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Vinolo-Gil MJ, García-Campanario I, Estebanez-Pérez MJ, Rodríguez-Huguet M, Linares-Gago M, Martin-Vega FJ. Lateral and Medial Elbow Tendinopathy and Previous Injuries to Adjacent Joints: A Multicenter Observational Study. Healthcare (Basel) 2024; 12:1758. [PMID: 39273782 PMCID: PMC11394790 DOI: 10.3390/healthcare12171758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 08/29/2024] [Accepted: 08/30/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Lateral and medial elbow tendinopathies are common soft tissue disorders affecting 1-3% of the general population, causing significant pain and functional impairment in the elbow and upper limb. While often associated with overuse and repetitive strain, their exact etiology, including potential associations with prior injuries in adjacent joints, remains unclear. This preliminary study aims to explore the distribution of lateral and medial elbow tendinopathies and investigate the occurrence of previous lesions in adjacent joints among diagnosed individuals, providing foundational insights for future research. METHODS A multicenter cross-sectional observational study was conducted involving 90 subjects diagnosed with lateral and/or medial elbow tendinopathy. The data collection occurred during the initial consultations, including demographic information, clinical assessments, and history of prior injuries in adjacent joints. RESULTS Among the sample, 44.4% reported prior injuries to adjacent joints in the affected upper limb, with 45.6% of these injuries identified as musculotendinous in nature. The analysis also showed that the type of elbow tendinopathy was significantly associated with sex (p = 0.01) and occupational origin (p = 0.022). CONCLUSIONS While a notable percentage of the subjects reported prior musculoskeletal injuries in the same limb, the study's geographic limitations and reliance on self-reported data introduce potential recall bias. These preliminary findings suggest a possible relationship between prior adjacent joint injuries and elbow tendinopathy. Further research with larger sample sizes and more rigorous study design is needed to confirm these observations and explore the underlying mechanisms.
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Affiliation(s)
- Maria Jesus Vinolo-Gil
- Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain
- Rehabilitation Clinical Management Unit, Interlevels-Intercenters Hospital Puerta del Mar, Hospital Puerto Real, Cadiz Bay-La Janda Health District, 11006 Cadiz, Spain
- Research Unit, Biomedical Research and Innovation Institute of Cadiz (INiBICA), Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain
| | | | - María José Estebanez-Pérez
- Department of Physiotherapy, Faculty of Health Science, University of Malaga, 29071 Malaga, Spain
- Department of Physiotherapy, Faculty of Health Science, University of Granada, 18071 Granada, Spain
| | - Manuel Rodríguez-Huguet
- Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain
| | - Marta Linares-Gago
- Rehabilitation Clinical Management Unit, Interlevels-Intercenters Hospital Puerta del Mar, Hospital Puerto Real, Cadiz Bay-La Janda Health District, 11006 Cadiz, Spain
| | - Francisco Javier Martin-Vega
- Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain
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Wallis JA, Bourne AM, Jessup RL, Johnston RV, Frydman A, Cyril S, Buchbinder R. Manual therapy and exercise for lateral elbow pain. Cochrane Database Syst Rev 2024; 5:CD013042. [PMID: 38802121 PMCID: PMC11129914 DOI: 10.1002/14651858.cd013042.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
BACKGROUND Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain. OBJECTIVES To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain. SEARCH METHODS We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication. SELECTION CRITERIA We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals. MAIN RESULTS Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials). AUTHORS' CONCLUSIONS Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.
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Affiliation(s)
- Jason A Wallis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Allison M Bourne
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rebecca L Jessup
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Renea V Johnston
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Aviva Frydman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sheila Cyril
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Nimura A, Shimura H, Hoshika S, Fukai A, Akita K. Elbow anatomy in perspective of joint capsule and surrounding aponeuroses: a narrative review. JSES Int 2024; 8:654-660. [PMID: 38707559 PMCID: PMC11064712 DOI: 10.1016/j.jseint.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background Because of the proximity of several ligaments, aponeuroses, and capsule in the limited area of the elbow joint, the precise anatomy is difficult to understand. In the current narrative review, we focused on two anatomical perspectives: the capsular attachment and structures consisting of ligaments. Methods Based on the previously performed studies regarding the elbow anatomy, a narrative review was prepared in terms of the capsular attachment and structures consisting of ligaments. Results At the tip of the coronoid process, the joint capsule attaches roughly 6 mm distal to its tip with 6-12 mm length. On the lateral epicondyle of the humerus, the capsular attachment at the anterior part of the extensor carpi radialis brevis origin is narrower than the one distal to it. A single interpretation of the lateral collateral ligament is the capsulo-aponeurotic membrane, which is composed of the joint capsule intermingling with the supinator aponeurosis. The anterior bundle of the ulnar collateral ligament could be interpreted as the grossly separated collagenous structure from the tendinous complex, which is composed of the tendinous septum between the flexor digitorum superficialis and pronator teres muscle, the medial part of the brachialis muscle, and deep aponeurosis of the flexor digitorum superficialis muscle. Discussion Based on these perspectives, ligaments could function as a "static-dynamic" stabilizer rather than a simple static one.
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Affiliation(s)
- Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Haruhiko Shimura
- Department of Clinical Anatomy, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shota Hoshika
- Department of Clinical Anatomy, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsuhiro Fukai
- Department of Clinical Anatomy, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
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Bal E, Cetin O. Demonstrating the relationship of ultrasonographic parameters with disease activity and pain in lateral epicondylitis. Medicine (Baltimore) 2023; 102:e35499. [PMID: 37800806 PMCID: PMC10553164 DOI: 10.1097/md.0000000000035499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
To evaluate the relationship of ultrasonographic evaluation parameters with pain, muscle strength and disease severity in lateral epicondylitis (LE). 64 people were included in present retrospective, cross-sectional study. Activity and rest pain was questioned with Visual Analog Scale (VAS). Also, Patient Rated Tennis Elbow Evaluation (PRTEE) and the maximum grip strength were evaluated. Hypoechoic region, neovascularity, cortical irregularity, enthesopathy and peritendinous fluid or bursitis were evaluated by ultrasonography. 48 of the patients were female and 16 were male. Mean age was 48.53 ± 6.12, body mass index was 27.70 ± 4.75. 55 (85.9%) hypoechoic region, 31 (48.4%) neovascularity, 21 (32.8%) cortical irregularity, 19 (29,7%) enthesopathy, and 18 (28.1%) peritendinous fluid or bursitis were detected by ultrasonography. When the ultrasonographic findings and clinical findings of the patients were compared, no significant difference was found between the hypoechoic region, cortical irregularity, enthesopathy and clinical findings (P > .05), while the extension grip strength was found to be significantly lower in patients with neovascularity (P = .045). In addition, patients with peritendinous fluid or bursitis, were found to be significantly lower in both flexion (P = .033) and extension (P = .023) grip strength, while PRTEE function (P = .021) subgroup and total (P = .038) scores were significantly higher. Hypoechoic region, cortical irregularities and enthesopathy were not evaluated to be associated with disease severity, pain and muscle strength. Neovascularity was found to be associated only with extension grip strength. Peritendinous fluid or bursitis was found to be associated with both flexion and extension grip strength and disease activity, but not associated with pain.
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Affiliation(s)
- Emre Bal
- Fatih Sultan Mehmet Education and Training Hospital Orthopedics and Traumatology Department, Istanbul, Turkey
| | - Onur Cetin
- Medipol University, Camlica Hospital, Orthopedics and Traumatology Department, Istanbul, Turkey
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Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023; 27:1-389. [PMID: 37929629 PMCID: PMC10641714 DOI: 10.3310/tfws2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy. Review questions (i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies? Methods A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021. Results Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship. Limitations Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made. Conclusion The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence. Future work There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes. Study registration This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review). Funding This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kay Cooper
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Lyndsay Alexander
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - David Brandie
- Sportscotland Institute of Sport, Airthrey Road, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Isabelle Harrison
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Colin MacLean
- Library Services, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Laura Mitchell
- NHS Grampian, Physiotherapy Department, Ellon Health Centre, Schoolhill, Ellon, Aberdeenshire, UK
| | - Dylan Morrissey
- William Harvey Research Institute, School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, UK
| | - Rachel Ann Moss
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | | | - Joanna Shim
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
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Bonczar M, Ostrowski P, Dziedzic M, Kasprzyk M, Obuchowicz R, Zacharias T, Marchewka J, Walocha J, Koziej M. Evaluation of lateral epicondylopathy, posterior interosseous nerve compression, and plica syndrome as co-existing causes of chronic tennis elbow. INTERNATIONAL ORTHOPAEDICS 2023; 47:1787-1795. [PMID: 37071147 PMCID: PMC10267267 DOI: 10.1007/s00264-023-05805-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/30/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE A great number of patients that suffer from lateral epicondylitis, commonly called tennis elbow (TE), are not successfully treated, meaning, not getting adequate therapeutic effects and the main origin of the pain not being handled appropriately. The hypothesis of the present study is that the inefficiency of the treatment of the chronic TE may often be due to underdiagnosis of posterior interosseous nerve (PIN) entrapment or and plica syndrome, as the authors believe that those pathologies can often occur simultaneously. METHODS A prospective cross sectional study was conducted. A total of 31 patients met the required criteria. RESULTS Thirteen (40.7%) of the patients had more than one source of the lateral elbow pain. Five patients (15.6%) had all three examined pathologies. Six patients (18.8%) had TE and PIN syndrome. Two patients (6.3%) had TE and plica syndrome. CONCLUSION The present study demonstrated concomitant potential sources of lateral elbow pain in patients diagnosed with chronic TE. Our analysis shows how important it is to systematically diagnose patients that present with lateral elbow pain. The clinical characteristics of the three most common causes of chronic lateral elbow pain, meaning, TE, PIN compression, and plicae syndrome were also analyzed. Having adequate knowledge about the clinical aspects of these pathologies can help with a more effective differentiation of the etiology of chronic lateral elbow pain, and with that, a more efficient and cost-effective treatment plan.
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Affiliation(s)
- Michał Bonczar
- Department of Anatomy, Jagiellonian University Medical College, Mikołaja Kopernika 12, 33-332, Kraków, Poland.
- Youthoria, Youth Research Organization, Kraków, Poland.
| | - Patryk Ostrowski
- Department of Anatomy, Jagiellonian University Medical College, Mikołaja Kopernika 12, 33-332, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Martyna Dziedzic
- Department of Anatomy, Jagiellonian University Medical College, Mikołaja Kopernika 12, 33-332, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | | | - Rafał Obuchowicz
- Department of Diagnostic Imaging, Jagiellonian University Medical College, Kraków, Poland
| | | | | | - Jerzy Walocha
- Department of Anatomy, Jagiellonian University Medical College, Mikołaja Kopernika 12, 33-332, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Mikołaja Kopernika 12, 33-332, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
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Lerchbaumer MH, Diekhoff T. [MRI or ultrasound-which imaging technique do we need?]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:349-358. [PMID: 37039910 DOI: 10.1007/s00132-023-04368-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/12/2023]
Abstract
Diagnostic imaging of epicondylitis is primarily performed using widely available, radiation-free ultrasound. The dynamic examination allows a rapid point-of-care assessment. Typical imaging findings of epicondylitis include intratendinous hypoechogenic foci at the humeral origin, ossification at the enthesis, intratendinous calcifications, or (partial) rupture. In particular, Doppler sonography increases sensitivity by assessing possible neovascularization within the tendon. When sonographic findings are unclear or extensive, or when ultrasound machines or the required expertise in elbow examinations are not available, magnetic resonance imaging is indicated. Here, the use of proton density-weighted sequences is appropriate for assessing bone marrow and soft tissue edema and tendon tears, while ossifications are best delineated in T1weighted sequences. Projection radiography and computed tomography can be helpful for larger ossifications, although they are not part of the standard imaging protocol.
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Affiliation(s)
- Markus H Lerchbaumer
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Deutschland
- Interdisziplinäres Ultraschallzentrum und US-Forschungslabor, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Deutschland
| | - Torsten Diekhoff
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Deutschland.
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Ricci V, Cocco G, Mezian K, Chang KV, Naňka O, Tamborrini G, Kara M, Özçakar L. Anatomy and Sonographic Examination for Lateral Epicondylitis: EURO-MUSCULUS/USPRM Approach. Am J Phys Med Rehabil 2023; 102:300-307. [PMID: 36002120 DOI: 10.1097/phm.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study is to define a standardized comprehensive sonographic approach for evaluating the different histoanatomical compartments of the lateral elbow. DESIGN Using high-frequency ultrasound probes, we tried to match the anatomical features of the lateral elbow and its different sonographic patterns in patients with the diagnosis of lateral epicondylitis. Moreover, high-sensitive color/power Doppler assessments have also been performed to evaluate the microcirculation. RESULTS Modern ultrasound equipment seems to provide an extremely detailed sonographic assessment of the different anatomical layers located in the lateral compartment of the elbow. Moreover, high-sensitive color/power Doppler imaging allows for clear visualization of the perfusion patterns in pathological conditions. CONCLUSIONS In clinical practice, high-frequency B-mode and high-sensitive color/power Doppler imaging can be integrated with the clinical findings to better define the pain generator(s) for optimizing the management of patients with lateral epicondylitis.
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Affiliation(s)
- Vincenzo Ricci
- From the Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy (VR); Unit of Ultrasound in Internal Medicine, Department of Medicine and Science of Aging, G. d'Annunzio University, Chieti, Italy (GC); Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic (KM); Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei City, Taiwan (K-VC); Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic (ON); UZR, Ultraschallzentrum und Institut für Rheumatologie, Basel, Switzerland (GT); Rheumatology Clinic, University Hospital of Basel, Basel, Switzerland (GT); and Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey (MK, LÖ)
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9
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Ricci V, Mezian K, Cocco G, Tamborrini G, Fari G, Zunica F, Chang KV, Kara M, Özçakar L. Ultrasonography for Injecting (Around) the Lateral Epicondyle: EURO-MUSCULUS/USPRM Perspective. Diagnostics (Basel) 2023; 13:diagnostics13040717. [PMID: 36832216 PMCID: PMC9955720 DOI: 10.3390/diagnostics13040717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Lateral epicondylitis (LE) is a very common and painful condition seen in the daily practice of musculoskeletal physicians. Ultrasound-guided (USG) injections are commonly performed to manage the pain, promote the healing phase, and plan a tailored rehabilitation treatment. In this aspect, several techniques were described to target specific pain generators i the lateral elbow. Likewise, the aim of this manuscript was to extensively review those USG techniques together with the patients' pertinent clinical/sonographic features. The authors believe that this literature summary could also be refined as a practical, ready-to-use guide for planning the USG interventions of the lateral elbow in clinical practice.
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Affiliation(s)
- Vincenzo Ricci
- Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy
- Correspondence: ; Tel.: +39-3381137042
| | - Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine and General University Hospital, Charles University, 12800 Prague, Czech Republic
| | - Giulio Cocco
- Unit of Ultrasound in Internal Medicine, Department of Medicine and Science of Aging, University “G. d’Annunzio”, 66100 Chieti, Italy
| | - Giorgio Tamborrini
- UZR, Ultraschallzentrum und Institut für Rheumatologie, 4051 Basel, Switzerland
- Rheumatology Clinic, University Hospital of Basel, 4001 Basel, Switzerland
| | - Giacomo Fari
- Department of Translational Biomedicine and Neuroscience (DiBraiN), Aldo Moro University, 70121 Bari, Italy
- Department of Biological and Environmental Science and Technologies (Di.S.Te.B.A.), University of Salento, 73100 Lecce, Italy
| | - Fiammetta Zunica
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei 10845, Taiwan
| | - Murat Kara
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, 06100 Ankara, Turkey
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, 06100 Ankara, Turkey
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Low-Load Resistance Training With Blood Flow Restriction Is Effective for Managing Lateral Elbow Tendinopathy: A Randomized, Sham-Controlled Trial. J Orthop Sports Phys Ther 2022; 52:803-825. [PMID: 36099170 DOI: 10.2519/jospt.2022.11211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE: To evaluate the effect of low-load resistance training with blood flow restriction (LLRT-BFR) when compared to LLRT with sham-BFR in patients with lateral elbow tendinopathy (LET). DESIGN: Randomized controlled trial. METHODS: Forty-six patients with LET were randomly assigned to a LLRT-BFR or a LLRT with sham-BFR treatment group. All patients received soft tissue massage, supervised exercises with BFR or sham intervention (twice a week for 6 weeks), advice, and a home exercise program. The primary outcome measures were pain intensity, patient-rated tennis elbow evaluation (PRTEE) score, pain-free grip strength, and global rating of change, measured at baseline, 6 weeks, and 12 weeks. Between-group differences were evaluated using mixed-effects models with participant-specific random effects for continuous data. Global rating of change was analyzed using logistic regression. RESULTS: Statistically significant between-group differences were found in favor of LLRT-BFR compared to LLRT with sham-BFR in pain intensity at 12-week follow-up (-1.54, 95% CI: -2.89 to -0.18; P = .026), pain-free grip strength ratio at 6-week follow-up (0.20, 95% CI: 0.06 to 0.34; P = .005), and PRTEE at 6- and 12-week follow-up (-11.92, 95% CI: -20.26 to -3.59; P = .006, and -15.23, 95% CI: -23.57 to -6.9; P<.001, respectively). At 6- and 12-weeks, patients in the LLRT-BFR group had greater odds of reporting complete recovery or significant improvement (OR = 6.0, OR = 4.09, respectively). CONCLUSION: Low-load resistance training with blood flow restriction produced significantly better results compared to the LLRT with sham-BFR for all primary outcomes. Considering the clinically significant between-group improvement in function (>11 points in PRTEE) and the better success rates in the LLRT-BFR group, this intervention may improve recovery in LET. J Orthop Sports Phys Ther 2022;52(12):803-825. Epub: 14 September 2022. doi:10.2519/jospt.2022.11211.
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11
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Mediators and Moderators of Education Plus Exercise on Perceived Improvement in Individuals With Gluteal Tendinopathy: An Exploratory Analysis of a 3-Arm Randomized Trial. J Orthop Sports Phys Ther 2022; 52:826-836. [PMID: 36306175 DOI: 10.2519/jospt.2022.11261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE: To investigate mediators and moderators of effects of an education-plus-exercise program compared to corticosteroid injections or wait and see on perceived improvement in individuals with gluteal tendinopathy. METHODS: Exploratory analysis from a clinical trial (n = 204) comparing education plus exercise, corticosteroid injection, and wait and see on global rating of change at 52 weeks. Potential mediators measured at baseline and 8 weeks were hip active abduction range, abductor muscle torque, pain self-efficacy, pain constancy, and patient-specific function. Potential moderators at baseline were Victorian Institute of Sport Assessment for gluteal tendinopathy, menopausal status, symptom duration, magnetic resonance imaging-determined tendon pathology, and pain catastrophizing. RESULTS: There is evidence from mediation analysis that the beneficial effect of education plus exercise on global rating of change relative to corticosteroid injection or wait and see may be due to changes in patient-specific function (indirect effect relative risk; 95% CI: 1.14 [1.05-1.29], 1.29 [1.12-1.58], respectively), pain constancy (1.12 [1.03-1.27], 1.2 [1.08-1.41]), and pain self-efficacy (1.1 [1.02-1.25], 1.18 [1.04-1.44])-not active hip movement/muscle torque. Moderation analysis did not support our included patient characteristics. CONCLUSION: Education plus exercise is likely to improve global rating of change for persons with gluteal tendinopathy relative to corticosteroid injection and wait and see through improvements in patient-specific function, pain self-efficacy, and reduced pain constancy. We found no evidence of differences in the effect of education plus exercise in patient subgroups based on disability, menopausal status, symptom duration, tendon pathology, or pain catastrophizing. J Orthop Sports Phys Ther 2022;52(12):826-836. Epub: 17 October 2022. doi:10.2519/jospt.2022.11261.
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Droppelmann G, Tello M, García N, Greene C, Jorquera C, Feijoo F. Lateral elbow tendinopathy and artificial intelligence: Binary and multilabel findings detection using machine learning algorithms. Front Med (Lausanne) 2022; 9:945698. [PMID: 36213676 PMCID: PMC9537568 DOI: 10.3389/fmed.2022.945698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Ultrasound (US) is a valuable technique to detect degenerative findings and intrasubstance tears in lateral elbow tendinopathy (LET). Machine learning methods allow supporting this radiological diagnosis. Aim To assess multilabel classification models using machine learning models to detect degenerative findings and intrasubstance tears in US images with LET diagnosis. Materials and methods A retrospective study was performed. US images and medical records from patients with LET diagnosis from January 1st, 2017, to December 30th, 2018, were selected. Datasets were built for training and testing models. For image analysis, features extraction, texture characteristics, intensity distribution, pixel-pixel co-occurrence patterns, and scales granularity were implemented. Six different supervised learning models were implemented for binary and multilabel classification. All models were trained to classify four tendon findings (hypoechogenicity, neovascularity, enthesopathy, and intrasubstance tear). Accuracy indicators and their confidence intervals (CI) were obtained for all models following a K-fold-repeated-cross-validation method. To measure multilabel prediction, multilabel accuracy, sensitivity, specificity, and receiver operating characteristic (ROC) with 95% CI were used. Results A total of 30,007 US images (4,324 exams, 2,917 patients) were included in the analysis. The RF model presented the highest mean values in the area under the curve (AUC), sensitivity, and also specificity by each degenerative finding in the binary classification. The AUC and sensitivity showed the best performance in intrasubstance tear with 0.991 [95% CI, 099, 0.99], and 0.775 [95% CI, 0.77, 0.77], respectively. Instead, specificity showed upper values in hypoechogenicity with 0.821 [95% CI, 0.82, −0.82]. In the multilabel classifier, RF also presented the highest performance. The accuracy was 0.772 [95% CI, 0.771, 0.773], a great macro of 0.948 [95% CI, 0.94, 0.94], and a micro of 0.962 [95% CI, 0.96, 0.96] AUC scores were detected. Diagnostic accuracy, sensitivity, and specificity with 95% CI were calculated. Conclusion Machine learning algorithms based on US images with LET presented high diagnosis accuracy. Mainly the random forest model shows the best performance in binary and multilabel classifiers, particularly for intrasubstance tears.
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Affiliation(s)
- Guillermo Droppelmann
- Research Center on Medicine, Exercise, Sport and Health, MEDS Clinic, Santiago, RM, Chile
- Health Sciences Ph.D. Program, Universidad Católica de Murcia UCAM, Murcia, Spain
- Principles and Practice of Clinical Research (PPCR), Harvard T.H. Chan School of Public Health, Boston, MA, United States
- *Correspondence: Guillermo Droppelmann,
| | - Manuel Tello
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Nicolás García
- MSK Diagnostic and Interventional Radiology Department, MEDS Clinic, Santiago, RM, Chile
| | - Cristóbal Greene
- Hand and Elbow Unit, Department of Orthopaedic Surgery, MEDS Clinic, Santiago, RM, Chile
| | - Carlos Jorquera
- Facultad de Ciencias, Escuela de Nutrición y Dietética, Universidad Mayor, Santiago, RM, Chile
| | - Felipe Feijoo
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
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Karjalainen TV, Ponkilainen V, Chong A, Johnston RV, Le TLA, Lähdeoja TA, Buchbinder R. Glucocorticoid injections for lateral elbow pain. Hippokratia 2022. [DOI: 10.1002/14651858.cd001978.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Teemu V Karjalainen
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
- Department of Surgery; Central Finland Hospital Nova; Jyvaskyla Finland
| | - Ville Ponkilainen
- Department of Surgery; Central Finland Hospital Nova; Jyvaskyla Finland
| | - Alphonsus Chong
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine; National University of Singapore; Singapore Singapore
- Department of Hand and Reconstructive Microsurgery; National University Hospital; Singapore Singapore
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Thi Lan Anh Le
- Department of Hand and Reconstructive Microsurgery; National University Hospital; Singapore Singapore
| | - Tuomas A Lähdeoja
- Finnish Center of Evidence based Orthopaedics (FICEBO); University of Helsinki; Helsinki Finland
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
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14
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Fukai A, Nimura A, Tsutsumi M, Fujishiro H, Fujita K, Imatani J, Akita K. Lateral Ulnar Collateral Ligament of the Elbow Joint: Reconsideration of Anatomy in Terms of Connection with Surrounding Fibrous Structures. J Bone Joint Surg Am 2022; 104:1370-1379. [PMID: 35594488 DOI: 10.2106/jbjs.21.01406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND To improve the clinical results of lateral ulnar collateral ligament (LUCL) reconstruction of the elbow joint, better understanding of the anatomy of the aponeuroses and joint capsule could be relevant. This study considers the previously described anatomy of the LUCL in relation to the related aponeuroses and joint capsule rather than as a discrete ligament. We hypothesized that the deep aponeuroses of the superficial extensor muscles and supinator form a relevant portion of the joint capsule previously defined as the LUCL. METHODS Twenty-four elbows (12 right) from 21 embalmed cadavers (age at the time of death, 54 to 99 years) were included in the study. Twenty elbows were studied macroscopically and 4, histologically. The joint capsule was detached from the bones, and local thickness was quantitatively analyzed using micro-computed tomography (micro-CT). RESULTS The supinator aponeurosis and joint capsule intermingled to form a thick membrane (mean and standard deviation, 4.8 ± 1.2 mm), which we termed "the capsulo-aponeurotic membrane." It was thicker than the anterior (1.3 ± 0.4 mm) and posterior (2.5 ± 0.9 mm) parts of the capsule of the humeroradial joint (p < 0.001). The capsulo-aponeurotic membrane had a wide attachment on the distal part of the extensor digitorum communis and extensor digiti minimi (EDC/EDM) origin of the humerus, the lateral part of the coronoid process, and the posterior part of the radial notch of the ulna. The humeral attachment had a fibrocartilaginous structure. The deep aponeuroses of the EDC and extensor carpi ulnaris (ECU) were connected to the capsulo-aponeurotic membrane. CONCLUSIONS The capsulo-aponeurotic membrane was composed of the supinator aponeurosis and joint capsule and was attached to the lateral epicondyle of the humerus, radial side of the coronoid process, and posterior part of the radial notch on the ulna. The entire structure appeared identical to the commonly defined lateral collateral ligament. The most posterior part was connected to the EDC and ECU aponeuroses, which is commonly labeled the LUCL but does not exist as a discrete ligament. CLINICAL RELEVANCE Consideration of the accurate anatomy of the extensive attachment of the capsulo-aponeurotic membrane could provide useful clues for improvement in techniques of LUCL reconstruction and lateral epicondylitis pathology.
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Affiliation(s)
- Atsuhiro Fukai
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masahiro Tsutsumi
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Inclusive Medical Science Research Institute, Morinomiya University of Medical Sciences, Osaka, Japan
| | - Hitomi Fujishiro
- Department of Anatomy and Physiological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koji Fujita
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junya Imatani
- Department of Orthopaedic Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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15
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Amako M, Arai T, Iba K, Ikeda M, Ikegami H, Imada H, Kanamori A, Namba J, Nishiura Y, Okazaki M, Soejima O, Tanaka T, Tatebe M, Yoshikawa Y, Suzuki K. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication. J Orthop Sci 2022; 27:514-532. [PMID: 34922804 DOI: 10.1016/j.jos.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/12/2021] [Accepted: 09/12/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society. METHODS The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature. CONCLUSIONS The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.
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Affiliation(s)
- Masatoshi Amako
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Rehabilitation Medicine, National Defense Medical College Hospital, Japan.
| | - Takeshi Arai
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Japan
| | - Kousuke Iba
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Japan
| | - Masayoshi Ikeda
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Shonan Central Hospital, Japan
| | - Hiroyasu Ikegami
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Toho University, Japan
| | - Hideaki Imada
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Higashihiroshima Medical Center, Japan
| | - Akihiro Kanamori
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Tsukuba University Hospital, Japan
| | - Jiro Namba
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Japan Community Health Care Organization, Hoshigaoka Medical Center, Japan
| | - Yasumasa Nishiura
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Tsuchiura Clinical Education and Training Center, Tsukuba University Hospital, Japan
| | - Masato Okazaki
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopedic Surgery, Ogikubo Hospital, Japan
| | - Osamu Soejima
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Fukuoka Sanno Hospital, Japan
| | - Toshikazu Tanaka
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Kikkoman General Hospital, Japan
| | - Masahiro Tatebe
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Hand Surgery, Nagoya University, Japan
| | - Yasuhiro Yoshikawa
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Komazawa Hospital, Japan
| | - Katsuji Suzuki
- Lateral Epicondylitis Clinical Practice Guidelines Development Committee, Japan; Department of Orthopaedic Surgery, Okazaki Medical Center, Fujita Medical University, Japan
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16
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Karabinov V, Georgiev GP. Lateral epicondylitis: New trends and challenges in treatment. World J Orthop 2022; 13:354-364. [PMID: 35582153 PMCID: PMC9048498 DOI: 10.5312/wjo.v13.i4.354] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/14/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
Lateral epicondylitis (LE) is a chronic aseptic inflammatory condition caused by repetitive microtrauma and excessive overload of the extensor carpi radialis brevis muscle. This is the most common cause of musculoskeletal pain syndrome in the elbow, inducing significant pain and limitation of the function of the upper limb. It affects approximately 1-3% of the population and is frequently seen in racquet sports and sports associated with functional overload of the elbow, such as tennis, squash, gymnastics, acrobatics, fitness, and weight lifting. Typewriters, artists, musicians, electricians, mechanics, and other professions requiring frequent repetitive movements in the elbow and wrists are also affected. LE is a leading causation for absence from work and lower sport results in athletes. The treatment includes a variety of conservative measures, but if those fail, surgery is indicated. This review summarizes the knowledge about this disease, focusing on risk factors, expected course, prognosis, and conservative and surgical treatment approaches.
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Affiliation(s)
| | - Georgi P Georgiev
- Department of Orthopedics and Traumatology, University Hospital Queen Giovanna-ISUL, Medical University of Sofia, Sofia 1527, Bulgaria
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17
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Kenmoku T, Nakai D, Nagura N, Onuma K, Sukegawa K, Tazawa R, Otake Y, Takahira N, Takaso M. Tenodesis with bone marrow venting under local anesthesia for recalcitrant lateral epicondylitis: Results of 2 years of follow-up. JSES Int 2022; 6:696-703. [PMID: 35813152 PMCID: PMC9264004 DOI: 10.1016/j.jseint.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hypothesis We hypothesized that the treatment of recalcitrant lateral epicondylitis requires accurate identification of the painful area to promote remodeling of the degenerated extensor insertion and to stabilize the tendon origin during tendon healing. Thus, we performed tenodesis with bone marrow venting under local anesthesia for recalcitrant lateral epicondylitis. Methods Twenty patients (21 elbows) were treated with bone marrow venting at the painful area of the lateral epicondyle of the elbow and tenodesis using 2 soft anchors lateral to the capitellum (immediately distal to the painful area) and were followed up for ≥2 years. Patients were assessed using the numerical rating scale for pain and the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, and objective evaluation included active range of motion. Results The mean preoperative and postoperative pain scores were 7.5 and 0.5, respectively, indicating significant pain relief (P < .001). The mean preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand questionnaire scores were 44.2 and 1.0, respectively (P < .001). Two elbows had a slightly positive Thomsen test at the final visit. No recurrence of intra-articular symptoms induced by synovial fringe impingement was observed. Patients experienced more pain at the bone-tendon junction of extensors than at the tendon parenchyma. Conclusion Tenodesis with bone marrow venting under local anesthesia was effective for subjective patient satisfaction and positive clinical outcomes at ≥2 years of follow-up in patients with recalcitrant lateral epicondylitis. Intra-articular symptoms can be improved by stabilization of the lateral soft tissue without treatment for intra-articular lesions.
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Efficacy of Fu's Subcutaneous Needling on Myofascial Trigger Points for Lateral Epicondylalgia: A Randomized Control Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:5951327. [PMID: 35321501 PMCID: PMC8938053 DOI: 10.1155/2022/5951327] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/30/2021] [Accepted: 02/12/2022] [Indexed: 11/17/2022]
Abstract
Lateral epicondylalgia (LE), a common overuse syndrome of the extensor muscle and tendons on the lateral epicondyle, causes persistent severe musculoskeletal pain on the outer part of the elbow. Fu's subcutaneous needling (FSN), a newly invented subtype of acupuncture and dry needling, is a new trend and potential treatment of LE by targeting the myofascial trigger points (MTrPs). However, no scientific evidence is available to support this method. This study aims to evaluate the distal FSN treatment on the LE by measuring pain-related scales, such as visual analog scale (VAS), pressure pain threshold (PPT), muscle tissue hardness (TH), pain-free grip (PFG), and the functional outcome by a patient-rated tennis elbow evaluation (PRTEE) questionnaire study. A total of 60 LE patients were randomly divided into FSN (n = 30) and transcutaneous electrical nerve stimulation (TENS, n = 30) as the control group. Every subject was treated with three regimens and followed up for 15 days. Results showed that FSN has an immediate effect on VAS, PPT, TH, and PFG. Moreover, sustained effects on pain relief were followed up to 15 days. Pain remission was consistent with long-term PRTEE results. Overall, FSN is a safe and efficient therapy option for LE, significantly improving pain relief and activity difficulty with immediate, short-term, and long-term effectiveness. This trial is registered with ClinicalTrials.gov NCT03605563.
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Ibrahim NH, El Tanawy RM, Mostafa AFS, Mahmoud MF. Extracorporeal shock wave therapy (ESWT) versus local corticosteroid injection in treatment of lateral epicondylitis (tennis elbow) in athletes: clinical and ultrasonographic evaluation. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2021. [DOI: 10.1186/s43166-021-00081-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Lateral epicondylitis is one of the commonly noticed disorders of the arm described by agony focused over lateral epicondyle which is the site of wrist extensors origin. The purpose of this work was to compare the efficiency of extracorporeal shock wave therapy and local corticoid injection in management of lateral epicondylitis both clinically and ultrasonographically as well as to assess the role of ultrasound in diagnosis and follow-up of lateral epicondylitis. This study was performed on 30 athletes diagnosed as lateral epicondylitis.
Results
Both corticosteroid injection and shock wave treatment showed a highly significant effectiveness on pain by visual analog scale (VAS). A highly significant difference between before treatment and after 2 as well as 4 weeks of treatment regarding the functional disability parameters as patient-rated tennis elbow evaluation (PRTEE) and quick disabilities of the arm, shoulder, and hand (DASH) was found. Likewise, a statistically significant improvement in favor of shock wave therapy group after 2 weeks was found, inversely insignificant difference after 8 and 12 weeks regarding to VAS occurred. Both PRTEE and Quick DASH test showed a statistically significant difference among groups through all follow-up period.
There was a statistically insignificant difference among the studied groups according to ultrasound (US) changes in the form of focal areas of hypo-echogenicity through follow-up periods. A significant improvement in favor of ESWT group is detected among the studied groups regarding tendon thickening in ultrasonography before treatment and after 2 and 4 weeks. However, the difference was insignificant after 8 and 12 weeks.
Conclusions
Both corticosteroid local injection and shock wave therapy are helpful and effective for lateral epicondylitis treatment. However, a shock wave therapy revealed better improvement on long-term clinical and ultrasonogrphic follow-up than corticosteroid injection. Musculoskeletal ultrasound represents a helpful diagnostic and follow-up tool for lateral epicondylitis.
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Daniels SP, De Tolla JE, Azad A, Fritz J. Imaging Evaluation of Medial and Lateral Elbow Pain: Acute and Chronic Tendon Injuries of the Humeral Epicondyles. Semin Musculoskelet Radiol 2021; 25:589-599. [PMID: 34706389 DOI: 10.1055/s-0041-1731790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.
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Affiliation(s)
- Steven P Daniels
- Department of Radiology, New York University Grossman School of Medicine, New York University, New York, New York
| | - Jadie E De Tolla
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York University, New York, New York
| | - Ali Azad
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York University, New York, New York
| | - Jan Fritz
- Department of Radiology, New York University Grossman School of Medicine, New York University, New York, New York
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21
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Evidenced-Based Management of Tennis Elbow. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021. [DOI: 10.1007/s40141-021-00322-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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22
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Karjalainen TV, Silagy M, O'Bryan E, Johnston RV, Cyril S, Buchbinder R. Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain. Cochrane Database Syst Rev 2021; 9:CD010951. [PMID: 34590307 PMCID: PMC8481072 DOI: 10.1002/14651858.cd010951.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Autologous whole blood or platelet-rich plasma (PRP) injections are commonly used to treat lateral elbow pain (also known as tennis elbow or lateral epicondylitis or epicondylalgia). Based on animal models and observational studies, these injections may modulate tendon injury healing, but randomised controlled trials have reported inconsistent results regarding benefit for people with lateral elbow pain. OBJECTIVES To review current evidence on the benefit and safety of autologous whole blood or platelet-rich plasma (PRP) injection for treatment of people with lateral elbow pain. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase for published trials, and Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal for ongoing trials, on 18 September 2020. SELECTION CRITERIA We included all randomised controlled trials (RCTs) and quasi-RCTs comparing autologous whole blood or PRP injection therapy to another therapy (placebo or active treatment, including non-pharmacological therapies, and comparison between PRP and autologous blood) for lateral elbow pain. The primary comparison was PRP versus placebo. Major outcomes were pain relief (≥ 30% or ≥ 50%), mean pain, mean function, treatment success, quality of life, withdrawal due to adverse events, and adverse events; the primary time point was three months. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 32 studies with 2337 participants; 56% of participants were female, mean age varied between 36 and 53 years, and mean duration of symptoms ranged from 1 to 22 months. Seven trials had three intervention arms. Ten trials compared autologous blood or PRP injection to placebo injection (primary comparison). Fifteen trials compared autologous blood or PRP injection to glucocorticoid injection. Four studies compared autologous blood to PRP. Two trials compared autologous blood or PRP injection plus tennis elbow strap and exercise versus tennis elbow strap and exercise alone. Two trials compared PRP injection to surgery, and one trial compared PRP injection and dry needling to dry needling alone. Other comparisons include autologous blood versus extracorporeal shock wave therapy; PRP versus arthroscopic surgery; PRP versus laser; and autologous blood versus polidocanol. Most studies were at risk of selection, performance, and detection biases, mainly due to inadequate allocation concealment and lack of participant blinding. We found moderate-certainty evidence (downgraded for bias) to show that autologous blood or PRP injection probably does not provide clinically significant improvement in pain or function compared with placebo injection at three months. Further, low-certainty evidence (downgraded for bias and imprecision) suggests that PRP may not increase risk for adverse events. We are uncertain whether autologous blood or PRP injection improves treatment success (downgraded for bias, imprecision, and indirectness) or withdrawals due to adverse events (downgraded for bias and twice for imprecision). No studies measured health-related quality of life, and no studies reported pain relief (> 30% or 50%) at three months. At three months, mean pain was 3.7 points (0 to 10; 0 is best) with placebo and 0.16 points better (95% confidence interval (CI) 0.60 better to 0.29 worse; 8 studies, 523 participants) with autologous blood or PRP injection, for absolute improvement of 1.6% better (6% better to 3% worse). At three months, mean function was 27.5 points (0 to 100; 0 is best) with placebo and 1.86 points better (95% CI 4.9 better to 1.25 worse; 8 studies, 502 participants) with autologous blood or PRP injection, for absolute benefit of 1.9% (5% better to 1% worse), and treatment success was 121 out of 185 (65%) with placebo versus 125 out of 187 (67%) with autologous blood or PRP injection (risk ratio (RR) 1.00; 95% CI 0.83 to 1.19; 4 studies, 372 participants), for absolute improvement of 0% (11.1% lower to 12.4% higher). Regarding harm, we found very low-certainty evidence to suggest that we are uncertain whether withdrawal rates due to adverse events differed. Low-certainty evidence suggests that autologous blood or PRP injection may not increase adverse events compared with placebo injection. Withdrawal due to adverse events occurred in 3 out of 39 (8%) participants treated with placebo versus 1 out of 41 (2%) treated with autologous blood or PRP injection (RR 0.32, 95% CI 0.03 to 2.92; 1 study), for an absolute difference of 5.2% fewer (7.5% fewer to 14.8% more). Adverse event rates were 35 out of 208 (17%) with placebo versus 41 out of 217 (19%) with autologous blood or PRP injection (RR 1.14, 95% CI 0.76 to 1.72; 5 studies; 425 participants), for an absolute difference of 2.4% more (4% fewer to 12% more). At six and twelve months, no clinically important benefit for mean pain or function was observed with autologous blood or PRP injection compared with placebo injection. AUTHORS' CONCLUSIONS Data in this review do not support the use of autologous blood or PRP injection for treatment of lateral elbow pain. These injections probably provide little or no clinically important benefit for pain or function (moderate-certainty evidence), and it is uncertain (very low-certainty evidence) whether they improve treatment success and pain relief > 50%, or increase withdrawal due to adverse events. Although risk for harm may not be increased compared with placebo injection (low-certainty evidence), injection therapies cause pain and carry a small risk of infection. With no evidence of benefit, the costs and risks are not justified.
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Affiliation(s)
- Teemu V Karjalainen
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
- Department of Surgery, Central Finland Hospital Nova, Jyvaskyla, Finland
| | - Michael Silagy
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Edward O'Bryan
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Sheila Cyril
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
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Ultrasound-Guided Percutaneous Neuromodulation in Patients with Chronic Lateral Epicondylalgia: A Pilot Randomized Clinical Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094877. [PMID: 34063673 PMCID: PMC8125558 DOI: 10.3390/ijerph18094877] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim was to analyze effects of a percutaneous neuromodulation (PNM) treatment on the radial nerve, regarding pain, functionality, electrophysiologic excitability, and morphology, in patients with chronic lateral epicondylalgia (LE). METHODS Twenty-four patients with chronic unilateral elbow pain were recruited for this preliminary study and were divided into two groups: control (n = 12) and PNM group (n = 12). The subjects in the PNM group received percutaneous peripheral neurostimulation with an acupuncture needle that was located next to the nerve with ultrasound guidance. Pain using a numerical rating scale (NRS), functional ability using patient-rated tennis elbow evaluation (PRTEE), radial nerve cross-sectional area measured by ultrasound, and chronaxie and accommodation index (AI) measured by the strength-duration curve were evaluated. RESULTS Both groups showed no differences in the baseline measurements (all p = 0.001). However, at the end of the treatment, there were significant differences between groups since only the PNM group significantly improved their values compared to their baseline values: level of pain and cross-sectional area (CSA) values showed a significant decrease while the PRTEE scores showed a significant improvement. Then, regarding AI, the PNM group showed significant improvement for the electrophysiologic nerve excitability pattern, reporting normal function in all radial nerves after treatment (p = 0.001). However, chronaxie values always reported similar values with no differences between groups (p >0.05); Conclusion: Ultrasound-PNM technique may be an interesting therapeutic tool for the treatment of chronic LE due to the improvement in the level of pain, functionality, nerve morphology, and excitability in this population.
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Turgay T, Günel Karadeniz P, Sever GB. Comparison of low level laser therapy and extracorporeal shock wave in treatment of chronic lateral epicondylitis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:591-595. [PMID: 33423990 DOI: 10.5152/j.aott.2020.19102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to compare the efficacy of extracorporeal shock wave therapy (ESWT) ver-sus low-level laser therapy (LLLT) in treating chronic lateral epicondylitis (CLE). METHODS In this prospective study, 52 patients (24 males, 28 females; mean age=48 years; age range=30-70 years) with a diagnosis of CLE were included and randomized into two groups (26 in each group): ESWT group (14 males, 12 females; mean age=48±10 years) or LLLT group (10 males, 16 females; mean age=48±11 years). ESWT was applied for 5 weeks with one session per week, while LLLT was applied with 15 sessions on consecutive days. All patients were evaluated using Disability of the Arm, Shoulder and Hand Questionnaire (DASH), Patient-Related Lateral Epicondy-litis Evaluation (PRTEE), and the 36-Item Short-Form Health Survey (SF-36) before and after the treatments. RESULTS In the comparison of baseline data between treatment groups, significant differences were observed only in SF-Physical functioning and SF-Energy/fatigue scores (p=0.035 and p=0.038, re-spectively), which were 77.1±17.2 and 56.3±17.2 in ESWT group and 66.5±18.0 and 44.8±21.5 in LLLT group, respectively. In the comparison of post-treatment data between groups, there were sig-nificant differences in all scores (p<0.05) except two subscales of SF-36, which were SF-role limita-tions due to emotional problems (p=0.092) and physical health (p=0.147), respectively. The other subscales of SF-36, PRTEE and DASH scores obtained after the treatments were better in ESWT group than in LLLT group. The comparison of pre-and post-treatment scores in each group revealed significant improvements in all scores (p<0.05), except SF-36 subscales, including energy/fatigue, emotional well-being, social functioning, and general health scores (p>0.05). CONCLUSION Evidence from this study revealed that although both treatment modalities were effective in the treatment of CLE, ESWT seemed to more effective in pain relief and functional recovery than LLLT. LEVEL OF EVIDENCE Level II, Therapeutic study.
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Affiliation(s)
- Türkan Turgay
- Department of Physiotherapy and Rehabilitation, SANKO University, School of Medicine, Gaziantep, Turkey;Department of Physical Medicine and Rehabilitation, SANKO University, Sani Konukoğlu Research and Practice Hospital, Gaziantep, Turkey
| | - Pınar Günel Karadeniz
- Department of Biostatistics, SANKO University, School of Medicine, Gaziantep, Turkey
| | - Gökhan Bülent Sever
- Department of Physiot herapy and Rehabilitation, SANKO University, School of Health Sciences, Gaziantep, Turkey
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Krogh TP, Fredberg U, Ammitzbøll C, Ellingsen T. Clinical Value of Ultrasonographic Assessment in Lateral Epicondylitis Versus Asymptomatic Healthy Controls. Am J Sports Med 2020; 48:1873-1883. [PMID: 32484714 DOI: 10.1177/0363546520921949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ultrasonography (US) is often used in the assessment of lateral epicondylitis (LE). The strength of evidence supporting its role is, however, not well-documented. PURPOSE To describe and compare the US tendinopathic changes observed in patients with LE and the general population, including any correlation between patient characteristics and US outcomes. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Tendon thickness, color Doppler activity, and bone spur were assessed by US in 264 participants with healthy elbows and 60 patients with chronic LE. In addition to patient characteristics, Patient-Rated Tennis Elbow Evaluation (PRTEE) score, pain, and disability were recorded. RESULTS Depending on the measurement technique used, mean LE tendon thickness increased by 0.53 mm (10.2%) or 0.70 mm (14.5%) as compared with the contralateral arm and 0.40 mm (7.9%) or 0.41 mm (8.5%) as compared with the general population. Mean color Doppler activity (scale, 0-4) was 3.47 in the LE arm versus 0.13 in the contralateral asymptomatic arm and 0.26 in the general population. Bone spur was observed in 78% of the LE arms as opposed to 45% in the contralateral arms and 50% in the general population. In the LE group and the general population, the prevalence of bone spur increases with age. No correlations were observed with pain, disability, PRTEE, and disease duration. CONCLUSION Increased common extensor tendon thickness is part of the tendinopathic changes observed in LE. However, given the marked variation in natural tendon thickness and small increases in tendon thickness in patients with LE, this technique cannot be used as a stand-alone diagnostic tool but rather as a supplement to the overall assessment. The contralateral elbow (if asymptomatic) is a better tendon thickness comparator than a general population mean value. Color Doppler activity is an indicator of ongoing tendinopathy and supports the LE diagnosis, but it is not pathognomonic for the condition. Absence of Doppler activity in a patient with suspected LE should raise suspicion of other diagnoses. Identification of a bone spur is of very limited clinical value given the high prevalence in the general population. The important outcomes of pain, disability, PRTEE, and disease duration did not correlate with any of the investigated US techniques.
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Affiliation(s)
- Thøger P Krogh
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Torkell Ellingsen
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Rheumatology, Odense University Hospital, Odense, Denmark
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[Ultrasound-guided percutaneous tenotomy in chronic wrist extensor enthesopathy]. Rehabilitacion (Madr) 2020; 54:211-214. [PMID: 32563618 DOI: 10.1016/j.rh.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 11/21/2022]
Abstract
Epicondylitis causes disability and tends to become chronic. Histologically, degenerative lesions are found in the common extensor tendon, which are visible on ultrasound or magnetic resonance imaging. Several conservative therapeutic measures are available, including corticosteroid infiltration by anatomical landmark. However, these measures sometimes fail, in which case patients are proposed for surgery. Ultrasound is a therapeutic tool that allows procedures on tendons to be performed without skin incisions. The technique of ultrasound-guided percutaneous tenotomy for the treatment of chronic epicondylitis was first reported in 2006. This procedure, demonstrated to date by surgeons and radiologists, attempts to transform a chronic degenerative process with failure to repair into an acute inflammatory process with self-regeneration. The aim of this study was to describe 5 cases of epicondylitis that failed to respond to routine therapeutic measures, in which we used ultrasound-guided percutaneous tenotomy with favourable results.
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Park CH, Kim BS, Lee JH, Chung SG. Optimal Elbow Positions for Identification of the Radial Collateral Ligament Using Ultrasonography. PM R 2019; 12:671-678. [PMID: 31671237 DOI: 10.1002/pmrj.12274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/24/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The standard position for examining the lateral elbow with ultrasonography is an "extended" or "slightly flexed" position. However, because the radial collateral ligament (RCL) is more deeply attached on the lateral epicondyle than the common extensor tendon, an anisotropic artifact of the RCL could be observed in the conventional positions, making it difficult to fully visualize the RCL. OBJECTIVES To determine optimal elbow positions for accurate identification of the RCL and to explore the relevant landmarks in ultrasonography. DESIGN Prospective study. SETTING Tertiary university hospital. PARTICIPANTS Forty healthy elbows of 20 participants. METHODS The RCL was evaluated using ultrasonography in six elbow flexion positions (0°, 30°, 60°, 90°, 120°, and 140°). The relative depth, defined as the depth of the capitellum subtracted by the depth of the radial head under ultrasonography, was measured at each angle. The rates of successful identification of ultrasonographic landmarks for localizing the RCL were calculated. After ultrasonography, the optimal elbow position for identifying the RCL was determined by group consensus. MAIN OUTCOME MEASUREMENTS Relative depth between radial head and capitellum, rates of successful identification of ultrasonographic landmarks, and consensus-based determination of the optimal angle. RESULTS The relative depth significantly decreased with an increase in the flexion angle (P for trend <.001), approaching zero at the angles of 90° and 120°. The rates of successful identification of the superior tubercle, hyperechogenic line, and anterior and posterior tubercles were 100%, 100%, 90%, and 80%, respectively. In the group consensus, the 90° and 120° flexion angles were selected with the highest frequency (90%; 36/40). CONCLUSION Our findings suggest that elbow flexion at 90° or 120° is optimal for visualization of the RCL with the least possibility of anisotropy under ultrasonography, suggesting that the elbow should be flexed considerably beyond the conventional extended or slightly flexed position.
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Affiliation(s)
- Chul-Hyun Park
- Department of Rehabilitation Medicine, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea.,Chung-Ang University College of Medicine and Graduate School of Medicine, Seoul, Republic of Korea
| | - Beom Suk Kim
- Department of Physical Medicine & Rehabilitation, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jae Hyun Lee
- Department of Rehabilitation Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Sun Gun Chung
- Department of Rehabilitation Medicine, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea.,Institute of Aging, Seoul National University, Seoul, Republic of Korea.,Rheumatism Research Institute, Medical Research Center, Seoul National University, Seoul, Republic of Korea
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Strength-Duration Curves of Radial Nerve in Patients With Lateral Elbow Pain. J Sport Rehabil 2019; 29:754-759. [PMID: 31629328 DOI: 10.1123/jsr.2018-0405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/20/2019] [Accepted: 05/28/2019] [Indexed: 11/18/2022]
Abstract
CONTEXT Lateral epicondylalgia (LE) refers to a painful condition at or around the lateral epicondyle of the humerus. LE is one of the most common injuries of the elbow; however, the cause of the pathology is not clear. Patients often experience symptoms consistent with a radial nerve injury; however, data on the involvement of the radial nerve are needed. OBJECTIVE To analyze the relationship between electrophysiologic excitability and morphology of the radial nerve in patients with unilateral chronic LE. DESIGN Cross-sectional study. SETTING Department of Physiotherapy, University of Seville. PATIENTS A total of 56 elbows (28 right, 28 left) in 28 patients (12 females, 16 males; age 49 [7.37] y) were recruited by convenience sampling. MAIN OUTCOME MEASURES Strength-duration curves (chronaxia and accommodation index) and cross-sectional area (CSA) of the radial nerve were made in all participants. All parameters were compared between both limbs. Also, pain with palpation in the lateral epicondyle and functional pain of involved extremities was assessed using visual analog scale and the Patient-Rated Tennis Elbow Evaluation, respectively. RESULTS Symptomatic limb showed higher CSA values of the radial nerve when compared with the asymptomatic limb (P < .001). On the symptomatic limb, duration of symptoms was positively correlated with CSA values. Chronaxia values were all normal and similar between both limbs (P = .35). Regarding accommodation index, 14 (54%) patients showed accommodation indices that suggested pathological radial nerve on the right limb, 4 (14%) on the left limb, 5 (18%) on both limbs, and 4 (14%) had none of the affected nerves. Eight-six percent of patients showed accommodation indices that suggested pathological radial nerve, independently of symptomatic limb. In these cases, affected nerves had higher CSA than the unaffected nerve (P = .01). On the affected nerves, duration of symptoms was positively correlated with accommodation indices. CONCLUSIONS These findings suggest that patients with unilateral chronic LE show a decreased excitability in any radial nerve, independently of the symptomatic limb, and that pathological nerves have higher CSA than the nonpathological nerves.
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Bureau NJ, Destrempes F, Acid S, Lungu E, Moser T, Michaud J, Cloutier G. Diagnostic Accuracy of Echo Envelope Statistical Modeling Compared to B-Mode and Power Doppler Ultrasound Imaging in Patients With Clinically Diagnosed Lateral Epicondylosis of the Elbow. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2631-2641. [PMID: 30729545 DOI: 10.1002/jum.14964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To compare the accuracy of homodyned K quantitative ultrasound (QUS) with that of B-mode and Doppler ultrasound imaging for discriminating between lateral epicondylosis (LE) and asymptomatic elbows. METHODS This prospective study received Institutional Review Board approval, and participants provided written informed consent. Between February 2015 and March 2017, 30 LE elbows in 27 patients and 24 asymptomatic elbows in 13 volunteers underwent B-mode, Doppler, and radiofrequency ultrasound imaging of the common extensor tendon (CET) and radial collateral ligament (RCL). Two readers classified the elbows independently on the basis of a review of B-mode and Doppler images. The global and local estimates of QUS parameters (μ n , 1/α, and k) were computed in the CET and CET-RCL regions, respectively, and the area of each region was calculated. A random-forest classifier identified the most discriminating 3-parameter combination: CET global estimate of 1/α, CET-RCL area, and local estimate of k. RESULTS The patients with LE had a mean age of 50 years (range, 31-66 years), and the volunteers had a mean age of 50 years (range, 37-57 years). The area under the receiver operating characteristic curve, sensitivity, and specificity of reader 1, reader 2, and the QUS-based model were 0.80 (95% confidence interval [CI], 0.66-0.95), 0.72 (95% CI, 0.56-0.89), and 0.88 (95% CI, 0.72-1.04); 0.79 (95% CI, 0.66-0.93), 0.65 (95% CI, 0.47-0.82), and 0.84 (95% CI, 0.67-1.01); and 0.82 (95% CI, 0.80-0.85), 0.73, and 0.79, respectively. CONCLUSIONS An automated, computer-based QUS technique diagnosed LE with accuracy of 0.82. This technique could provide quantitative biomarkers for the characterization of LE disease.
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Affiliation(s)
- Nathalie J Bureau
- Departments of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
- Departments of Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - François Destrempes
- Departments of Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Souad Acid
- Department of Radiology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain, Brussels, Belgium
| | - Eugen Lungu
- Departments of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Thomas Moser
- Departments of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
- Departments of Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Johan Michaud
- Departments of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Guy Cloutier
- Departments of Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Alessio-Mazzola M, Repetto I, Biti B, Trentini R, Formica M, Felli L. Autologous US-guided PRP injection versus US-guided focal extracorporeal shock wave therapy for chronic lateral epicondylitis: A minimum of 2-year follow-up retrospective comparative study. J Orthop Surg (Hong Kong) 2019; 26:2309499017749986. [PMID: 29320964 DOI: 10.1177/2309499017749986] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To compare the efficacy of two independent groups of patients treated with ultrasound (US)-guided extracorporeal shock wave (ESW) therapy and with US-guided injection of platelet-rich plasma (PRP) for chronic lateral epicondylitis (LE) with a minimum of 2-year follow-up. METHODS We retrospectively evaluated 63 patients treated for chronic LE (31 patients with autologous US-guided PRP injection and 32 patients with US-guided focal ESW therapy) from 2009 to 2014. All the patients were evaluated by means of Roles-Maudsley (RM) score, quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, visual analogic scale (VAS) and patient-rated tennis elbow evaluation (PRTEE) to retrospectively assess the pain relief, level of activity, the self-reported function and subjective satisfaction at minimum of 2-year follow-up. RESULTS Both US-guided autologous PRP injection and US-guided focal ESW administration proved effective in chronic LE with significant improvement in the QuickDASH, VAS, RM and PRTEE scores ( p < 0.0001). No adverse effects or complications were recorded in any groups. No differences were found in recurrence rate and final results of the QuickDASH, VAS, RM and PRTEE scores between the two groups ( p > 0.05). The mean time between treatment and symptom resolution was significantly shorter for the PRP treatment ( p = 0.0212); furthermore, the mean time to return to the normal activities was quicker for PRP group ( p = 0.0119). CONCLUSION Both PRP injection and ESW therapy are feasible and safe options for the treatment of chronic LE with low risk of complications and with good long-term follow-up results. US-guided PRP injection has quick efficacy when compared with US-guided focal ESW therapy.
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Affiliation(s)
- Mattia Alessio-Mazzola
- Orthopaedic Clinic, Department of Surgical Sciences (DISC), IRCCS San Martino IST, Genova, Italy
| | - Ilaria Repetto
- Orthopaedic Clinic, Department of Surgical Sciences (DISC), IRCCS San Martino IST, Genova, Italy
| | - Besmir Biti
- Orthopaedic Clinic, Department of Surgical Sciences (DISC), IRCCS San Martino IST, Genova, Italy
| | - Roberto Trentini
- Orthopaedic Clinic, Department of Surgical Sciences (DISC), IRCCS San Martino IST, Genova, Italy
| | - Matteo Formica
- Orthopaedic Clinic, Department of Surgical Sciences (DISC), IRCCS San Martino IST, Genova, Italy
| | - Lamberto Felli
- Orthopaedic Clinic, Department of Surgical Sciences (DISC), IRCCS San Martino IST, Genova, Italy
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31
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Magnetic resonance imaging of patients with lateral epicondylitis: Relationship between pain and severity of imaging features in elbow joints. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2019; 53:366-371. [PMID: 31040053 PMCID: PMC6819801 DOI: 10.1016/j.aott.2019.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 03/05/2019] [Accepted: 04/07/2019] [Indexed: 11/21/2022]
Abstract
Objective The aim of this study was to determine the inter- and intra-observer reliabilities of magnetic resonance imaging (MRI) for the diagnosis of lateral epicondylitis, to examine whether degree of common extensor tendon (CET) injury is related to other elbow abnormalities on MRI, and to investigate the correlation between elbow abnormalities on MRI and patients' symptoms. Methods Fifty-one patients (32 women and 19 men; mean age: 50 years (range, 22–63)) with a diagnosis of lateral epicondylitis were included in the study. The average duration of symptoms was 2.3 years. MRI scoring system was used to grade the CET injuries and associated injuries in the elbow joint. Three independent radiologists retrospectively reviewed MRI images. Inter- and intra-observer reliabilities for diagnosing lateral epicondylitis were calculated using kappa statistics, and Spearman's rank correlation analysis was used to analyze relationships between degree of CET injury and the associated abnormalities of elbow joints. Statistical relations were considered significant for p values of <0.05. In addition, using Spearman's rank correlation analysis, CET injuries and associated abnormalities of elbow joints were correlated with clinical symptoms using visual analog scale pain scores. Results Various degrees of CET injuries were found in total of 51 patients. Radial collateral ligament and lateral ulnar collateral ligament (RCL/LCL) was the most common accompanying elbow abnormality other than CET injuries. Inter- and intra-observer agreements of CET and RCL/LUCL injuries on MRI were excellent. There were significant correlation between degrees of CET and RCL/LUCL injuries (correlation coefficient r = 0.667, p < 0.01) and between degree of RCL/LUCL injuries and visual analog 11-point pain box scale (VAS) scores (correlation coefficient r = 0.478, p = 0.033). Conclusion MRI showed excellent inter- and intra-observer reliabilities for the evaluation of lateral epicondylitis. In addition to common extensor tendinopathy, RCL/LUCL abnormality was the most common accompanying finding and degree of RCL/LUCL injuries positively correlated with degree of CET injuries. Furthermore, degree of RCL/LUCL injuries positively correlates with severity of pain. Level of evidence Level IV, Diagnostic study.
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The Effectiveness of Shockwave Therapy in Patients with Lateral Epicondylitis. CURRENT HEALTH SCIENCES JOURNAL 2019; 44:368-373. [PMID: 31123614 PMCID: PMC6421473 DOI: 10.12865/chsj.44.04.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/30/2018] [Indexed: 11/18/2022]
Abstract
Shockwave therapy is based on generating a very intense energy in a very short period of time. It creates a mechanical pressure over the affected tissues that leads to an increased cellular permeability, thus increasing the microcirculation and the cellular metabolism. Therefore, the healing process is accelerated. Lateral epicondylitis represents a common arm injure, which usually affects early to late middle-aged patients, more common and with a longer evolution period in women, characterized by inflammation of the arm muscles’ tendon insertion and manifests with pain on elbow extension and forearm rotation. Our study aims to investigate the efficacity of the shockwave therapy in comparison with a classical treatment of local and systemic drugs. The 50 patients were evenly split into two groups. The diagnosis of lateral epicondylitis was based on exhaustive physical examination. Enthesis evaluation was performed through power Doppler ultrasound. The pain was quantified using the visual analogue scale for pain intensity. All parameters were evaluated at diagnosis and after 30 days, following treatment. One group received shockwave therapy, while the other group received nonsteroidal anti-inflammatory drugs and local topics associated with laser and ultrasound application. The results of our study report that both groups experienced significant improvement after treatment. The shockwave therapy recorded a higher improvement rate in all the parameters. Consequently, this new non-invasive, effective and safe technique can be successfully used in the treatment of abarticular pathology of the elbow.
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Martin JI, Atilano L, Merino J, Gonzalez I, Iglesias G, Areizaga L, Bully P, Grandes G, Andia I. Predictors of Outcome Following Tenotomy in Patients with Recalcitrant Epicondylopathy. PM R 2019; 11:979-988. [PMID: 30609276 DOI: 10.1002/pmrj.12064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 12/02/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Elbow tendinopathies are associated with tenderness, pain, and functional disability with ensuing socioeconomic costs. There is lack of consensus regarding the best treatment for patients recalcitrant to first-line conservative treatments. Percutaneous needle tenotomy is considered a regenerative approach that injures the tendon to elicit a healing response. OBJECTIVE To investigate whether demographic characteristics, clinical factors, baseline sonographic entities, or their interactions are related to the likelihood of responding positively to needle tenotomy over a 1-year follow-up period. DESIGN Prospective case series. SETTING Tertiary institutional hospital. PARTICIPANTS Patients with elbow tendinopathy for whom conservative treatments had failed and who had persistent symptoms lasting for at least 3 months. METHODS Patients underwent needle tenotomy with or without PRP followed by a lighter needle tenotomy within a 2-week interval as part of treatment. MAIN OUTCOME MEASUREMENTS Disabilities of the Arm, Shoulder and Hand (DASH) and Visual Analogue Scale for pain (VAS-P) scores were assessed before intervention (baseline) and at 6 weeks and 3, 6, and 12 months after intervention. A generalized linear mixed effects model was created to examine whether injectate type, clinical, demographic, or pretreatment sonographic entities or their interactions influenced clinical outcomes. RESULTS The authors analyzed 74 elbows (71 patients). At baseline, analyzed patients (mean age: 49.48 years; 51.35% women) scored 43.30 and 5.83 on the DASH and VAS-P, respectively. Pretreatment tendon vascularization was a predictor of pain (P = .011) and DASH score changes (P = .019). The linear mixed effect model revealed that male gender and hypercholesterolemia were associated with enhanced functional recovery, (P = .020 and P < .001, respectively). Moreover, the interactions between pretreatment vascular status (P = .039), echotexture (P = .037) and enthesophytes (P = .028) influenced the temporal pattern of functional recovery after needle tenotomy. CONCLUSIONS Baseline patient characteristics, such as gender and hypercholesterolemia, along with ultrasound features may be predictive of outcomes following needle tenotomy for elbow tendinopathy. LEVEL OF EVIDENCE IV (NCT01945528).
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Affiliation(s)
- Jose I Martin
- Department of Radiology, Interventional Sonography Cruces, University Hospital, Barakaldo, Spain.,Regenerative Medicine, BioCruces Health Research Institute, Cruces University Hospital, Biscay, Spain
| | - Leire Atilano
- Department of Radiology, Interventional Sonography Cruces, University Hospital, Barakaldo, Spain.,Regenerative Medicine, BioCruces Health Research Institute, Cruces University Hospital, Biscay, Spain
| | - Josu Merino
- Regenerative Medicine, BioCruces Health Research Institute, Cruces University Hospital, Biscay, Spain.,Department of Orthopedic Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Igor Gonzalez
- Regenerative Medicine, BioCruces Health Research Institute, Cruces University Hospital, Biscay, Spain.,Department of Orthopedic Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Gotzon Iglesias
- Department of Radiology, Interventional Sonography Cruces, University Hospital, Barakaldo, Spain.,Regenerative Medicine, BioCruces Health Research Institute, Cruces University Hospital, Biscay, Spain
| | - Luis Areizaga
- Regenerative Medicine, BioCruces Health Research Institute, Cruces University Hospital, Biscay, Spain.,Department of Orthopedic Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Paola Bully
- Primary Care Research Unit of Bizkaia, BioCruces Health Research Institute, Bilbao, Spain
| | - Gontzal Grandes
- Primary Care Research Unit of Bizkaia, BioCruces Health Research Institute, Bilbao, Spain.,Enkarterrri-Ezkerraldea-Cruces Health Region, Basque Health Service (Osakidetza), Bilbao, Spain
| | - Isabel Andia
- Regenerative Medicine, BioCruces Health Research Institute, Cruces University Hospital, Biscay, Spain
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Relationship between ultrasound detected tendon abnormalities, and sensory and clinical characteristics in people with chronic lateral epicondylalgia. PLoS One 2018; 13:e0205171. [PMID: 30356266 PMCID: PMC6200215 DOI: 10.1371/journal.pone.0205171] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 09/20/2018] [Indexed: 12/22/2022] Open
Abstract
Objective To investigate the relationship between tendon structural changes determined by static ultrasound images (US) and sensory changes using quantitative sensory testing (QST), and clinical measures in lateral epicondylalgia. Materials and methods Both elbows of 66 adult participants with a clinical diagnosis of lateral epicondylalgia were investigated. Using a standardised ultrasound image rating scale, common extensor hypoechogenicity, heterogenicity, neovascularity, and bony abnormalities at the enthesis were scored, and tendon thickness (longitudinal and transverse plane) was measured by a trained assessor. Sensory measures of pressure, heat and cold pain thresholds and vibration detection threshold were recorded. Pain and function were assessed using the patient-rated tennis elbow (PRTEE), pain-free grip strength, pain visual analog scale (PVAS) and quality of life (EuroQoL EQ -5D). Univariate and multivariate linear regression analyses were used to explore the association between tendon structural, sensory and clinical variables which were adjusted for age, gender and duration of symptoms. Results A negative correlation was identified between the presence of neovascularity and cold pain threshold (P = 0.015). Multiple regression analyses revealed that a combination of female gender (P = 0.044) and transverse tendon thickness (P = 0.010) were significantly associated with vibration detection threshold in affected elbows, while gender (P = 0.012) and total ultrasound scale score (P = 0.024) were significantly associated with heat pain threshold and vibration detection threshold in unaffected elbows. Heat pain threshold and gender were significantly associated with pain and disability (PRTEE; P < 0.001), and pain-free grip strength (P < 0.001) respectively, in the affected elbows. Conclusion Generally, structural and sensory measures were weakly correlated. However, neovascularity and transverse tendon thickness may be related to sensory system changes in LE.
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Prado-Costa R, Rebelo J, Monteiro-Barroso J, Preto AS. Ultrasound elastography: compression elastography and shear-wave elastography in the assessment of tendon injury. Insights Imaging 2018; 9:791-814. [PMID: 30120723 PMCID: PMC6206379 DOI: 10.1007/s13244-018-0642-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/22/2018] [Accepted: 06/21/2018] [Indexed: 12/27/2022] Open
Abstract
Ultrasound elastography (USE) is a recent technology that has experienced major developments in the past two decades. The assessment of the main mechanical properties of tissues can be made with this technology by characterisation of their response to stress. This article reviews the two major techniques used in musculoskeletal elastography, compression elastography (CE) and shear-wave elastography (SWE), and evaluates the studies published on major electronic databases that use both techniques in the context of tendon pathology. CE accounts for more studies than SWE. The mechanical properties of tendons, particularly their stiffness, may be altered in the presence of tendon injury. CE and SWE have already been used for the assessment of Achilles tendons, patellar tendon, quadriceps tendon, epicondylar tendons and rotator cuff tendons and muscles. Achilles tendinopathy is the most studied tendon injury with USE, including the postoperative period after surgical repair of Achilles rupture tendon. In relation to conventional ultrasound (US), USE potentially increases the sensitivity and diagnostic accuracy in tendinopathy, and can detect pathological changes before they are visible in conventional US imaging. Several technical limitations are recognised, and standardisation is necessary to ensure repeatability and comparability of the results when using these techniques. Still, USE is a promising technique under development and may be used not only to promote an early diagnosis, but also to identify the risk of injury and to support the evaluation of rehabilitation interventions. KEY POINTS: • USE is used for the assessment of the mechanical properties of tissues, including the tendons. • USE increases diagnostic performance when coupled to conventional US imaging modalities. • USE will be useful in early diagnosis, tracking outcomes and monitoring treatments of tendon injury. • Technical issues and lack of standardisation limits USE use in the assessment of tendon injury.
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Affiliation(s)
- Rui Prado-Costa
- Department of Physical and Rehabilitation Medicine, Centro Hospitalar São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - João Rebelo
- Department of Radiology, Centro Hospitalar São João, Porto, Portugal.
| | - João Monteiro-Barroso
- Department of Physical and Rehabilitation Medicine, Centro Hospitalar São João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Ana Sofia Preto
- Department of Radiology, Centro Hospitalar São João, Porto, Portugal
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Frydman A, Johnston RV, Smidt N, Green S, Buchbinder R. Manual therapy and exercise for lateral elbow pain. Hippokratia 2018. [DOI: 10.1002/14651858.cd013042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Aviva Frydman
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash Department of Clinical Epidemiology, Cabrini Hospital; 154 Wattletree Road Malvern VIC Australia 3144
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash Department of Clinical Epidemiology, Cabrini Hospital; 154 Wattletree Road Malvern VIC Australia 3144
| | - Nynke Smidt
- University Medical Center Groningen, University of Groningen; Department of Epidemiology; Hanzeplein (Entrance 24) Groningen Groningen Netherlands PO Box 30.001, 9700 RB
| | - Sally Green
- School of Public Health & Preventive Medicine; Cochrane Australia; Monash University 553 St Kilda Road Melbourne Victoria Australia 3004
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash Department of Clinical Epidemiology, Cabrini Institute; 4 Drysdale Street Malvern Victoria Australia 3144
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Lungu E, Grondin P, Tétreault P, Desmeules F, Cloutier G, Choinière M, Bureau NJ. Ultrasound-guided tendon fenestration versus open-release surgery for the treatment of chronic lateral epicondylosis of the elbow: protocol for a prospective, randomised, single blinded study. BMJ Open 2018; 8:e021373. [PMID: 29886446 PMCID: PMC6009557 DOI: 10.1136/bmjopen-2017-021373] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Chronic lateral epicondylosis (CLE) of the elbow is a prevalent condition among middle-aged people with no consensus on optimal care management but for which surgery is generally accepted as a second intention treatment. Among conservative treatment options, ultrasound (US)-guided fenestration has shown encouraging results that should be explored before surgery is considered. The primary objective of this study is to compare the efficacy of US-guided fenestration with open-release surgery in patients with failure to improve following a minimum 6 months of conservative treatment. METHODS AND ANALYSIS This study protocol entails a two-arm, single-blinded, randomised, controlled design. Sixty-four eligible patients with clinically confirmed CLE will be assigned to either US-guided fenestration or open-release surgery. Fisher's exact test will be used to compare the proportion of patients reporting a change of 11/100 points or more in the Patient Rated Tennis Elbow Evaluation score at 6 months, according to an intention-to-treat analysis. Secondary analyses will compare the two treatment groups in terms of pain and disability, functional limitations at work, pain-free grip strength, medication burden, patients' global impression of change and level of satisfaction at 6 weeks, 3, 6 and 12 months, using mixed linear models for repeated measures or Fisher's exact test, as appropriate. Finally, recursive partitioning analyses will investigate US and elastography parameters as predictors of treatment success at 6 and 12 months. This data will contribute to evidence-based treatment guidelines for CLE and explore the value of imaging biomarkers to improve risk stratification plans and assist clinicians. ETHICS AND DISSEMINATION The study has been approved by the Research Ethics Board of our institution on 23 March 2016 (REB 15.327). In case of important protocol modifications, a new version of the protocol with appropriate amendments will be submitted to the REB for approval. Study results will be published in peer-reviewed journals and presented at local, national and international conferences. TRIAL REGISTRATION NUMBER NCT02710682.
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Affiliation(s)
- Eugen Lungu
- Department of Radiology, Centre Hospitalier de L'Universite de Montreal (CHUM), Montreal, Quebec, Canada
- Department of Radiology, Radio-oncology and Nuclear Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Philippe Grondin
- Department of Surgery, Centre Hospitalier de L'Universite de Montreal (CHUM), Montreal, Quebec, Canada
- Department of Surgery, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Patrice Tétreault
- Department of Surgery, Centre Hospitalier de L'Universite de Montreal (CHUM), Montreal, Quebec, Canada
- Department of Surgery, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - François Desmeules
- Research Center, Hôpital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec, Canada
- School of Rehabilitation, Faculty of Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Guy Cloutier
- Department of Radiology, Radio-oncology and Nuclear Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Manon Choinière
- Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
- Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Nathalie J Bureau
- Department of Radiology, Centre Hospitalier de L'Universite de Montreal (CHUM), Montreal, Quebec, Canada
- Department of Radiology, Radio-oncology and Nuclear Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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Pompilio da Silva M, Tamaoki MJS, Blumetti FC, Belloti JC, Smidt N, Buchbinder R. Electrotherapy modalities for lateral elbow pain. Hippokratia 2018. [DOI: 10.1002/14651858.cd013041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Milla Pompilio da Silva
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; R. Borges Lagoa, 783 - 5º Andar ? Vila Clementino São Paulo Brazil 04032-038
| | - Marcel JS Tamaoki
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; R. Borges Lagoa, 783 - 5º Andar ? Vila Clementino São Paulo Brazil 04032-038
| | - Francesco C Blumetti
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; R. Borges Lagoa, 783 - 5º Andar ? Vila Clementino São Paulo Brazil 04032-038
| | - João Carlos Belloti
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; R. Borges Lagoa, 783 - 5º Andar ? Vila Clementino São Paulo Brazil 04032-038
- Escola Paulista de Medicina; São Paulo Brazil
| | - Nynke Smidt
- University Medical Center Groningen, University of Groningen; Department of Epidemiology; Hanzeplein (Entrance 24) Groningen Groningen Netherlands PO Box 30.001, 9700 RB
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash Department of Clinical Epidemiology, Cabrini Institute; 4 Drysdale Street Malvern Victoria Australia 3144
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Nocerino EA, Cucchi D, Arrigoni P, Brioschi M, Fusi C, Genovese EA, Messina C, Randelli P, Masciocchi C, Aliprandi A. Acute and overuse elbow trauma: radio-orthopaedics overview. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:124-137. [PMID: 29350642 PMCID: PMC6179073 DOI: 10.23750/abm.v89i1-s.7016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 02/07/2023]
Abstract
The correct management of acute, subacute and overuse-related elbow pathologies represents a challenging diagnostic and therapeutic problem. While major trauma frequently requires a rapid surgical intervention, subluxation and minor trauma allow taking more time for diagnostics and planning the correct elective treatment after careful clinical and radiological investigation. In these conditions, communication between orthopaedic surgeon and radiologist allow to create a detailed radiology report, tailored to the patient's and surgeon's needs and optimal to plan proper management. Imaging technique as X-Ray, CT, US, MRI, CTA and MRA all belong to the radiologist's portfolio in elbow diagnostics. Detailed knowledge of elbow pathology and its classification and of the possibilities and limits of each imaging technique is of crucial importance to reach the correct diagnosis efficiently. The aim of this review is to present the most frequent elbow pathologies and suggest a suitable diagnostic approach for each of them.
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Dynamic weight bearing analysis is effective for evaluation of tendinopathy using a customized corridor with multi-directional force sensors in a rat model. Sci Rep 2017; 7:8708. [PMID: 28821728 PMCID: PMC5562883 DOI: 10.1038/s41598-017-07812-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 07/03/2017] [Indexed: 01/03/2023] Open
Abstract
Few studies discuss kinetic changes in tendinopathy models. We propose a customized corridor to evaluate dynamic weight bearing (DWB) and shearing forces. Sixty rats were randomly given ultrasound-assisted collagenase injections (Collagenase rats) or needle punctures (Control rats) in their left Achilles tendons, and then evaluated 1, 4, and 8 weeks later. The Collagenase rats always had significantly (p < 0.001) higher histopathological and ultrasound feature scores than did the Controls, significantly lower DWB values in the injured than in the right hindlimbs, and compensatorily higher (p < 0.05) DWB values in the contralateral than in the left forelimbs. The injured hindlimbs had lower outward shearing force 1 and 4 weeks later, and higher (p < 0.05) push-off shearing force 8 weeks later, than did the contralateral hindlimbs. Injured Control rat hindlimbs had lower DWB values than did the contralateral only at week 1. The Collagenase rats had only lower static weight bearing ratios (SWBRs) values than did the Controls at week 1 (p < 0.05). Our customized corridor showed changes in DWB compatible with histopathological and ultrasound feature changes in the rat tendinopathy model. The hindlimb SWBRs did not correspond with any tendinopathic changes.
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Bachta A, Rowicki K, Kisiel B, Żabicka M, Elert-Kopeć S, Płomiński J, Tłustochowicz W, Maliborski A. Ultrasonography versus magnetic resonance imaging in detecting and grading common extensor tendon tear in chronic lateral epicondylitis. PLoS One 2017; 12:e0181828. [PMID: 28749994 PMCID: PMC5531525 DOI: 10.1371/journal.pone.0181828] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/08/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To investigate the diagnostic performance and reliability of ultrasonography (US) in detecting and grading common extensor tendon (CET) tear in patients with chronic lateral epicondylitis (LE), using magnetic resonance imaging (MRI) as the reference standard. MATERIALS AND METHODS The study comprised fifty-eight chronic LE patients. Each patient underwent US and MRI. CET status was classified as: high-grade tear (≥50% thickness), low-grade tear (<50% thickness), suspected tear (possible but not evident tear), no tear. Additionally, the following dichotomous scale was used: confirmed or unconfirmed CET tear. Relative US parameters (versus MRI) for detecting CET tear included: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy. The agreement between US and MRI findings was measured using the weighted Cohen kappa coefficient (κ). RESULTS US showed moderate agreement with MRI in detecting and grading CET tear (κ = 0.49). Sensitivity, specificity, and accuracy in CET tear detecting by US were 64.52%, 85.19%, and 72.73%, respectively. PPV and NPV of US were 83.33% and 67.65%, respectively. No patient with unconfirmed CET tear on US had high-grade CET tear on MRI. CONCLUSION Ultrasonography is a valuable imaging modality that can be used as a screening tool to exclude high-grade CET tear in chronic LE patients. Once a tear is evident on US, MRI should be considered to assess precisely the extent of tendon injury.
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Affiliation(s)
- Artur Bachta
- Department of Internal Diseases and Rheumatology, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
- Musculoskeletal Ultrasound Office, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
- * E-mail:
| | - Krzysztof Rowicki
- Department of Orthopedics, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
| | - Bartłomiej Kisiel
- Department of Internal Diseases and Rheumatology, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
| | - Magdalena Żabicka
- Department of Radiology, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
| | - Sylwia Elert-Kopeć
- Department of Internal Diseases and Rheumatology, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
| | - Janusz Płomiński
- Department of Orthopedics, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
| | - Witold Tłustochowicz
- Department of Internal Diseases and Rheumatology, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
| | - Artur Maliborski
- Department of Radiology, Military Institute of Medicine, ul. Szaserów 128, Warszawa, Poland
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Lee SY, Chieh HF, Lin CJ, Jou IM, Sun YN, Kuo LC, Wu PT, Su FC. Characteristics of Sonography in a Rat Achilles Tendinopathy Model: Possible Non-invasive Predictors of Biomechanics. Sci Rep 2017; 7:5100. [PMID: 28698601 PMCID: PMC5506063 DOI: 10.1038/s41598-017-05466-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 05/31/2017] [Indexed: 12/21/2022] Open
Abstract
The purpose of this study was to investigate the dynamic changes of histopathology, biomechanical properties, echo intensity, and ultrasound features in a collagenase-induced tendinopathy model of rat Achilles tendons, and to examine the associations among biomechanical properties, echo intensity, and ultrasound features. Forty-two rats received an ultrasound-guided collagenase injection on their left Achilles tendons, and needle puncture on the right ones as the control. At four, eight, and twelve weeks post-injury, the tendons were examined via measurements of their biomechanical properties, histopathological and ultrasonographic characteristics. The injured tendons showed significantly higher histopathological scores, lower Young’s modulus, and higher ultrasound feature scores than the those of control ones throughout the study period. Up to week 12, all injured tendons showed defective healing. The neovascularization score had a significant negative linear association with the failure stress and Young’s modulus. Maximum normalized echo intensity had a significant positive linear association with maximum strain. Therefore, neovascularization and maximum normalized echo intensity are associated with mechanically altered tendinopathic tendons. Non-invasive ultrasound methodology, including echo intensity and ultrasound feature scores, may provide useful information about biomechanical properties of tendinopathic tendons.
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Affiliation(s)
- Su-Ya Lee
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Hsiao-Feng Chieh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Ju Lin
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - I-Ming Jou
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan.,Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yung-Nien Sun
- Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.,Department of Computer Science & Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Li-Chieh Kuo
- Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.,Department of Occupational Therapy, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ting Wu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan. .,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Fong-Chin Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan. .,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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Ultrasound-guided percutaneous bone drilling for the treatment of lateral epicondylitis. Eur Radiol 2017; 28:390-397. [PMID: 28677063 DOI: 10.1007/s00330-017-4932-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 05/17/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine the clinical efficacy of sonographically-guided percutaneous bone drilling of the lateral epicondyle (LE) for the treatment of patients with LE. METHODS We included 24 patients with LE who reported pain in this study. All patients underwent sonographically-guided percutaneous bone drilling of the lateral epicondyle. Follow-up sonography and physical examinations were performed 1, 3 and 6 months after the procedure. The outcome measures included sonographic findings, visual analogue scale (VAS) score, maximum voluntary grip strength (MVGS) and patient-related tennis elbow evaluation (PRTEE) score. RESULTS None of the patients had immediate complications during the procedure. The area of the extensor carpi radialis brevis (ECRB) tears decreased significantly at 1 month and declined gradually over the remaining 5 months of the study (p < 0.001). The mean pain VAS score was significantly lower at 6 months than preoperatively (respectively; p < 0.001). The mean MVGS increased significantly between pretreatment and 6 months post-treatment (p < 0.001), whereas the PRTEE score decreased significantly during the same period (p < 0.001). CONCLUSION Sonographically-guided percutaneous drilling is a quick and safe treatment option for LE that can be performed in an outpatient setting. KEY POINTS • Percutaneous drilling of the lateral condyle is effective for the treatment of LE. • The area of ECRB tears can be measured by US-guided saline injection. • US-guided percutaneous drilling is a quick and safe treatment option for LE.
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Arrigoni P, Cucchi D, D'Ambrosi R, Menon A, Aliprandi A, Randelli P. Arthroscopic R-LCL plication for symptomatic minor instability of the lateral elbow (SMILE). Knee Surg Sports Traumatol Arthrosc 2017; 25:2264-2270. [PMID: 28337591 DOI: 10.1007/s00167-017-4531-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/20/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE Minor instability has been proposed as a possible aetiology of lateral elbow pain. This study presents the results of the arthroscopic plication of the radial component of the lateral collateral ligament (R-LCL) to reduce minor instability of the lateral elbow. METHODS Twenty-seven patients with recalcitrant lateral epicondylitis who had failed conservative therapy and who had no previous trauma or overt instability, were included. R-LCL plication was performed in the presence of at least one sign of lateral ligamentous patholaxity and one intra-articular abnormal finding. Single-assessment numeric evaluation (SANE), Oxford Elbow Score (OES), quickDASH (Disabilities of the Arm, Shoulder, Hand), patient satisfaction and post-operative range of motion were evaluated. RESULTS SANE improved from a median of 30 [2-40] points pre-operatively to 90 [80-100] at final follow-up (p < 0.0001), and 96.3% patients obtained good or excellent subjective results. Post-operative median quickDASH was 9.1 [0-25] points and OES 42 [34-48]. Median post-operative flexion was 145°, and extension was 0°. Post-operative flexion was restrained in seven patients and extension in eight patients; 59% of patients reached full ROM at final follow-up. CONCLUSIONS R-LCL plication produces subjective satisfaction and positive clinical results in patients presenting with a symptomatic minor instability of the lateral elbow (SMILE) at 2-year median follow-up. A slight limitation in range of motion is a possible undesired consequence of this intervention. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Affiliation(s)
- Paolo Arrigoni
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy.,U.O. Ortopedia II, IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese, Milan, Italy
| | - Davide Cucchi
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy. .,U.O. Ortopedia II, IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese, Milan, Italy.
| | - Riccardo D'Ambrosi
- IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese, Milan, Italy
| | - Alessandra Menon
- IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese, Milan, Italy
| | - Alberto Aliprandi
- Servizio di Radiologia, IRCCS Policlinico San Donato, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy
| | - Pietro Randelli
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy.,U.O. Ortopedia II, IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese, Milan, Italy
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Arrigoni P, Cucchi D, D'Ambrosi R, Butt U, Safran MR, Denard P, Randelli P. Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE). Knee Surg Sports Traumatol Arthrosc 2017; 25:2255-2263. [PMID: 28341879 DOI: 10.1007/s00167-017-4530-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/20/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE Lateral epicondylitis is generally considered an extra-articular condition. The role of minor instability in the aetiology of lateral elbow pain has rarely been considered. The aim of this study was to evaluate the correlation of lateral ligamentous laxity with aspects of intra-articular lateral elbow pathology and investigate the role of minor instability in lateral elbow pain. METHODS Thirty-five consecutive patients aged between 20 and 60 years with recalcitrant lateral epicondylitis who had failed conservative therapy and had no previous trauma or overt instability, were included. The presence of three signs of lateral ligamentous patholaxity and five intra-articular findings were documented during arthroscopy. The relative incidence of each of these was calculated, and the correlation between patholaxity and intra-articular pathology was evaluated. RESULTS At least one sign of lateral ligamentous laxity was observed in 48.6% of the studied cohort, and 85.7% demonstrated at least one intra-articular abnormal finding. Radial head ballottement was the most common sign of patholaxity (42.9%). Synovitis was the most common intra-articular aspect of pathology (77.1%), followed by lateral capitellar chondropathy (40.0%). A significant correlation was found between the presence of lateral ligamentous patholaxity signs and capitellar chondropathy (p = 0.0409), as well as anteromedial synovitis (p = 0.0408). CONCLUSIONS Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity, and over 85% demonstrate at least one intra-articular abnormality. The most frequent intra-articular findings are synovitis and lateral capitellar chondropathy, which correlate significantly with the presence of lateral ligamentous patholaxity. The fact that several patients demonstrated multiple intra-articular findings in relation to laxity provides support to a sequence of pathologic changes that may result from a symptomatic minor instability of the lateral elbow (SMILE) condition. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Paolo Arrigoni
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
- U.O. Ortopedia II, IRCCS Policlinico San Donato, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy
| | - Davide Cucchi
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy.
- U.O. Ortopedia II, IRCCS Policlinico San Donato, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.
| | - Riccardo D'Ambrosi
- IRCCS Policlinico San Donato, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy
| | - Usman Butt
- Salford Royal NHS Foundation Trust, Salford, UK
| | - Marc R Safran
- Stanford University, 450 Broadway, M/C 6342 Redwood City, Stanford, CA, 94063, USA
| | - Patrick Denard
- Southern Oregon Orthopedics, 2780 E Barnett Rd, Suite 200, Medford, OR, 97504, USA
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, USA
| | - Pietro Randelli
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
- U.O. Ortopedia II, IRCCS Policlinico San Donato, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy
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Krogh TP, Fredberg U, Ammitzbøl C, Ellingsen T. Ultrasonographic Characteristics of the Common Extensor Tendon of the Elbow in Asymptomatic Individuals: Thickness, Color Doppler Activity, and Bony Spurs. Orthop J Sports Med 2017; 5:2325967117704186. [PMID: 28540316 PMCID: PMC5431425 DOI: 10.1177/2325967117704186] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Ultrasonography (US) of the common extensor tendon (CET) of the elbow is often part of the assessment of patients with lateral epicondylitis. This US assessment is currently based on general tendinopathy references and not well-defined US entities. Purpose: To describe CET thickness, color Doppler activity, and bony spurs on US in asymptomatic volunteers and to investigate the influence of sex, age, height, body mass index (BMI), weight, and elbow dominance on the measurements. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Tendon thickness, color Doppler activity, and bony spurs of the CET were measured sonographically in 264 adults (50% women) aged 20 to 96 years. Two different tendon-thickness measuring techniques were applied, labeled the “plateau measure” and the “1-cm measure.” Color Doppler activity was based on a 0 to 4 rating scale (negative, grades 0 and 1; positive, grades 2-4). A bony spur was defined as a bony outgrowth (≥0.3 mm) arising at the insertional site of the CET. Results: With both tendon-thickness measuring techniques, the CET in the dominant elbow was thicker than that in the nondominant elbow, and male tendons were thicker than female tendons (all P ≤ .03). In regression analysis, tendon thickness correlated with weight, color Doppler activity, and arm dominance for both measuring techniques in multiple regression analysis. In addition, the plateau measure correlated with height and the presence of bony spurs. No correlations were observed regarding BMI, sex, or age. Positive color Doppler activity was found in 9% of examined elbows, with no difference between the sexes regarding dominant versus nondominant elbows (all P ≥.20). Bony spurs were found to increase with age, from 23% for people in their 20s to 74% in people older than 70 years. Bony spurs were more common in the dominant elbow (P ≤ .01). Women had a higher prevalence of bony spurs than men, but only in the dominant elbow (P = .03). Conclusion: This study presents the US characteristics and normal values of the CET. In 264 asymptomatic participants, the CET was found to be thicker in men and in the dominant elbow. No difference in tendon thickness could be demonstrated with regard to different age groups. Color Doppler activity was found to be positive in nearly 1 of 10 asymptomatic subjects. Bony spurs were a common finding; they increased in prevalence with every decade in age and were considered part of the aging process. Normal variations in CET morphologic characteristics should therefore be considered when implementing US in trials and clinical practice.
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Affiliation(s)
- Thøger P Krogh
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Torkell Ellingsen
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Rheumatology, Odense University Hospital, Odense, Denmark
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Gowda A, Kennedy G, Gallacher S, Garver J, Blaine T. The Three-Portal Technique in Arthroscopic Lateral Epicondylitis Release. Orthop Rev (Pavia) 2016; 8:6081. [PMID: 28503289 PMCID: PMC5402316 DOI: 10.4081/or.2016.6081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 12/06/2016] [Indexed: 11/24/2022] Open
Abstract
Lateral epicondylitis, commonly referred to as tennis elbow, is a syndrome characterized by pain over the origin of the common extensor muscles of the fingers, hand and wrist at the lateral epicondyle. Reports of 70-90% response to conservative treatment at one year have been documented in the literature though refractory cases often require surgical management. Arthroscopic treatment of lateral epicondylitis allows for intra-articular visualization for concomitant pathology and localization of the Extensor Carpi Radialis Brevis tendon. Additionally, compared to the open technique, the arthroscopic technique has a lower morbidity and an earlier return to work and activity. Here we describe a three portal technique for improved visualization in arthroscopic lateral epicondylitis release.
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Affiliation(s)
- Ashok Gowda
- Orthopedic Surgery Department, Beaumont Health System, Royal Oak, MI
| | - Gannon Kennedy
- Orthopaedic Surgery Department, New York Medical College, Westchester Medical Center, Valhalla, NY
| | - Stacey Gallacher
- Orthopedic Surgery Department, Yale Medical School, Yale University, New Haven, CT, USA
| | - Jennie Garver
- Orthopedic Surgery Department, Yale Medical School, Yale University, New Haven, CT, USA
| | - Theodore Blaine
- Orthopedic Surgery Department, Yale Medical School, Yale University, New Haven, CT, USA
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Bhabra G, Wang A, Ebert JR, Edwards P, Zheng M, Zheng MH. Lateral Elbow Tendinopathy: Development of a Pathophysiology-Based Treatment Algorithm. Orthop J Sports Med 2016; 4:2325967116670635. [PMID: 27833925 PMCID: PMC5094303 DOI: 10.1177/2325967116670635] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Lateral elbow tendinopathy, commonly known as tennis elbow, is a condition that can cause significant functional impairment in working-age patients. The term tendinopathy is used to describe chronic overuse tendon disorders encompassing a group of pathologies, a spectrum of disease. This review details the pathophysiology of tendinopathy and tendon healing as an introduction for a system grading the severity of tendinopathy, with each of the 4 grades displaying distinct histopathological features. Currently, there are a large number of nonoperative treatments available for lateral elbow tendinopathy, with little guidance as to when and how to use them. In fact, an appraisal of the clinical trials, systematic reviews, and meta-analyses studying these treatment modalities reveals that no single treatment reliably achieves outstanding results. This may be due in part to the majority of clinical studies to date including all patients with chronic tendinopathy rather than attempting to categorize patients according to the severity of disease. We relate the pathophysiology of the different grades of tendinopathy to the basic science principles that underpin the mechanisms of action of the nonoperative treatments available to propose a treatment algorithm guiding the management of lateral elbow tendinopathy depending on severity. We believe that this system will be useful both in clinical practice and for the future investigation of the efficacy of treatments.
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Affiliation(s)
- Gev Bhabra
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Allan Wang
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.; Department of Orthopaedic Surgery, St John of God Subiaco Hospital, Perth, Western Australia, Australia
| | - Jay R Ebert
- School of Sport Science, Exercise, and Health, University of Western Australia, Perth, Western Australia, Australia
| | - Peter Edwards
- School of Sport Science, Exercise, and Health, University of Western Australia, Perth, Western Australia, Australia
| | - Monica Zheng
- Pulse Podiatry, Wembley, Western Australia, Australia
| | - Ming H Zheng
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.; Centre for Orthopaedic Translational Research, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
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Obuchowicz R, Bonczar M. Ultrasonographic Differentiation of Lateral Elbow Pain. Ultrasound Int Open 2016; 2:E38-46. [PMID: 27689169 DOI: 10.1055/s-0035-1569455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Lateral elbow pain is often attributed to degenerative or posttraumatic impairment of the common extensor tendon. Ultrasonography assesses the soft tissue structures of the lateral elbow, allowing the differentiation between various underlying processes, including angiofibroblastic degeneration, hyaline degeneration, and inflammation, and exclusion of other possible causes of pain such as posterior interosseous and lateral antebrachial nerve compression. Furthermore, the real-time imaging nature of ultrasonography enables the detection of impingement of the lateral synovial fold, degenerative changes in the elbow recess, and elbow posterolateral instability during dynamic maneuvers. Ultrasonography is widely accessible and well tolerated by patients, making it a perfect method for establishing an initial diagnosis and monitoring the healing process. This review describes the possible causes of lateral elbow pain and their ultrasonographic differentiation.
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Affiliation(s)
- R Obuchowicz
- Radiology, Jagiellonian University, Krakow, Poland
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50
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Marcolino AM, Fonseca MDCR, Leonardi NT, Barbosa RI, Neves LMSD, de Jesus Guirro RR. The influence of different non-articular proximal forearm orthoses (brace) widths in the wrist extensors muscle activity, range of motion and grip strength in healthy volunteers. J Back Musculoskelet Rehabil 2016; 30:BMR727. [PMID: 27392841 DOI: 10.3233/bmr-160727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose this study was perform a biomechanical evaluation to compare the influence of commercial models of different non-articular proximal forearm orthoses widths (2.5 cm, 5.5 cm, 7.5 cm and 12.0 cm) in the extensor muscle activation, range of motion and grip strength in healthy subjects. METHODS Was analyzed data from extensor carpi radialis, extensor carpi ulnares and extensor digitorum comunis using surface electromyography, simultaneous with a wrist electrogoniometer MiotecTM and a hydraulic dynamometer JamarTM. The sequence of tests with all the commercial orthoses models was randomized. Statistics analyses were performed by linear model with mixed effects. RESULTS According to our findings the non-articular proximal forearm orthoses (2.5 cm - narrowest) positioned close to lateral epicondyle provided lesser muscle activation on extensor carpi radialis brevis/longus and extensor digitorum comunis, decreased wrist extension and grip strength during submaximal grip task (p< 0.01). CONCLUSIONS A narrow non-articular proximal forearm orthosis positioned close to the lateral epicondyle might decrease the extensor muscle activation and therefore could reduce mechanical stress on its insertion, based on this sample. Clinical studies must be conducted to confirm these findings.
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Affiliation(s)
- Alexandre Márcio Marcolino
- Federal University of the Santa Catarina, Campus Araranguá-SC, Brazil
- Rehabilitation and Functional Performance Post-Graduate Program, Ribeirão Preto of the Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marisa de Cássia Registro Fonseca
- Rehabilitation and Functional Performance Post-Graduate Program, Ribeirão Preto of the Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Naiara Tais Leonardi
- Rehabilitation and Functional Performance Post-Graduate Program, Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Rafael Inácio Barbosa
- Federal University of the Santa Catarina, Campus Araranguá-SC, Brazil
- Rehabilitation and Functional Performance Post-Graduate Program, Ribeirão Preto of the Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Lais Mara Siqueira das Neves
- Rehabilitation and Functional Performance Post-Graduate Program, Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Rinaldo Roberto de Jesus Guirro
- Rehabilitation and Functional Performance Post-Graduate Program, Ribeirão Preto of the Medical School, University of São Paulo, Ribeirão Preto, Brazil
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