 12. Secondary outcomes were collected at weeks 3 and 12.

RESULTS

In Group 2, VAS-A and VAS-R (at week 3), handgrip strength and pressure-pain threshold (at week 12) were significantly different than other groups (P<.05). In Groups 1 and 2, there was a difference in primary outcomes at week 12 than baseline (P<.05). In Group 3, there was no difference in VAS-R, VAS-A, and handgrip strength at weeks 3 and 12 than baseline (P>.05).

CONCLUSION

In chronic lateral epicondylitis, 5% and 15% dextrose PrT is more effective in pain, handgrip strength, functionality, and clinical improvement than %0.9 saline. There was no difference in functionality, clinical improvement, side effects, and complications between the PrT groups. 15% dextrose PrT was more effective in handgrip strength and pressure-pain threshold at week 12 and pain at week 3. We recommend 15% dextrose PrT based on this study.

Healthcare Utilization for Lateral Epicondylitis: A 9-Year Analysis of the 2010–2018 Health Insurance Review and Assessment Service National Patient Sample Data

This retrospective cross-sectional study examined healthcare utilization among 213,025 patients with lateral epicondylitis over a nine-year period using the 2010–2018 Health Insurance Review and Assessment Service (HIRA) data (ICD code M771). Healthcare utilization, types of treatment, and the route of the visit were analyzed with frequency analysis for Western medicine (WM) and Korean medicine (KM). The findings revealed that the number of patients visiting WM and KM facilities for lateral epicondylitis rose every year from 2010 to 2018. Over this period, the age distribution of patients was 45–54 years (39.93%), 55–64 (23.12%), and 35–44 years (21.07%), and there were slightly more female patients (53.66%) than male patients (46.34%). The number of claims for lateral epicondylitis tended to increase with decreasing average monthly temperature; an increased proportion of middle-aged patients (45–64 years) was the most evident. The most frequently performed interventions in WM were subcutaneous or intramuscular injection (injection), deep heat therapy (physical therapy), and spinal peripheral nerve block-axillary nerve block (treatment/operation); the most frequently performed intervention in KM was acupuncture (injection). For pharmacological treatment, analgesics and anti-inflammatory medications were most frequently prescribed. The findings can be useful for health policymakers and as foundational data for clinicians and researchers.

Tender point examination with palpation in different shoulder pathologies: A retrospective study

BACKGROUND

Shoulder pain is a common symptom for non-traumatic shoulder pathologies and affects 4.7-66.7% of entire population. Even with the latest technological advantages, palpation still is a cost and time efficient tool to evaluate the shoulder pathologies. Our aim was to investigate and compare palpation findings in different shoulder pathologies.

METHOD

We used first assessments of impingement syndrome (IS) (n = 205), rotator cuff tear (RCT) (n = 185) and frozen shoulder (FS) (n = 210) patients who received treatment between 2010 and 2019 years. Two experienced physiotherapists palpated predefined points: long head of biceps brachii, pectoralis minor, lateral intermuscular septum, proximal tendons of extensor group. These points categorized into "proximal", "mid-proximal", "mid-distal", "distal", "irregular". We also grouped patients by their BMIs.

RESULTS

We found RCT patients had higher BMI than IS and FS patients (p < 0.001, p = 0.001); more tender intermuscular septum points and night pain than IS patients (p = 0.001, p = 0.003) and more extensor group proximal tendon points than IS and FS patients (p < 0.001, p = 0.001). "No tenderness" group had lesser resting pain than distal group (p < 0.001) and lesser activity and night pain than middle-proximal, middle-distal, and distal groups (all ps < 0.002). Distal group had higher night pain than middle-proximal group (p = 0.003). Morbidly obese patients had higher night pain than normal and overweight patients (p = 0.003 and p = 0.009).

CONCLUSIONS

Tender point distribution varies depending on the pathology with biceps brachii being the most common. RCT patients had higher night pain related to more distal tender points. Patients with higher night pain had increased tenderness in septum intermuscular and extensor muscles' proximal tendons.

Comparison of scapular position and upper extremity muscle strength in patients with and without lateral epicondylalgia: a case-control study

BACKGROUND

The symptoms of lateral epicondylalgia (LE) can be persistent, and recurrence is frequent. Recurrence can be related to proximal segment impairment of the kinetic chain. Knowledge of any relation in the kinetic chain in LE may help treatment. We aimed to investigate scapular position and upper extremity muscle strength in patients with LE and to compare them with controls.

METHODS

The study enrolled 51 patients with LE and 51 age-matched controls. We assessed scapular position asymmetry using the lateral scapular slide test and measured the strength of the upper trapezius (UT), middle trapezius (MT), lower trapezius, and serratus anterior muscles in addition to shoulder abduction, external rotation, and internal rotation and grip strength.

RESULTS

The percentage of participants with scapular asymmetry was greater in the patients than in the controls (P = .005). The involved side regarding shoulder external rotation among the patients was significantly weaker than in the controls (P = .016, P = .009). The involved side of the LE patients was significantly weaker than the uninvolved side in terms of shoulder abduction, external rotation, and internal rotation (P = .013, P = .048, P = .013). The UT/MT ratio on the nondominant side of the controls was significantly greater than that on the involved side of the LE patients (P = .016).

CONCLUSION

Upper extremity muscle strength, grip strength, UT/MT ratio, and scapular position are affected in patients with LE. In addition to the elbow, focusing on the upper segments is essential in the management of LE.

Efficacy of extracorporeal shockwave therapy in patients with lateral epicondylitis: A randomized, placebo-controlled, double-blind clinical trial

OBJECTIVE:

Lateral epicondylitis is a common elbow problem. Although extracorporeal shockwave therapy (ESWT) is widely used in the treatment of lateral epicondylitis, its efficacy is still controversial. Moreover, the number of prospective, randomized, controlled studies in the literature is not sufficient. Here, we intend to investigate the efficacy of ESWT.

METHODS:

The study was randomized, placebo-controlled, double-blind, and prospectively planned. Forty patients who met the inclusion criteria were divided into two groups, real ESWT (Group 1, n=20) and placebo ESWT (Group 2, n=20), in a 1: 1 randomized closed envelope manner. Patients were evaluated for Patient-Rated Tennis Elbow Evaluation-Turkish Version (PRTEE-T), visual analog scale (VAS) pain scores, and grip and pinching strengths. The evaluation were performed thrice before, at the end of treatment and 1 month after treatment. Both groups were treated with wrist splinting, ice treatment, and rest.

RESULTS:

There was no statistical difference between sex and dominant hand in both groups. There was no significant difference in the grasp and pinching strength between the measurements of the groups themselves (p>0.05). When examined in terms of VAS scores, only significant changes were found in the actual ESWT group (p<0.05). According to the PRTEE-T scores, both groups showed significant changes (p<0.05). No significant difference was found between post-treatment and control measures in the grip and pinching power between groups, VAS and PRTEE-T scores before treatment (p>0.05).

CONCLUSION:

Although pain and functional improvement were more prominent in our patients treated with ESWT than placebo, no statistically significant results were found.

Comparison of muscle activity of wrist extensors and kinematics of wrist joint during wrist extension in automobile assembly line workers with and without lateral epicondylitis

BACKGROUND

Overuse of the extensor carpi radialis (ECR) may play a role in the development of lateral epicondylitis (LE). However, no studies have investigated the muscle activity ratio between the ECR and extensor carpi ulnaris (ECU) associated with the kinematics during wrist extension in workers with LE.

OBJECTIVE

We compared the ratio (ECR/ECU) of muscle activity between the ECR and ECU and the kinematics of the wrist during wrist extension between workers with and without LE.

METHODS

Fifteen automobile assembly line workers with LE and 15 workers without LE participated in this study. The ratio of muscle activity was measured using surface electromyography, and wrist kinematics were measured by a three-dimensional motion analysis system while the workers extended their wrists actively to the maximum range to which they did not feel uncomfortable.

RESULTS

Significantly greater ratios of muscle activity, ranges of radial deviation, and combined motion of radial deviation and extension (CMDE) were shown in workers with LE compared to those without LE. Also, the range of wrist extension was significantly lower in workers with LE than in those without LE.

CONCLUSIONS

Quantifying the ratio of muscle activity with altered kinematics of wrist extension may help researchers to understand why overuse of ECR is occurring and explain LE development in automobile assembly line workers.

A Newly Designed Tennis Elbow Orthosis With a Traditional Tennis Elbow Strap in Patients With Lateral Epicondylitis

BACKGROUND

Lateral epicondylitis is a common cause of pain and upper limb dysfunction. The use of counterforce straps for treatment of lateral epicondylitis is widespread. This kind of orthosis can be modified to have a greater effect on relieving pain by reducing tension on the origin of the extensor pronator muscles.

OBJECTIVES

To determine the immediate effects of a newly designed orthosis on pain and grip strength in patients with lateral epicondylitis.

MATERIALS AND METHODS

Twelve participants (six men and six women) were recruited (mean age = 41 ± 6.7 years) and evaluated for pain and grip strength in three sessions. A 48-hour break was taken between each session. The first session was without any orthosis, the second session was with the new modified tennis elbow orthosis, and the third session was with a conventional tennis elbow strap.

RESULTS

Both counterforce straps were effective. However, significantly more improvement was observed in pain and grip strength after using the newly modified orthosis (P < 0.05).

CONCLUSIONS

The newly designed strap reduces pain more effectively and improves grip strength by causing greater localized pressure on two regions with different force applications (two component vectors versus one).

Tennis Elbow Diagnosis Using Equivalent Uniform Voltage to Fit the Logistic and the Probit Diseased Probability Models

To develop the logistic and the probit models to analyse electromyographic (EMG) equivalent uniform voltage- (EUV-) response for the tenderness of tennis elbow. In total, 78 hands from 39 subjects were enrolled. In this study, surface EMG (sEMG) signal is obtained by an innovative device with electrodes over forearm region. The analytical endpoint was defined as Visual Analog Score (VAS) 3+ tenderness of tennis elbow. The logistic and the probit diseased probability (DP) models were established for the VAS score and EMG absolute voltage-time histograms (AVTH). TV₅₀ is the threshold equivalent uniform voltage predicting a 50% risk of disease. Twenty-one out of 78 samples (27%) developed VAS 3+ tenderness of tennis elbow reported by the subject and confirmed by the physician. The fitted DP parameters were TV₅₀ = 153.0 mV (CI: 136.3–169.7 mV), γ₅₀ = 0.84 (CI: 0.78–0.90) and TV₅₀ = 155.6 mV (CI: 138.9–172.4 mV), m = 0.54 (CI: 0.49–0.59) for logistic and probit models, respectively. When the EUV ≥ 153 mV, the DP of the patient is greater than 50% and vice versa. The logistic and the probit models are valuable tools to predict the DP of VAS 3+ tenderness of tennis elbow.

Management of Tennis Elbow with sodium hyaluronate periarticular injections

Objectives

To determine the efficacy and safety of peri-articular hyaluronic acid injections in chronic lateral epicondylosis (tennis elbow).

Design

Prospective randomized clinical trial in primary care sport medicine.

Patients

Three hundred and thirty one consecutive competitive racquette sport athletes with chronic (>3 months) lateral epicondylosis were administered 2 injections (first injection at baseline) into the subcutaneous tissue and muscle 1 cm. from the lateral epicondyle toward the primary point of pain using a two-dimensional fanning technique. A second injection was administered 1 week later.

Outcomes measures

Assessments were done at baseline, days 7, 14, 30, 90 and 356. Efficacy measures included patient's visual analogue scale (VAS) of pain at rest (0-100 mm) and following assessment of grip strength (0-100 mm). Grip strength was determined using a jamar hydraulic hand dynamometer. Other assessments included patients' global assessment of elbow injury (5 point categorical scale; 1 = no disability, 5 = maximal disability), patients' assessment of normal function/activity (5 point categorical scale), patients/physician satisfaction assessment (10 point categorical scale), time to return to pain-free and disability-free sport and adverse events as per WHO definition. Differences between groups were determined using an intent-to-treat ANOVA.

Results

Average age of the study population was 49 years (± 12 years). One hundred and sixty-five patients were randomized to the HA and 166 were randomized to the control groups. The change in VAS pain was -6.7 (± 2.0) for HA vs -1.3 (± 1.5) for control (p < 0.001). The VAS post handgrip was -7.8 (± 1.3) vs +0.3 (± 2.0) (p < 0.001) which corresponded to a significant improvement in grip of 2.6 kg in the HA vs control groups (p < 0.01). Statistically significant improvement in patients' global assessment of elbow injury (p < 0.02), patients' assessment of normal function/activity (p < 0.05) and patients/physician satisfaction assessment (p < 0.05) were also observed favoring the HA group. Time to return to pain-free and disability-free sport was 18 (± 11) days in the HA group but was not achieved in the control group. VAS changes were maintained in the HA group at each followup while those in the control significantly declined from baseline. Assessment of patient and physician satisfaction continued to favor the HA group at subsequent followup.

Conclusion

Peri-articular HA treatment for tennis elbow was significantly better than control in improving pain at rest and after maximal grip testing. Further, HA treatment was highly satisfactory by patients and physicians and resulted in better return to pain free sport compared to control.

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.

An alternative approach to treating lateral epicondylitis. A randomized, placebo-controlled, double-blinded study

OBJECTIVE

To investigate the effect of noxious level electrical stimulation on pain, grip strength and functional abilities in subjects with chronic lateral epicondylitis.

DESIGN

Randomized, placebo-control, double-blinded study.

SETTING

Physical Therapy Department, North Georgia College and State University.

SUBJECTS

Eighteen subjects with chronic lateral epicondylitis between the ages of 24 and 72 years participated in this study. Subjects were randomly assigned into treatment or placebo groups.

INTERVENTIONS

Subjects received six sessions of low-frequency electrical stimulation over the palpated tender points. The intensity of electrical stimulation was set at 0 in the placebo group.

MAIN MEASUREMENTS

Grip strength, functional status, pain intensity and limited activity due to pain were assessed before and after treatment. Six-month follow-up data were collected in treatment group only.

RESULTS

Both clinically and statistically significant improvements in average grip strength were found (treatment group: 28% increase; placebo group: 2.5% decrease; P=0.04), functional activity (treatment group: 110% increase; placebo group: 22% increase; P= 0.003), pain intensity (treatment group: 3.1 point decrease; placebo group: 0.2 point increase; P=0.01) and activity limitation due to pain (treatment group: 4.1 points increase; placebo group: 1.9 point decrease; P= 0.003) between the treatment and placebo groups. Follow-up data showed that 100% of subjects maintained the improved function, and 83% remained pain-free for at least six months post treatment.

CONCLUSION

The results of this study indicated that symptoms of chronic lateral epicondylitis could be effectively treated by noxious level low-frequency electrical stimulation.

The effect of oscillating-energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study

Symptoms of lateral epicondylitis (LE) are attributed to degenerative changes and inflammatory reactions in the common extensor tendon induced by microscopic tears in the tissue after repetitive or overload functions of the wrist and hand extensor muscles. Conventional treatments, provided on the premise of inflammatory basis of LE, have shown 39-80% failure rate. An alternative approach suggests that symptoms of LE could be due to active tender points developed in the origin of hand and wrist extensor muscles after overuse or repetitive movements. Oscillating-energy Manual Therapy (OEMT), also known as V-spread, is a craniosacral manual technique that has been clinically used for treating tender points over the suture lines in the skull. Considering symptoms of LE may result from active tender points, the purpose of this study was to investigate the effect of OEMT on pain, grip strength, and functional abilities of subjects with chronic LE. Twenty-three subjects with chronic LE (>3mo) between ages of 24 and 72 years participated in this study. Before their participation, all subjects were screened to rule out cervical and other pathologies that could possibly contribute to their lateral elbow pain. Subjects who met the inclusion criteria were randomized into treatment and placebo treatment groups by a second (treating) therapist. Subjects were blinded to their group assignment. Subjects in the treatment group received OEMT for six sessions. During each treatment session, first a tender point was located through palpation. After proper hand placement, the therapist focused the direction of the oscillating energy on the localized tender point. Subjects in the placebo group underwent the same procedure, but the direction of the oscillating energy was directed to an area above or below the tender points, not covering the affected area. Jamar Dynamometer, Patient Specific Functional Scale (PSFS), and Numeric Rating Scale (NRS) were used to measure grip strength, functional status, and pain intensity and limited activity due to pain, respectively. The screening therapist who was blinded to the subjects' group assignment performed pretest, posttest, and six-month follow-up measurements. Subjects in the treatment group showed both clinically and statistically significant improvement in grip strength (p=0.03), pain intensity (p=0.006), function (p=0.003), and limited activity due to pain (p=0.025) compared with those in the placebo group. Follow-up data, collected after six months, showed no significant difference between posttest and follow-up measurements in functional activity (p=0.35), pain intensity (p=0.72), and activity limitation due to pain (p=0.34). Of all the subjects contacted for follow-up assessment, 91% maintained improved function and 73% remained pain free for at least six months. OEMT seems to be a viable, effective, and efficient alternative treatment for LE.

Strain reduction of the extensor carpi radialis brevis tendon proximal origin following the application of a forearm support band

STUDY DESIGN

Experimental laboratory design.

OBJECTIVES

To measure the strain at the proximal origin of the extensor carpi radialis brevis (ECRB), and to determine the influence of a forearm support band.

BACKGROUND

A forearm support band is often used with the intent to decrease stresses around the origin of the wrist extensors. However, the influence of the location of the band has not been studied.

METHODS AND MEASURES

The forearm support band was applied on 8 cadaver arms (mean +/- SD age, 78.4 +/- 10.3 years) and 2 experimental conditions were performed. First, strain measurements were made without applying tension to the distal ECRB tendon, then strain measurements were made with a traction force of 21.5 N being applied to the distal ECRB tendon. Strain of the proximal origin of the ECRB, 1.0 cm distal from the lateral epicondyle, was recorded using a strain gauge. The band was mounted on the forearm at distances equal to 80%, 70%, 60%, 50%, 40%, 30%, and 20% of the forearm length as measured from the wrist. Testing order was randomized. Tension applied to the band was 19.6 N.

RESULTS

When no tension was applied to the ECRB, there was no statistically significant difference (P>.05) in strain values at the ECRB origin by mounting the band at any of the forearm positions. In the tension condition, the average (SD) strain with no band was 2.40% (1.40%). The average strain value of 0.85% (0.65%), when the band was mounted 80% of the forearm length proximal to the wrist, was statistically smaller than that obtained without the band (P<.05).

CONCLUSIONS

The strain on the ECRB origin was less when the forearm support band was applied 80% proximal from the wrist joint.

LEVEL OF EVIDENCE

Therapy, level 5.

Effects of low-level laser and plyometric exercises in the treatment of lateral epicondylitis

OBJECTIVE

This study was undertaken to compare the effectiveness of a protocol of combination of laser with plyometric exercises and a protocol of placebo laser with the same program, in the treatment of tennis elbow.

BACKGROUND DATA

The use of low-level laser has been recommended for the management of tennis elbow with contradictory results. Also, plyometric exercises was recommended for the treatment of the tendinopathy.

METHODS

Fifty patients who had tennis elbow participated in the study and were randomised into two groups. Group A (n = 25) was treated with a 904 Ga-As laser CW, frequency 50 Hz, intensity 40 mW and energy density 2.4 J/cm(2), plus plyometric exercises and group B (n = 25) that received placebo laser plus the same plyometric exercises. During eight weeks of treatment, the patients of the two groups received 12 sessions of laser or placebo, two sessions per week (weeks 1-4) and one session per week (weeks 5-8). Pain at rest, at palpation on the lateral epicondyle, during resisted wrist extension, middle finger test, and strength testing was evaluated using Visual Analogue Scales. Also it was evaluated the grip strength, the range of motion and weight test. Parameters were determined before the treatment, at the end of the eighth week course of treatment (week 8), and eighth (week 8) after the end of treatment.

RESULTS

Relative to the group B, the group A had (1) a significant decrease of pain at rest at the end of 8 weeks of the treatment (p < 0.005) and at the end of following up period (p < 0.05), (2) a significant decrease in pain at palpation and pain on isometric testing at 8 weeks of treatment (p < 0.05), and at 8 weeks follow-up (p < 0.001), (3) a significant decrease in pain during middle finger test at the end of 8 weeks of treatment (p < 0.01), and at the end of the follow-up period (p < 0.05), (4) a significant decrease of pain during grip strength testing at 8 weeks of treatment (p < 0.05), and at 8 weeks follow-up (p < 0.001), (5) a significant increase in the wrist range of motion at 8 weeks follow-up (p < 0.01), (6) an increase in grip strength at 8 weeks of treatment (p < 0.05) and at 8 weeks follow-up (p < 0.01), and (7) a significant increase in weight-test at 8 weeks of treatment (p < 0.05) and at 8 weeks follow-up (p < 0.005).

CONCLUSION

The results suggested that the combination of laser with plyometric exercises was more effective treatment than placebo laser with the same plyometric exercises at the end of the treatment as well as at the follow-up. Future studies are needed to establish the relative and absolute effectiveness of the above protocol.

Muscle strain on the radial wrist extensors during motion-simulating stretching exercises for lateral epicondylitis: a cadaveric study

The purpose of this study is to measure muscle strain on the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) in cadavers and to identify effective stretching positions. In 12 frozen/thawed cadaveric arms, a strain gauge was attached to the ECRL and ECRB muscles, and increases in muscle strain were measured from a standard position (45 degrees elbow flexion, neutral forearm, and neutral wrist) to 12 sequential arm and wrist positions. Muscle strain on the ECRL and ECRB with the elbow at 45 degrees flexion was less than 10% regardless of forearm and wrist positions, whereas the majority of it was greater than 10% with the elbow extended. Maximal muscle strain on the ECRL and ECRB was obtained with elbow extension, forearm pronation, and wrist flexion-ulnar deviation, with mean values of 17.8% and 13.8%, respectively (greater than standard position, P < .05). Muscle stretching of the wrist extensors for lateral epicondylitis should be performed in this position.

Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial

OBJECTIVES

Pulsed low-intensity ultrasound therapy (LIUS) has been found to be beneficial in accelerating fracture healing and has produced positive results in animal tendon repair. In the light of this we undertook a randomized, double-blind, placebo controlled trial to assess the effectiveness of LIUS vs placebo therapy daily for 12 weeks in patients with chronic lateral epicondylitis (LE).

METHODS

Patients with LE of at least 6 weeks' duration were recruited from general practice, physiotherapy and rheumatology clinics, and had to have failed at least one first-line treatment including non steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injection. Participants were assigned either active LIUS or placebo. Treatment was self-administered daily for 20 min over a 12-week period. The primary end-point was a 50% improvement from baseline in elbow pain measured at 12 weeks using a patient-completed visual analogue scale.

RESULTS

Fifty-five subjects aged 18-80 were recruited over a 9-month period. In the active group 64% (16/25) achieved at least 50% improvement from baseline in elbow pain at 12 weeks compared with 57% (13/23) in the placebo group (difference of 7%; 95% confidence interval -20 to 35%). However, this was not statistically significant (chi(2) = 0.28, P = 0.60).

CONCLUSION

In this study LIUS was no more effective for a large treatment effect than placebo for recalcitrant LE. This is in keeping with other interventional studies for the condition.

Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy

OBJECTIVE

To identify key factors associated with outcomes of patients who underwent 8 weeks of physical therapy (PT) for lateral epicondylitis.

DESIGN

Multicenter prospective design with inception cohort of lateral epicondylitis patients commencing PT. Baseline clinical examinations were conducted by 1 physical therapist; self-report outcome measures were completed at baseline and 8 weeks later.

SETTING

Nine private sports medicine clinics and 2 hospital outpatient departments in Ontario, Canada.

PARTICIPANTS

Eighty-three patients with unilateral lateral epicondylitis identified by the treating physical therapists.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The final scores of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and a vertical pain visual analog scale (VAS) were used as the dependent variables.

RESULTS

The final prognostic model for the 8-week DASH scores included the baseline score (95% confidence interval [CI], 0.34-0.66), sex (female) (95% CI, 3.3-14.5), and self-reported nerve symptoms (95% CI, 0.8-13.8). The model for the 8-week VAS scores included the baseline score (95% CI, 0.01-0.37), sex (female) (95% CI, 0.4-18.2), and self-reported nerve symptoms (95% CI, 4.7-25.5). A subanalysis indicated that women were more likely than men to have work-related onsets, repetitive keyboarding jobs, and cervical joint signs. Among women, these factors were associated with higher final DASH and VAS scores.

CONCLUSIONS

Women and patients who report nerve symptoms are more likely to experience a poorer short-term outcome after PT management of lateral epicondylitis. Work-related onsets, repetitive keyboarding jobs, and cervical joint signs have a prognostic influence on women.

Litigants' epicondylitis

The speculated pathological causes of tennis elbow and the part work might play in its causation are briefly reviewed. The excellent surgical results, whatever operative technique was employed in those surgical series reported prior to the wave of work-related upper limb disorders is noted. One hundred and eight consecutive patients with tennis elbow who were also litigants (seeking compensation) were reviewed and the result of treatment and specifically surgery, analysed. Disappointing results of surgery were found in litigants and recommendations are made as to the management of litigants epicondylitis.

Biomechanical models for the pathogenesis of specific distal upper extremity disorders

BACKGROUND

Knowledge of the pathogenesis of most disorders that occur in the distal upper extremity is generally lacking. The individual roles of postulated etiologic factors, such as biomechanical or psychosocial exposures, are poorly understood and their potential interactions even less so. This article proposes biomechanical or physiological models of pathogenesis for specific distal upper extremity disorders.

METHODS

Tendon entrapment of the dorsal wrist compartments (tenosynovitis), peritendinitis, lateral epicondylitis, and carpal tunnel syndrome are common specific neuromusculoskeletal disorders of the upper extremities observed among workers. The normal anatomy and function of the targeted structures is considered the initial state; their pathology is considered the final state. Using biomechanical or physiological principles combined with clinical observations and experimental studies, pathways leading from the initial state to the final state are proposed. Each model defined a critical biomechanical or physiological attribute that was considered to best characterize 'dose.' Two temporal patterns of exposure (duration vs. repetition) were used to characterize 'dosage.' The roles of long-term exposure vs. unaccustomed work were mentioned, but not incorporated into the models.

RESULTS

Compressive force transmitted to the extensor retinaculum was considered the critical factor in the model for tendon entrapment at the dorsal wrist compartments. Two models were proposed for lateral epicondylitis. One emphasized the role of eccentric exertions; the other emphasized contact pressure from the radial head. The model for peritendinitis relied on localized muscle fatigue. Seven plausible models were presented for carpal tunnel syndrome.

CONCLUSIONS

It is possible to propose biologically plausible models of pathogenesis that are both coherent with current knowledge of tissue responses and consistent with clinical observations; however, more than one model was plausible for some conditions. Additional research is needed to determine which, if any, of the proposed models might be correct. Such models may be useful to health care providers and ergonomists in the context of primary, secondary, or tertiary prevention.

Associations between pain, grip strength, and manual tests in the treatment evaluation of chronic tennis elbow

OBJECTIVE

The objective was to assess the associations between changes in pain and grip strength and manual tests among patients with chronic tennis elbow.

DESIGN

Measurements for 45 consecutive patients with unilateral tennis elbow were made before and after an exercise intervention.

SETTING

The setting was a physiatric outpatient clinic.

PATIENTS

The patients were 45 persons with chronic unilateral tennis elbow: 32 women and 13 men. The mean age was 44 (31-54) years; mean duration of symptoms was 35 (10-66) weeks.

OUTCOME MEASURES

Manual tests, pressure pain thresholds at three cubital points, a pain questionnaire, a pain drawing, and grip strength measurements were assessed.

RESULTS

Grip strength became normal during the treatment. Pressure pain thresholds reached 66% of that of the healthy arm. Lowered pain thresholds and changes in pain thresholds of the lateral epicondyle were strongly associated with the findings in the manual tests. Mills test and resisted wrist extension tests were associated with perceived pain, and resisted wrist extension tests also were associated with decreased grip strength. Pain on palpation was associated with lowered pain thresholds at the lateral epicondylus and with perceived pain under physical load. After the treatment, for 13 patients all 4 manual tests were still positive; for 17 patients, 3 were still positive; and for 5 patients, all were negative. Positive clinical tests were associated with lowered pain thresholds, decreased grip strength, and high perceived pain scores.

CONCLUSIONS

Pain thresholds at the lateral epicondyles are strongly associated with pain on palpation and with a positive Mills test. Resisted wrist extension test results reflect decreased grip strength. Impaired function of the hand is associated with the number of positive clinical tests. Pain threshold evaluation is a simple, easy, inexpensive method that provides useful additional quantitative data on pain and disability among patients with chronic tennis elbow.

Chronic medial and lateral epicondylitis: a comparison of pain, disability, and function

OBJECTIVES

To investigate pain, disability, and muscle function of the arm in medial epicondylitis and to compare the results with those in chronic lateral epicondylitis.

DESIGN

Cross-sectional, case-control study.

SETTING

University hospital clinic admitting chronic hand patients.

PARTICIPANTS

Twenty-five patients with chronic unilateral medial epicondylitis and 25 age- and gender-matched patients with chronic unilateral lateral epicondylitis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Pain drawing (PD) and a pain questionnaire with 7 items of pain and disability on visual analog scale (VAS). Dolorimeter measurements of pressure pain thresholds (PPT) on 3 defined cubital points. The isometric grip strength and isokinetic performance of wrist and forearm at a radial velocity of 90 degrees/s.

RESULTS

Patients with medial epicondylitis had significantly less pain under strain (6.7 vs 7.9cm on VAS, P =.03) and a smaller PD (1.9 vs 2.5, P =.02) than patients with lateral epicondylitis. The PPTs of medial epicondyles were 54% (P =.0000) lower in medial epicondylitis. In lateral epicondylitis, all 3 cubital points showed significant decreases in PPTs. The isometric grip strength (mean and maximal) decreased by 6.2% and 3.6%, compared with the patients' healthy arms (P =.03,.16) and by 11.4% and 8.9% (P =.008,.02), respectively, compared with the expected value; in lateral epicondylitis, the grip strength decreased by 11.8% and 10.6% (P =.005,.01) and by 15% and 14% (P =.003,.007), respectively, when compared with the expected grip strength. Peak torque and produced work in wrist flexion were significantly reduced by 13% and 17% (P =.005,.0001), respectively, in both diseases. In lateral epicondylitis, supination and pronation were also reduced by 10% and 15% (P =.03).

CONCLUSIONS

In chronic medial epicondylitis, muscle function and pain measures showed a lesser impaired function of the arm than in chronic lateral epicondylitis. The results may be useful in rehabilitation and treatment of epicondylitis.

Orthotic devices for tennis elbow

BACKGROUND

Lateral epicondylitis (tennis elbow) is a frequently reported condition. A wide variety of treatment strategies has been described. As of yet, no optimal strategy has been identified.

OBJECTIVES

The objective of this review was to assess the effectiveness of orthotic devices for treatment of tennis elbow.

SEARCH STRATEGY

An electronic database search was conducted using Medline, Embase, Cinahl, the Cochrane Controlled Trial Register, Current Contents and reference lists from all retrieved articles. Experts on the subjects were approached for additional trials.

SELECTION CRITERIA

All randomised clinical trials (RCT) describing individuals with diagnosed lateral epicondylitis and comparing the use of an orthotic device as a treatment strategy were evaluated for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the validity of the included trials and extracted data on relevant outcome measures. Dichotomous outcomes were expressed as Relative Risks (RRs) and continuous outcomes as Standardised Mean Differences (SMD), both with corresponding 95% confidence intervals (95% CI). Statistical pooling and subgroup analyses were intended

MAIN RESULTS

Five small-size RCTs (N per group 7-49) were included. Validity score ranged from 3-9 positive items out of 11. Subgroup analyses were not performed due to the small number of trials. The limited number of included trials present few outcome measures and limited long-term results. Pooling was not possible due to large heterogeneity amongst trials.

REVIEWER'S CONCLUSIONS

No definitive conclusions can be drawn concerning effectiveness of orthotic devices for lateral epicondylitis. More well-designed and well-conducted RCTs of sufficient power are warranted.

Electromyographic patterns of individuals suffering from lateral tennis elbow

This study investigated the applicability of using surface electromyography (EMG) as a tool for differentiating between persons suffering from lateral tennis elbow and the healthy age-matched adults. Temporal muscle activation patterns of the tennis elbow group were evaluated to determine if they varied between subject groups and if noted variations might be interpreted as arresting or exacerbating the injury. Sixteen subjects (Healthy Controls, n = 6; Tennis Elbow, n = 10) were tested under simulated tennis playing conditions. All subjects were males (Healthy group (CON) 38.8 +/- 13.1, Injured group (INJ) 40.8 +/- 10.8 yrs). EMG response data, temporal and spatial muscle activities, of the forearm extensors (Ext), the forearm flexors (Flex) and the triceps (Tri) were recorded for each subject during a single test session using all combinations of three different velocities on three different racket head impact locations. Data were collected at a frequency of 1000 Hz. Statistical analysis was performed using a 2 x 3 x 3 (Health status x Impact velocity x Impact location) ANOVA with repeated measures. Results indicated statistically significant differences (p < 0.05) between the CON and INJ subject groups for the response variables associated with forearm extensor muscle activation. During simulated play, the INJ group employed an earlier, longer, and greater activation of Ext than the CON group, such changes may be considered detrimental to the healing process. These results support the use of surface EMG to quantify differences in muscle activation strategies employed by individuals suffering from soft tissue muscle microtrauma injuries and healthy controls.

Disputed radial tunnel syndrome

True neurogenic radial tunnel syndrome is an uncommon condition caused by entrapment of the radial or posterior interosseous nerve in the radial tunnel and is usually easily identifiable by focal motor weakness in the distribution of the posterior interosseous nerve. Roles and Maudsley, analogizing to carpal tunnel syndrome, believed "radial tunnel syndrome" had a different presentation: proximal forearm pain and tenderness in the region of the supinator muscle. However, their patients lacked weakness or other neurologic deficit. They and subsequent surgeons have decompressed the radial nerve to treat forearm pain and tenderness, even though it is debatable whether radial nerve entrapment causes the forearm discomfort. The term "radial tunnel syndrome" is best reserved for the truly neurogenic cases. Surgical approaches to "persistent tennis elbow" should be assessed in a controlled fashion, rather than adopted on the basis of a flawed analogy to carpal tunnel syndrome.

Reliability of a patient-rated forearm evaluation questionnaire for patients with lateral epicondylitis

PURPOSE

To determine the reliability of a questionnaire designed to assess forearm pain and function in patients with lateral epicondylitis.

METHODS

Forty-seven patients with unilateral lateral epicondylitis completed a patient-related forearm evaluation questionnaire (PRFEQ) on two occasions. Intraclass correlation coefficients (ICC 2,1), standard error of measurement (SEM), and 95% confidence intervals (CIs) were determined for the whole group and for three subgroup comparisons of male vs. female subjects, subacute vs. chronic lateral epicondylitis, and work-related vs. non-work-related lateral epicondylitis.

RESULTS

The test-retest reliability for the overall PRFEQ (ICC, 0.89), and its pain (ICC, 0.89) and function (ICC, 0.83) subscales was excellent. Test-retest reliability for patients with work-related lateral epicondylitis (ICC, 0.80) was significantly (p = 0.018) less than for patients with non-work-related lateral epicondylitis (ICC, 0.94).

CONCLUSIONS

The PRFEQ can provide a simple, quick, and reliable estimate of arm pain and function in patients with lateral epicondylitis. However, large SEM and 95% CIs limit its ability to accurately predict individual scores.

Bilaterally decreased motor performance of arms in patients with chronic tennis elbow

OBJECTIVE

To measure the motor performance of arms in patients with chronic unilateral tennis elbow.

DESIGN

Cross-sectional case-control study.

SETTING

University hospital clinic admitting chronic hand patients.

SUBJECTS

Thirty-two patients with chronic unilateral tennis elbow syndrome and 32 age- and gender-matched controls.

MAIN OUTCOME MEASURES

The motor performance of arms was measured with the Human Performance Measurement/Basic Elements of Performance system using the module for hands and the protocol of the device. Reaction times, speed of movement, and coordination as a combination of speed of movement and accuracy (number of correct hits) were measured. The results were compared between patients and controls.

RESULTS

Simple one-choice and two-choice reaction times were 19% to 36% slower in the patients than in the controls, and speed of movement was 31% to 32% slower in the patients than in the controls. The differences were statistically significant. The coordination results were 9.6bits/sec in the patients and 9.7bits/sec in the controls. The difference was not statistically significant. The reaction times and speed of movement did not differ significantly between the patients' involved and healthy arms. The patients' healthy arms showed significantly slower reaction times and speed of movement than the corresponding arms of the controls.

CONCLUSIONS

Unilateral chronic tennis elbow patients have bilaterally decreased reaction times and speed of movement of arms compared with age- and gender-matched controls. The cause for this phenomenon is unclear; the decreased motor performance may be primary and show an increased susceptibility to develop the tennis elbow syndrome or it may be a result of chronicity.

Radial epicondylalgia ('tennis elbow'): treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements

Stretching or upper forearm bands were used in the treatment of radial epicondylalgia ('tennis elbow') in a prospective study of 185 patients. The two consecutive series did not differ with respect to, for example, age (median 43 years), gender (57% men), symptom duration (mean 12 months) and symptomatic elbow (68% right), and were examined before and after 1 month of treatment, then at 3 and 9 months, and at a long-term follow-up (44/33 months). The 94 stretching-treated patients were instructed to perform home exercises twice daily, but were also treated at six physiotherapist sessions the first month. The other 91 patients were told to use a prescribed proximal forearm band in daily activities as much as possible. Both treatments were successful with a continuous symptom reduction, but the outcome was statistically significant in favour of stretching at all follow-ups, as assessed by subjective evaluation on a visual analogue pain scale, tabulated pain and condition alternatives on questionnaires, and objective findings such as palpation tenderness at the radial epicondyle, the (Mills') 'tennis elbow pain test', and range-of-motion. Practically all measured range-of-motions were restricted in both groups before treatment and did increase with stretching during the follow-up period, while the various changes in the forearm band group were statistically non-significant.

Corticosteroid injections for lateral epicondylitis: a systematic overview

BACKGROUND

Lateral epicondylitis (tennis elbow) is a common complaint, for which corticosteroid injections are a frequently applied therapy. However, there were no up-to-date reviews available that systematically addressed the effectiveness and adverse effects, including questions concerning optimal timing of injections and composition of the injection fluid.

AIM

The aim of the study was to assess the effectiveness of corticosteroid injections in the treatment of lateral epicondylitis (tennis elbow) by systematic review of the available randomized clinical trials.

DATA SOURCES

The data sources used were randomized clinical trials identified by literature searches of the MedLine (1966-1994) and Embase (Exerpta Medica) (1980-1994) databases for the keywords epicondylitis, tendinitis and elbow, injection. References given in relevant publications were further examined.

STUDY SELECTION

The criteria for selecting studies were as follows: randomized clinical trials (treatment allocation in random or alternate order); one of the treatments to include one or more corticosteroid injections (additional interventions were allowed); participants suffering from lateral epicondylitis; and publication in English, German or Dutch. Abstracts and unpublished studies were not included.

DATA SYNTHESIS

Methodological quality was assessed by means of a standardized criteria list (range 1-100 points). The extracted outcomes were the general conclusion drawn by the authors of the reports on the trials, and the success rates at the various follow-up points as (re)calculated by us. The success rates were subsequently graphically displayed and statistically pooled. Separate stratified analyses were conducted according to a predetermined analysis plan.

RESULTS

Twelve randomized clinical trials were identified. The median methodological score was 40 points, indicating an overall poor to moderate quality. The pooled analysis indicated short-term effectiveness (2-6 weeks): pooled odds ratio (OR) = 0.15 [95% confidence interval (CI) 0.10-0.23], chi 2 [degrees of freedom (df = 5) = 13.3], indicating statistical heterogeneity. At longer term follow-up, no difference could be detected. The studies of better methodological quality indicated more favourable results than those of lesser methodological quality. The most suitable corticosteroid to use as well as dosage, injection interval and injection volume could not be derived from the various trials.

CONCLUSION

The existing evidence on corticosteroid injections for the treatment of tennis elbow is not conclusive. Many trials were conducted in a secondary care setting and clearly had serious methodological flaws, and there was statistical heterogeneity among the trials. Corticosteroid injections appear to be relatively safe and seem to be effective in the short term (2-6 weeks). Although the treatment seems to be suitable for application in general practice, further trials in this setting are needed. As yet, questions regarding the optimal timing, dosage, injection technique and injection volume remain unanswered.

Tennis elbow: a review

Tennis elbow is a common yet sometimes complex musculoskeletal condition affecting many patients treated by physical therapists. The purpose of this article is to review the anatomy, clinical examination, differential diagnosis, conservative care, and surgical treatment for tennis elbow or lateral epicondylitis. Particular attention is given to determining the precise pathological cause of lateral epicondylitis, with consideration of intrinsic and extrinsic factors associated with this condition. This information should assist health care practitioners who treat patients with this disorder.

Diagnosing and treating lateral epicondylitis

Lateral epicondylitis is often encountered in primary care. Although its diagnosis can be fairly straightforward, its treatment is often difficult. This review examines the epidemiology, pathophysiology, and clinical presentation of tennis elbow. Management options are discussed.

Assessment of tennis elbow using the Marcy Wedge-Pro

The Marcy Wedge-Pro (MWP), a device used in training by tennis players, was employed in the assessment of tennis elbow. The MWP was used to measure the ability of patients to perform wrist extension exercises, since pain resulting from this specific activity is a prominent symptom of the condition. The MWP results were compared with clinical measures and found to identify accurately patients who responded to treatment (P < 0.05). This study illustrates the potential of the MWP to assess tennis elbow quantitatively.

Is low-energy laser treatment effective in lateral epicondylalgia?

The aim of this double-blind study was to explore the pain-alleviating effect of low energy laser in lateral epicondylalgia. Forty-nine patients were consecutively assigned at random to two groups, laser or placebo. The Mid 1500 Irradia laser was used with the following parameters: wavelength 904 nm; average power output 12 mW; peak value 8.3 W; frequency 70 Hz (pulse train 8000 Hz). The laser (Ga-As) was locally applied to 6 sites on and around the epicondyle. Each point was treated for 30 sec, resulting in a dose of 0.36 J/point and an area of treatment of 0.2 mm2. Patients were treated 2-3 times weekly, for a total of 10 treatments. Follow-ups were done after three and 12 mo. The statistical analysis showed that the laser treated group had a significant improvement in some objective outcomes after the treatment period and at the 3 mo follow-up, but there were no significant differences in the subjective outcomes between the groups. Irradia laser treatment may be a valuable therapy in lateral epicondylalgia, if carried out as described in this study. However, further studies are necessary before low energy laser can be employed as a pain-relieving method.

Fascial deformation in the lateral elbow region: a conceptual approach

In embalmed preparations, the antebrachial fascia in the lateral elbow region is shown to be deformed by load application to the triceps muscle. From this fascia, muscles arise which are primarily concerned with the extension of wrist and fingers. In the case of lateral epicondylitis (tennis elbow), the superficial site of attachment of these extensors at the lateral epicondyle is extremely painful. Triceps training may help to diminish (or prevent) this pain by altering the forces acting at the lateral epicondyle.

A rational management of tennis elbow

Tennis elbow is due to a torque injury or sudden overstretching of tendons which insert into the epicondyles of the humerus. The predominant lesion is an enthesopathy--a pathological lesion at the insertion of tendon into bone. The most common site is at the lateral epicondyle and this is 3 times as frequent as at the medial epicondyle. Approximately 50% of tennis players can expect to get a tennis elbow at some time during their playing lifetime. In one-third of the players this will be severe enough to interfere with their tasks of daily living. The major unresolved question about the aetiology of tennis elbow is why it has its peak incidence between the ages of 40 and 50 years and why 90% of players then have no further recurrence. Making sense of the literature on the treatment of tennis elbow is difficult because there are few studies that have used the acceptable epidemiological techniques of the prospective randomised controlled trial or case-controlled study. Most papers are based on a collection of highly selected cases which represent the more intractable end of the tennis elbow spectrum and their reported results have been inconsistent. Tennis elbow is largely a self-limiting condition. The prime aim of treatment should be based on Hippocrates' first tenet of medicine--first do no harm. Therapy should start with the simple and conservative before progressing to the more complex and invasive therapies. It should be acceptable to the patient, cost-effective and where invasive therapy is recommended, the potential benefits should clearly outweigh the risks. The principles of therapy for tennis elbow are to relieve pain, microbleeding and inflammation, promote healing, rehabilitate the injured arm and try to prevent recurrence. The most effective modalities of treatment are found to be cryotherapy in the acute stage then nonsteroidal anti-inflammatory drugs and heat in its various modalities including ultrasound. This is combined with rest which is best defined as the absence of painful activity. Injection of a depot preparation of cortisone is effective although patient reports are not as flattering as those of doctors. There is no advantage and in fact considerable disadvantage in using more than 2 such injections. Therapies such as acupuncture and chiropractic have not been evaluated. Nevertheless they cause no harm, may result in good and should be tried before resorting to more invasive therapy. Rehabilitation should run parallel to treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

Tennis elbow

Tennis elbow, or lateral epicondylitis, is a common condition of the elbow resulting from overuse during athletic or occupational activity. Functionally, it is a tendinitis of the origin of the forearm extensor muscle mass. Diagnosis is mainly based on symptoms and signs, including lateral elbow pain during twisting and gripping and tenderness at the lateral forearm exacerbated by stress testing of the forearm extensors. Comprehensive treatment should include rest, use of ice, antiinflammatory drug therapy, use of sleep-cycle modifiers, and sometimes surgery in otherwise unresponsive cases.

Decompression of the posterior interosseous nerve for tennis elbow

Decompression of the posterior interosseous nerve (PIN) was performed in 111 cases of tennis elbow. After a median follow-up time of 5 years, 85% showed improvement and 30% were almost completely relieved of their symptoms, the latter figure being considered to represent the real frequency of PIN entrapment. It thus seems that the PIN is one etiological factor in tennis elbow, but it cannot be distinguished from other causative factors by currently available methods. The confounding factor of PIN decompression being effective in cases of tennis elbow of other origins is discussed.

Effect of the counterforce armband on wrist extension and grip strength and pain in subjects with tennis elbow

This study investigated the effect of the lateral counterforce armband on wrist extension and grip strength, and pain of 14 subjects with tennis elbow. Dynametric strength tests and pain analogue scale assessments were obtained on the affected and unaffected arms of subjects, while wearing the armband and without wearing the armband. Use of the armband produced parallel effects in both the affected and unaffected arms, i.e., increases in wrist extension and grip strength. The greatest effects were seen in the affected arm. There was a statistically significant increase in wrist extension strength with the armband on relative to without the armband. The increase in wrist extension strength approximately doubled the increase in grip strength for both arms, indicating the armband's greater influence on wrist extension. Although there was a low negative correlation between changes in pain and strength, it was not statistically significant. J Orthop Sports Phys Ther 1989;11(5):192-197.