Lateral Elbow Tendinopathy: Development of a Pathophysiology-Based Treatment Algorithm

Defining tennis elbow characteristics - The assessment of magnetic resonance imaging defined tendon pathology in an asymptomatic population

Background

This radiological study aims to assess the prevalence of lateral elbow pathology in an asymptomatic population using 3.0T magnetic resonance imaging (MRI).

Methods

Bilateral elbow MRI was undertaken in 30 asymptomatic volunteers. Exclusion criteria included elbow pain within 3 months, elbow trauma or previous diagnosis of lateral epicondylar tendinopathy. Baseline patient-reported outcome measures were recorded along with age and body mass index (BMI). Two musculoskeletal radiologists independently graded the degree of abnormality at the common extensor tendon.

Results

Thirty volunteers were categorised according to age; 35-44 (n = 10), 45-54 (n = 11), and 55-65 (n = 9) with a 1:1 male-to-female ratio. Radiological evidence of tendon abnormality was found in 37% of volunteers. The proportion with abnormal findings increased with age; 35-44 (10%), 45-54 (36%), 55-65 (67%) and BMI; 18-24.9 (23%), 25-29.9 (43%), > 30 (67%). Changes were generally 'mild' or 'moderate', with a single volunteer showing 'severe' pathology. Kappa for the radiographic agreement was 0.91 (0.83-0.98).

Discussion

This study has demonstrated MRI findings suggestive of pathology at the common extensor tendon to be prevalent in an asymptomatic population, increasing with age and BMI. This draws into question the diagnostic and prognostic value of MRI imaging in lateral epicondylar tendinopathy, especially in older patients.

Rehabilitation of the painful elbow

Although lateral elbow pain and medial ulnar collateral ligament injury are common musculoskeletal pathologies in overhead athletes, the evidence supporting specific interventions for managing these conditions is scarce. Management of these conditions has been guided mostly by expert opinion rather than empirical evidence, yet the lack of comparative data in the literature has not negatively affected return-to-play rates following surgery. However, an understanding of what is known regarding unimodal and multimodal treatments for lateral elbow pain and medial ulnar collateral ligament injury is needed for clinicians to select evidence-based treatment pathways and highlight what is not known to develop future high-quality investigations.

Pathophysiology of sex difference in refractoriness in lateral epicondylitis: Biomechanical study of wrist torque

Eccentric contractions of the wrist extensors worsen lateral epicondylitis (LE), whose pathophysiology may involve sex differences in wrist torque. This study aimed to investigate sex differences in wrist torque in patients with LE. The wrist extension and flexion torques of 22 patients with LE (11 males and 11 females) were measured. Maximum muscle output over time was measured for 20 s, initial torque was defined as muscle strength, and the degree of eccentric contraction was quantified and defined as the eccentric contraction index (ECI). The affected/unaffected side ratio of the wrist extensor, extensor/flexor ratio of muscle strength, and affected/unaffected side difference of ECI between sexes were statistically analyzed. Furthermore, correlations between wrist extensor torque, ECI, and Visual Analog Scale of pain during the examination were evaluated. Females were found to display lower affected/unaffected side ratios of the wrist extensor and wrist extension/flexion ratios for the affected side, compared with males; however, no differences were found in the wrist extension/flexion ratios for the unaffected side in both sexes. Additionally, females presented with larger differences between the affected and unaffected sides in the ECI. Based on correlations between wrist torques, ECI, and pain, females tended to suppress muscle output to prevent pain from eccentric contraction of wrist extensors more than males, which would induce an imbalance in muscle strength of the wrist extensors and flexors. This imbalance may result in chronic eccentric contraction of the wrist extensors with gripping, exacerbating LE.

Is there structural change on MRI in gluteal tendinopathy after treatment? Single outcome measure extension of an RCT

BACKGROUND

The etiology of tendinopathy remains controversial and it is unknown whether degenerative structural changes in tendinopathies are reversible.

HYPOTHESIS

There will be no structural change on magnetic resonance imaging (MRI) taken > 2-years after treatment for gluteal tendinopathy.

STUDY DESIGN

Extension of a single site, double-blind, prospective randomized-controlled trial to analyze the additional outcome measure; MRI changes.

METHODS

University of Melbourne ethics approval number: 1852900, trial registration: ACTRN12613000677707. Participants with gluteal tendinopathy who had previously received a leukocyte-rich platelet-rich plasma injection (LR-PRP) or a corticosteroid injection (CSI) had a post treatment MRI between at least 2-years and up to 7 years following trial completion. A blinded, senior musculoskeletal radiologist graded all de-identified MRI scans using the Melbourne Hip Score (MHIP). The primary outcome measure was the change in overall pre- and post-treatment score.

RESULTS

Participants (n = 20) underwent MRI at mean time of 4.15 (SD 1.11; range 2-7) years after their initial treatment. There was no change in the overall mean MHIP score for the CSI group (Pre 4.3 (SD 2.3) Post 4.3 (SD 1.1), p = 1.00). Although there was an improvement in the LR-PRP group mean MHIP score (Pre 5.3 (SD 3.0) Post 4.77 (SD 2.5), p = 0.56) it was not statistically significant. However, in the LR-PRP intervention group, five out of nine of participants' MHIP score improved, with four of these improving by 2-4 points.

CONCLUSION

The hypothesis that there would be no improvement in MHIP scores following treatment of gluteal tendinopathy was supported. Findings of improvement in the LR-PRP group at 4 years would support further studies powered to look for structural improvement. These findings suggest that structural change following treatment for tendinopathy may be possible supporting the inclusion of MRI as a core outcome for future studies.

CLINICAL RELEVANCE

The study suggests that degenerative structural changes in tendons may be reversible.

Clinical efficacy of botulinum toxin in lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Botulinum toxin injections for lateral elbow tendinopathy have been used as an alternative therapeutic option. However, few studies have quantitatively summarized the effect of botulinum toxin as well as its clinical significance. We aimed to evaluate the clinical efficacy (based on pain and grip strength) and adverse events of botulinum toxin on lateral elbow tendinopathy.

PATIENTS AND METHODS

The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched until March 2023 for randomized controlled trials reporting the effects of botulinum toxin injections on lateral elbow tendinopathy. A random- or fixed-effects model (depending of inter-study variability) and generic inverse variance method were used to pool quantitative data from outcomes. The risk of bias was assessed with the Cochrane Risk of Bias 2.0 tool.

RESULTS

A total of 8 clinical trials recruiting 438 subjects were included for meta-analysis. Pooled analysis revealed that botulinum toxin significantly reduced pain (mean difference [MD] -0.95, 95% CI [-1.63, -0.26], p=0.007) but it was not clinically relevant. No significant effect was detected for grip strength (MD-0.62kg, 95% CI [-2.25, 1.02], p=0.46) or in the risk for adverse events (odds ratio [OR] 0.41, 95% CI [0.05, 3.56], p=0.42) between botulinum toxin injection and control interventions.

DISCUSSION

The use of botulinum toxin reached greater pain relief than control interventions and normal saline after a period of 12 to 24 weeks. However, changes in pain relief did not reach clinical significance. The studies that had the greatest reduction in pain used higher doses of botulinum toxin (60 U). Additionally, differences in grip strength and adverse events did not reach statistical or clinical importance. A subanalysis indicated that botulinum toxin outperformed corticosteroid injections in terms of improving grip strength. Botulinum toxin only causes local and minimal side effects such as irritation, ecchymosis, and paralysis.

LEVEL OF EVIDENCE

I.

Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level.» The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics.» Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments.» In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review

Objective

The primary objective of this review was to summarize systematic reviews and meta-analyses reporting on nonoperative management of lateral epicondyle tendinopathy.

Methods

An umbrella review of all published systematic reviews and meta-analyses was performed. Three databases were searched using the key words "tennis elbow," "lateral epicondylitis," "non-operative," and "non-surgical modalities." The search was limited to English-language systematic reviews and meta-analyses between the years of 2000 and 2022.

Results

There were 114 systematic reviews/meta-analyses, of which 35 met our inclusion criteria. These articles reviewed the following nonoperative management strategies: ultrasound, shockwave therapy, injection procedures, low-level laser therapy, joint mobilizations, exercise therapy, and electrophysical modalities. Exercise therapy was beneficial in decreasing pain regardless of dosage or type. Conflicting results were seen with ultrasound, laser, and shockwave therapy. Corticosteroid injections provided the most short-term pain relief, and platelet-rich plasma and autologous blood injections were most effective in the long term.

Conclusion

A variety of nonoperative interventions were found to be effective for short- and long-term pain relief as well as functional improvement, with most interventions indicating mixed results. Due to variations in study populations and study quality, results should be interpreted with caution.

Role of platelet-rich plasma in the treatment of rotator cuff tendinopathy

Shoulder pain is a common musculoskeletal complaint, and rotator cuff (RC) pathologies are one of the main causes. The RC undergoes various tendinopathic and avascular changes during the aging process. Other degenerative changes affecting its healing potential make it an appealing target for biological agents. Platelet-rich plasma (PRP) has demonstrated the potential to deliver a high concentration of several growth factors and anti-inflammatory mediators, and its clinical use is mainly supported by experiments that demonstrated its positive effect on muscle, ligaments, and tendinous cells. This review aimed to specify the role of PRP and its future applications in RC tendinopathies based on the current clinical evidence. Due to the different characteristics and conflicting outcomes, clinicians should use PRP with moderate expectations until more consistent evidence is available. However, it is reasonable to consider PRP in patients with contraindications to corticosteroid injections or those with risk factors for inadequate healing. Its autologous origin makes it a safe treatment, and its characteristics make it a promising option for treating RC tendinopathy, but the efficacy has yet to be established.

A Clinical Overview of the Natural Course and Management of Lateral Epicondylitis

Lateral epicondylitis (LE), also often called tennis elbow, is a frequent cause of elbow pain. The most characteristic symptom of LE is pain and burning around the lateral epicondyle of the humerus that may radiate to the forearm or to the upper arm. Ultrasonography is a quick and noninvasive tool used to confirm (or exclude) the diagnosis of LE. Management of LE symptoms should be directed to the management of pain, protection of movement, and improvement of arm performance. Treatment of LE includes nonoperative techniques and surgery. [Orthopedics. 2023;46(4):e210-e218.].

[Treatment of lateral and medial epicondylopathy : Are platelet-rich plasma, shock wave therapy, etc. effective for both?]

Lateral and medial epicondylopathy (epicondylitis), which are common and in most cases self-limiting, frequently result in relevant reduction of quality of life and may also affect the ability to work. Recently, the use of orthobiologics, such as platelet-rich plasma (PRP), has been proposed to promote tendon regeneration and is supposed to be a valuable treatment option. However, scientific data are conflicting and the short- and long-time results are controversial. The use of stem cells is new approach and preliminary clinical data are promising. Shock wave therapy is widely used and part of the daily routine in treating lateral epicondylopoathy, although it is questionable for medial epicondylopathy.

Effect of premodulated interferential current versus diadynamic current on the management of lateral elbow tendinopathy

Study aim: To compare the effect of premodulated interferential current (PREMOD IFC) and diadynamic current (DD) with exercise training on the management of lateral elbow tendinopathy (LET).

Material and methods: One hundred and four patients with unilateral LET from both genders (55 females and 49 males) were randomly allocated into two groups. Group A received PREMOD IFC in addition to the exercises, and group B received DD with the same exercises. The outcomes were maximum grip strength assessed by the hand dynamometer, the pinch strength assessed by the pinch gauge dynamometer, and pain and functional disability of the forearm assessed by a patient-rated tennis elbow evaluation (PRTEE) questionnaire. All participants received electrical stimulation, consisting of three sessions per week for six weeks.

Results: The mean PRTEE score, and grip strength were significantly improved after six weeks in favour of group A, while there was no significant difference between the two groups in pinch strength. (p < 0.05).

Conclusion: The results revealed that the combination of PREMOD IFC with exercises could improve pain, functional disability, and grip strength compared to DD with exercises in LET patients without a significant difference between the two groups in pinch strength.

Low-Load Resistance Training With Blood Flow Restriction Is Effective for Managing Lateral Elbow Tendinopathy: A Randomized, Sham-Controlled Trial

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.

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

Managing work‐related lateral elbow tendinopathy: Australian hand therapist's experiences with workplace‐based interventions

INTRODUCTION

Lateral elbow tendinopathy (LET) is one of the most prevalent work-related musculoskeletal conditions. Current treatments for LET focus mainly on the physiological symptoms of pain, grip strength, and function. Recently, a novel workplace-based hand therapy educational intervention, Working Hands-ED, was developed based on the Person-Environment-Occupation- Performance model, International Classification of Functioning, Disability and Health framework and the Australian Clinical Framework for the Delivery of Health Services. Combining a hand therapist's specialised knowledge and skills in upper limb rehabilitation with an approach that considers injured workers' occupations and work environments may provide a more holistic approach to managing work-related LET. To the best of our knowledge, no previous studies have investigated the experiences of hand therapists who perform workplace-based educational interventions for the management of LET.

METHOD

An exploratory, descriptive qualitative design using semi-structured interviews was used with hand therapists who delivered the novel hand therapy intervention Working Hands-ED.

FINDINGS

Ten occupational therapists working in hand therapy were interviewed. Three main themes and eight subthemes were identified from interview data: Person-centred approach, opportunity for therapists to provide enhanced service, and improved stakeholder engagement in the return-to-work process. Logistical challenges such as the costs and time spent away from the clinical setting were identified.

CONCLUSION

All hand therapists reported delivering Working Hands-ED when managing work-related LET was a positive experience for them. They believed that the novel intervention could provide a more holistic approach to care that added value to their service delivery; however, there were some logistical factors to consider including the additional time and costs associated with the intervention.

Tendinopathies and Allied Disorders of the Hip

There are many soft tissue structures around the hip joint that may serve as a source of pain in both the native and prosthetic hip. In this review, the role of the gluteal, piriformis, iliopsoas, and rectus femoris musculotendinous units in the etiology of pathology around the hip joint will be discussed. Management options ranging from tailored physical therapy regimens to local steroid infiltration along with more invasive open and arthroscopic surgical techniques will be reviewed for each pathological entity. While not all conditions are well understood, advancements have been made in the management of each of these often challenging cases in both the native and prosthetic hip settings. This review explores these advancing treatment methods which will supplement the practice of any hip surgeon who is presented with problematic tendinopathy around both the native and prosthetic hip joint.

Individual Evaluation of the Common Extensor Tendon and Lateral Collateral Ligament Improves the Severity Diagnostic Accuracy of Magnetic Resonance Imaging for Lateral Epicondylitis

The effectiveness of magnetic resonance imaging for diagnosing lateral epicondylitis severity is controversial. We aimed to verify whether individual evaluations of the common extensor tendon and lateral collateral ligament would improve the severity diagnostic accuracy of magnetic resonance imaging for lateral epicondylitis. We obtained coronal images of the lateral elbow in three groups: healthy, clinically mild, and clinically severe. We used our scoring system for evaluation using combined and individual methods. We developed the receiver operating characteristic curve for diagnosis using the scores of the healthy and mild groups and that for severity diagnosis using the scores of the mild and severe groups. The scores, in decreasing value, were those of the severe, mild, and healthy groups, with a significant difference in both methods. The curve for diagnosis showed an area under the curve of 0.85 for the combined evaluation and 0.89 for the individual evaluation, without a significant difference between the methods (p = 0.23). The curve for severity diagnosis showed an area under the curve of 0.69 for combined and 0.81 for individual evaluation, with a significant difference between the methods (p = 0.046). Individual evaluation of the common extensor tendon and lateral collateral ligament improved the severity diagnostic accuracy of lateral epicondylitis.

The use of platelet-rich plasma therapy in treating tennis elbow: A critical review of randomised control trials

Tennis elbow (TE) is a painful and debilitating condition of the elbow. Recently, the use of orthobiologics, such as platelet-rich-plasma (PRP), has been proposed to promote tendon regeneration. Despite their popularity, there is a paucity of updated reviews on the use of PRP compared with other treatment modalities for treating TE. The aim of this review is to summarise high quality studies that compare the use of PRP therapy with other therapies for TE and to identify areas where further research is warranted. This systematic review was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive literature search of PubMed, Scopus and Cochrane Library databases was undertaken in May 2021. Articles were screened for the following criteria: randomised control trials (RCTs) involving PRP in at least one of the treatment arms for tennis elbow. The quality of the RCTs included were analysed for their risk of bias using the modified Cochrane Collaboration Risk of Bias Assessment Tool for randomised trials. A total of 20 RCTs of which 1520 TE patients were analysed. The RCTs included in this review compared PRP with various treatment modalities routinely used in clinical practice such as physiotherapy, steroid injections, Autologous Whole Blood (AWB) and surgical interventions. With regards to the quality of RCTs, collectively, selection bias was found to be low risk however, performance bias in terms of blinding of participants and personnel performed poorly. Of the 20 RCTs, only 5 studies were classified as low risk of bias. In these 5 studies, 2 RCTs compared PRP with steroids and reported contrasting results, 1 RCT compared PRP with AWB injections which reported both to be similarly efficacious, 3 RCTs included a placebo group and only 1 reported superior effects with PRP. There are 2 main types of PRP classified according to the number of pro-inflammatory leukocyte i.e. leukocyte-rich and leukocyte-poor PRP. However, only 8 studies documented the formulation of PRP used. While the heterogeneity of PRP formulations could in-part explain the reported differences in outcomes, overall there is limited robust evidence to recommend PRP therapy for TE. Further research is required to establish the optimal formulation and administration of PRP injections. Proper documentation of TE patients need to be standardised before concrete recommendations on the use of PRP therapy may be offered.

Intratendinous Injection of Autologous Conditioned Serum for Treatment of Lateral Epicondylitis of the Elbow: A Pilot Study

BACKGROUND

Autologous conditioned serum (ACS) has been effectively used in treatment of osteoarthritis. However, less is known about its efficacy in tendon disorders. In this pilot study, we aimed to evaluate the short- and long-term effects of intratendinous injection of ACS in lateral epicondylitis (LE) of the elbow.

METHODS

This prospective cohort included 42 patients with LE of the elbow who received 4 intratendinous injections of Orthokine^® (Orthogen Lab Services GmbH, Düsseldorf, Germany) under local anesthesia over 2 weeks in an outpatient setting. The clinical and functional outcomes of injections were evaluated at 3 months and 1 year after the procedure. Pain was assessed using a visual analog scale (VAS) and functional assessment was made using the Mayo Elbow Performance Score (MEPS) and Oxford Elbow Score (OES).

RESULTS

The pre-injection VAS score (7.07±1.19) improved significantly after the procedure at both 3 months (3.55±0.56, P<0.001) and 1 year (1.73±0.82, P<0.001). Similarly, the mean MEPSs were significantly different between baseline and 3 months (56.42±7.51 vs. 79.76±3.81, P<0.001) and between baseline and 1 year (56.42±7.51 vs. 94.28±4.06, P<0.001). The baseline OESs (84.17±6.07) also improved with intratendinous injection of ACS at 3 months (41.96±9.23, P<0.001) and 1 year (7.43±4.31, P<0.001). Only six patients (14.2%) had mild ecchymosis and swelling around the injection site which resolved spontaneously.

CONCLUSION

ACS is a promising option for treatment of LE of the elbow, given its early onset of pain-relieving action and longlasting functional effects. These findings await confirmation by large-scale and prospective trials.

Platelet-rich plasma injection vs. operative treatment for lateral elbow tendinosis: a systematic review and meta-analysis

BACKGROUND

Although surgical treatment is considered reliable for lateral elbow tendinosis, local injection therapy may be preferable, as it avoids surgery. Among a number of local injections, platelet-rich plasma has been used successfully to treat lateral elbow tendinosis. The purpose of this study was to compare the outcomes in patients treated with either platelet-rich plasma injections or surgery for lateral elbow tendinosis using a systematic literature review and meta-analysis.

METHODS

MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 1, 2021, that compared platelet-rich plasma with operative treatment for lateral elbow tendinosis. The pooled analysis was designed to compare the visual analog scale scores and the Patient-Related Tennis Elbow Evaluation scores between the platelet-rich plasma and surgical treatment groups at serial time points.

RESULTS

We included 5 studies involving 340 patients with lateral elbow tendinosis, comprising of 154 patients treated with platelet-rich plasma and 186 patients who underwent surgical treatment. The pooled analysis showed no statistically significant differences in the visual analog scale scores at any of the follow-up time points, namely, 2 months (mean difference [MD] 1.11, 95% confidence interval [CI] -2.51 to 4.74, P = .55, I² = 94%), 6 months (MD 0.80, 95% CI -2.83 to 4.42, P = .67, I² = 92%), and 12 months (MD -0.92, 95% CI -4.63 to 2.80, P = .63, I² = 93%) postintervention and in the Patient-Related Tennis Elbow Evaluation scores at 12 weeks (MD -1.86, 95% CI -22.30 to 18.58, P = .86, I² = 81%), 24 weeks (MD -3.33, 95% CI -21.82 to 15.17, P = .72, I² = 74%), and 52 weeks (MD -3.64, 95% CI -19.65 to 12.37, P = .66, I² = 69%) postintervention.

CONCLUSIONS

Local platelet-rich plasma injections and surgical treatment produced equivalent pain scores and functional outcomes in patients with lateral elbow tendinosis. Thus, platelet-rich plasma injections may represent a reasonable alternative treatment for patients who are apprehensive to proceed with surgery or for poor surgical candidates.

Comparison of the efficacy of corticosteroid, dry needling, and PRP application in lateral epicondylitis

PURPOSE

The aim of this study was to compare the short-term efficacy of dry needling, corticosteroids, and platelet-rich plasma application (PRP) in the management of lateral epicondylitis.

METHODS

The study included 72 patients diagnosed with lateral epicondylitis divided into three groups of 24 individuals using the sealed envelope method. Group 1 underwent dry needling, Group 2 received 40 mg methylprednisolone acetate, and Group 3 received PRP treatment. Patients were assessed using the visual analog scale (VAS) and the Disabilities of the Shoulder, Arm, and Hand (DASH) score, and Jamar grip strength before treatment and 3rd week and 3rd month.

RESULTS

At the 3rd month, the mean VAS score was 1.16 ± 0.56 in dry needling group and 0.75 ± 0.60 in corticosteroids group, showing a statistically significant difference between dry needling and corticosteroids group, and between corticosteroids and PRP group (p = 0.015 and p = 0.000, respectively). At the 3rd week and 3rd month, VAS scores decreased in each treatment modality group, showing a statistically significant difference between the groups (p < 0.01). Jamar grip strength increased over time in all groups. There were no significant differences between the DASH scores of all groups at the 3rd week (p > 0.05). DASH scores decreased significantly from the 3rd week to the 3rd month in dry needling and corticosteroids group (p < 0.01), while it increased slightly in PRP group during the same period with a statistically insignificant change (p > 0.05). DASH scores decreased significantly at the 3rd month for all groups (p = 0.014).

CONCLUSION

Dry needling is an effective and safe application for the short-term treatment of lateral epicondylitis.

Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation

Background:

Gluteal tendinopathy is the most common lower limb tendinopathy. It presents with varying severity but may cause debilitating lateral hip pain.

Purpose:

To review the therapeutic options for different stages of gluteal tendinopathy, to highlight gaps within the existing evidence, and to provide guidelines for a stage-adjusted therapy for gluteal tendinopathy.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We screened Scopus, Embase, Web of Science, PubMed, PubMed Central, Ovid MEDLINE, CINAHL, UpToDate, and Google Scholar databases and databases for grey literature. Patient selection, diagnostic criteria, type and effect of a therapeutic intervention, details regarding aftercare, outcome assessments, complications of the treatment, follow-up, and conclusion of the authors were recorded. An assessment of study methodological quality (type of study, level of evidence) was also performed. Statistical analysis was descriptive. Data from multiple studies were combined if they were obtained from a single patient population. Weighted mean and range calculations were performed.

Results:

A total of 27 studies (6 randomized controlled trials) with 1103 patients (1106 hips) were included. The mean age was 53.7 years (range, 17-88 years), and the mean body mass index was 28.3. The ratio of female to male patients was 7:1. Radiological confirmation of the diagnosis was most commonly obtained using magnetic resonance imaging. Reported treatment methods were physical therapy/exercise; injections (corticosteroids, platelet-rich plasma, autologous tenocytes) with or without needle tenotomy/tendon fenestration; shockwave therapy; therapeutic ultrasound; and surgical procedures such as bursectomy, iliotibial band release, and endoscopic or open tendon repair (with or without tendon augmentation).

Conclusion:

There was good evidence for using platelet-rich plasma in grades 1 and 2 tendinopathy. Shockwave therapy, exercise, and corticosteroids showed good outcomes, but the effect of corticosteroids was short term. Bursectomy with or without iliotibial band release was a valuable treatment option in grades 1 and 2 tendinopathy. Insufficient evidence was available to provide guidelines for the treatment of partial-thickness tears. There was low-level evidence to support surgical repair for grades 3 (partial-thickness tears) and 4 (full-thickness tears) tendinopathy. Fatty degeneration, atrophy, and retraction can impair surgical repair, while their effect on patient outcomes remains controversial.

Do hand therapists have a role in workplace-based education to manage tennis elbow? Beliefs about effective treatments among Australian hand therapists and medical practitioners

BACKGROUND

Lateral elbow tendinopathy (LET), commonly known as tennis elbow, is a prevalent work-related upper extremity musculoskeletal disorder. Medical practitioners and hand therapists manage LET with commonly available clinic-based treatments, despite no sound evidence to suggest long-term relief and functional restoration for workers with LET. Workplace-based rehabilitation is effective for injured workers with other health conditions, but no studies have investigated this rehabilitation approach in the management of LET.

OBJECTIVES

(i) Identify, compare, and contrast Australian hand therapists' and medical practitioners' perceptions about the effectiveness of common treatments for LET, and (ii) obtain their views towards a hand therapist delivered workplace-based education approach.

METHODS

In this cross-sectional study, 38 medical practitioners from Western Australia and 104 hand therapists around Australia completed online surveys. Independent t-tests were used to identify between-group differences in responses.

RESULTS

Despite some between-group differences regarding the perceived effectiveness of common LET treatments, both groups believed education about LET pathology, activity modification, postures, and workplace recommendations were most effective. Most medical practitioners (81%) and hand therapists (71%) believed workplace-based education delivered by a hand therapist would be beneficial for patients with acute and chronic LET.

CONCLUSION

Australian hand therapists and medical practitioners believed educational approaches were the most important component in the management of LET, and supported workplace-based educational interventions provided by hand therapists in the management of LET.

Hamid MS. Efficacy of prolotherapy in comparison to other therapies for chronic soft tissue injuries: A systematic review and network meta-analysis

Introduction

Prolotherapy and other injections, primarily acting on pathways associated with maladaptive tissue repair, are recommended for recalcitrant chronic soft tissue injuries (CSTI). However, selection of injection is challenging due to mixed results. This network meta-analysis (NMA) aimed to compare prolotherapy with other therapies, particularly injections, for CSTI and establish robustness of the results.

Methodology

Pubmed, Medline, SPORTDiscus and Google scholar were searched from inception to 4^th January 2021 for randomised controlled trials (RCTs) involving injection therapies (e.g. blood derivatives, corticosteroid, hyaluronic acid, botulinum toxin) for CSTI. The primary and secondary outcomes were pain and function, respectively, at (or nearest to) 6 months. Effect size (ES) was presented as standardised mean difference with 95% confidence interval (CI). Frequentist random effect NMA was used to generate the overall estimates, subgroup estimates (by region and measurement time point) and sensitivity analyses.

Results

A total of 91 articles (87 RCTs; 5859 participants) involving upper limb (74%), lower limb (23%) and truncal/hip (3%) injuries were included. At all time points, prolotherapy had no statistically significant pain benefits over other therapies. This observation remained unchanged when tested under various assumptions and with exclusion of studies with high risk of bias. Although prolotherapy did not offer statistically significant functional improvement compared to most therapies, its ES was consistently better than non-injections and corticosteroid injection for both outcomes. At selected time points and for selected injuries, prolotherapy demonstrated potentially better pain improvement over placebo (<4 months: shoulder [ES 0.65; 95% CI 0.00 to 1.30]; 4–8 months: elbow [ES 0.91; 95% CI 0.12 to 1.70]; >8 months: shoulder [ES 2.08; 95% CI 1.49, to 2.68]). Injections generally produced greater ES when combined with non-injection therapy.

Conclusion

While clinical outcomes were generally comparable across types of injection therapy, prolotherapy may be used preferentially for selected conditions at selected times.

Association between clinical parameters and size of three-dimensionally reconstructed anatomical abnormalities in patients with lateral epicondylitis: a cross-sectional study

Background

The association of the severity of clinical symptoms and level of functional performance with the degree of magnetic resonance imaging abnormalities in patients with lateral epicondylitis has not been fully elucidated. This study aimed to investigate the association between the degree of anatomical abnormalities by evaluating three-dimensional magnetic resonance imaging models of the common extensor tendon and clinical parameters in patients with lateral epicondylitis.

Materials and methods

A total of 61 patients (24 men and 37 women) with lateral epicondylitis were included in this study. 3-Tesla magnetic resonance imaging was performed for all patients, and clinical parameters, including pain visual analog scale score, Quick Disabilities of Arm, Shoulder and Hand questionnaire score, elbow range of motion, and demographic factors, were evaluated. The proportion of lesion volume of common extensor tendon was adopted for three-dimensional model analysis. To determine the factors associated with clinical parameters, univariate, and multivariate linear regression analyses were performed.

Results

The proportion of lesion volume of common extensor tendon was not associated with clinical parameters. Gender and muscle edema were independently associated with pain visual analog scale scores. However, demographic factors and magnetic resonance imaging abnormalities were not associated with the Quick Disabilities of Arm, Shoulder, and Hand questionnaire score or elbow range of motion.

Conclusions

The three-dimensional volumetric lesion size of common extensor tendon was not associated with clinical symptoms and functional performance in patients with lateral epicondylitis. The clinical parameters of lateral epicondylitis may be influenced by several factors.

Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) - A systematic review

BACKGROUND

Reviews on the diagnostic performance of the examination tests for lateral elbow tendinopathy (LET) based on updated context-specific tools and guidelines are missing.

PURPOSE

To review the diagnostic accuracy of examination tests used in LET.

DESIGN

Systematic review following PRISMA-DTA guidelines.

METHODS

We searched MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, and Cochrane Library databases. The QUADAS-2 checklist was used to assess the methodological quality of the eligible studies. We included diagnostic studies reporting the accuracy of physical examination tests or imaging modalities used in patients with LET.

RESULTS

Twenty-four studies with 1370 participants were identified reporting the diagnostic performance of Ultrasound Imaging (USI) (18 studies), physical examination tests (2 studies) and Magnetic Resonance Imaging (MRI) (4 studies). Most studies (97%) were assessed with "unclear" or "high risk" of bias. Sonoelastography showed the highest sensitivity (75- 100%) and specificity (85- 96%). Grayscale with or without Doppler USI presented poor to excellent values (sensitivity: 53%-100%, specificity: 42%-90%). MRI performed better in the diagnosis of tendon thickening and enthesopathy (sensitivity and specificity: 81%-100%). The Cozen's test reported high sensitivity (91%) while a grip strength difference of 5%-10% between elbow flexion and extension showed high sensitivity (78%-83%) and specificity (80%-90%).

CONCLUSIONS

Cozen's test and grip strength measurement present high accuracy in the diagnosis of LET but are poorly investigated. USI and MRI provide variable diagnostic accuracy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary. Substantial heterogeneity was found in inclusion criteria, operator/ examiner, mode of application, type of equipment and reference standards across the studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID CRD42020160402.

Promising improvement of chronic lateral elbow tendinopathy by using adipose derived mesenchymal stromal cells: a pilot study

Purpose

Study the effect of Adipose derived stromal cells (ASCs) injection as therapeutic procedure on the common extensor tendinopathy.

Methods

Eighteen Tennis players with chronic, recalcitrant LET (who have previously been unsuccessfully treated with nonoperative treatments) underwent clinical evaluation and magnetic resonance imaging (MRI) before intervention. Stromal vascular fraction cells (SVF) were expanded by in vitro culture and ASCs were obtained and characterized by flow cytometry. ASCs were injected into the site of tendinopathy (identified by ultrasound imaging at the origin of the common extensor tendon) on a single occasion followed by physiotherapy. Players underwent serial clinical evaluations during a 12-month period and repeated MRI at 6-month post-injection.

Results

At 6-month clinical evaluation revealed significant improvements compared to baseline in mean Visual Analog Scale (VAS) scores for: (1) maximum pain score (from 6.28 ± 1.65, to 1.0 ± 0.43; p < .001); (2) Mean quick Disabilities of the Arm, Shoulder and Hand (QuickDASH-Compulsory score: 51.38 ± 12.02 to 12.33 ± 4.66; p < .001); (3) QuickDASH-Sport score: 56.94 ± 15.44 to 8.68 ± 8.86; p < .001). Validated MRI scoring system grade of tendinopathy also improved significantly: 4.22 ± 0.26 to 2.22 ± 0.10 (p < .001). At 12-month from injection, VAS maximun pain score further decreased to 0.74 ± 0.44 (p < .001) and QuickDASH-Compulsory score to 5.56 ± 3.58 (p < .001). Average time to return to play tennis was 3,31 ± 0,61 month post-intervention.

Conclusion

Tennis players with recalcitrant LET showed significant clinical improvement and structural repair at the origin of the common tendon origin after injection of autologous ASCs. Results of this study are promising and open a new biological therapeutic modality to treat LET. Even if the results of this pilot study are positive, future well-designed studies, i.e. prospective randomized trials are needed to define the role of cell therapy in treating LET.

The Effect of Scapular Muscle Strengthening on Functional Recovery in Patients With Lateral Elbow Tendinopathy: A Pilot Randomized Controlled Trial

CONTEXT

There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET.

OBJECTIVE

The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET.

DESIGN

Prospective randomized clinical trial.

SETTING

Multisite outpatient physical therapy.

PATIENTS

Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS.

INTERVENTIONS

Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises.

MAIN OUTCOME MEASURE

The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure.

RESULTS

The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05).

CONCLUSION

The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

Elbow tendinopathy and occupational biomechanical overload: A systematic review with best-evidence synthesis

OBJECTIVES

To evaluate the evidence of an association between occupational and non-occupational exposure to biomechanical risk factors and lateral elbow tendinopathy, medial elbow tendinopathy, and olecranon bursitis.

METHODS

We carried out a systematic review of the literature. We searched MEDLINE (up to November 2019) and checked the reference lists of relevant articles/reviews. We aimed to include studies where (a) the diagnosis was based on physical examination (symptoms plus clinical signs) and imaging data (if any); and (b) the exposure was evaluated with video analysis and/or direct measurements. A quality assessment of the included studies was performed along with an evaluation of the level of evidence of a causal relationship.

RESULTS

We included four studies in the qualitative synthesis: two prospective cohorts and two cross-sectional studies. All the included studies investigated "lateral/medial epicondylitis", albeit the diagnosis was not supported by imaging techniques. Two cohort studies suggested that a combination of biomechanical risk factors for wrist/forearm is associated with increased risk of "lateral epicondylitis". This association was not observed in the two included cross-sectional studies. The cohort studies suggested that a Strain Index score higher than 5 or 6.1 could double the risk of "lateral epicondylitis". No association with increased risk of "medial epicondylitis" was observed.

CONCLUSIONS

There is limited evidence of a causal relationship between occupational exposure to biomechanical risk factors and lateral elbow tendinopathy. For medial elbow tendinopathy, the evidence is insufficient to support this causal relationship. No studies on olecranon bursitis and biomechanical overload were identified.

Arthroscopic Modified Bosworth Procedure for Refractory Lateral Elbow Pain With Radiocapitellar Joint Snapping

Background:

Radiocapitellar joint snapping due to the presence of synovial plica has been described as a contributory intra-articular pathology of lateral epicondylitis (LE).

Hypothesis:

The arthroscopic modified Bosworth technique can provide a safe and favorable outcome for refractory LE with radiocapitellar snapping.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients treated with the arthroscopic modified Bosworth procedure for refractory LE with radiocapitellar joint snapping were included in this study. The sequential surgical procedures included excision of the upper portion of the anterolateral annular ligament, removal of the synovial plicae, and release of the extensor carpi radialis brevis for all patients. Clinical outcomes were measured at a minimum 1-year follow-up.

Results:

A total of 22 patients with a mean ± SD age of 51.2 ± 10.4 years were included in this study. The mean follow-up was 29.4 ± 7.7 months (range, 21-42 months). The overall visual analog scale score (from preoperative to final follow-up) was 7.5 ± 1.2 vs 2.5 ± 1.8 (P < .001); flexion-extension motion arc was 133.8° ± 11.2° vs 146.4° ± 7.1° (P = .001); pronation-supination motion arc was 101.8° ± 9.2° vs 141.7° ± 10.2° (P = .001); Disabilities of the Arm, Shoulder and Hand score was 54.5 ± 13.2 vs 3.6 ± 4.1 (P < .001); and Mayo Elbow Performance Score was 51.9 ± 12.2 vs 84.3 ± 10.3 (P < .001).

Conclusion:

Radiocapitellar joint snapping may coexist with LE as a disease spectrum. The arthroscopic modified Bosworth technique provides safe and favorable outcomes for patients with refractory LE associated with radiocapitellar joint snapping.

[Ultrasound-guided percutaneous tenotomy in chronic wrist extensor enthesopathy]

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.

Functional Outcome at Short and Middle Term of the Extracorporeal Shockwave Therapy Treatment in Lateral Epicondylitis: A Case-Series Study

Lateral epicondylitis (LE) of the humerus is a chronic degeneration of wrist extensor tendons at their attachments to the lateral epicondyle of the humerus. There is not a common consensus on a specific therapeutic algorithm, but Extracorporeal Shockwave Therapy (ESWT) is widely used. The purpose of this study is to evaluate the clinical benefits of low dose ESWT in LE-affected patients in short and medium follow-up. Between January 2015 and December 2017, 60 patients (38 male, mean age 52.2 ± 10.1 years, the duration of the disease was 3.6 ± 1.3 months) were clinically evaluated using visual analog scale (VAS) and Patient Rated Tennis Elbow Evaluation Test (PRTEE-I) scores before treatment, at one, three, six and 12 months after treatment. According to the VAS and PRTEE-I scoring systems, all patients achieved an improvement of pain and functional outcome comparing the baseline results with one, six and 12 months values. Low dose ESWT is a safe and effective treatment of LE in the short and middle term. In elderly subjects, patients with a long disease history, or those with occupational and sportive risk factors, a longer persistence of the symptomatology could be observed.

Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up

BACKGROUND

A previously published trial showed that patients with chronic gluteal tendinopathy achieved greater clinical improvement at 12 weeks when treated with a single platelet-rich plasma (PRP) injection than those treated with a single corticosteroid injection (CSI).

PURPOSE

This follow-up study was conducted to determine whether there would be a sustained long-term difference in the modified Harris Hip Score (mHHS) at 2 years for a leucocyte-rich PRP (LR-PRP) injection in the treatment of chronic gluteal tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This trial included 80 patients randomized 1:1 to receive LR-PRP or CSI intratendinously under ultrasound guidance. Patients had a mean age of 60 years, a 9:1 ratio of women to men, a mean body mass index of 27, and a mean length of symptoms >15 months. No patients had full-thickness tears of the gluteal tendons. An open-labeled extension allowed patients to receive crossover treatment after 3 months. The main outcome measure was the mHHS.

RESULTS

The mean mHHS improved significantly at 12 weeks in the PRP group (74.05; SD, 13.92) as compared with the CSI group (67.13; SD, 16.04) ( P = .048). At 24 weeks, the LR-PRP group (77.60; SD, 11.88) improved further than the CSI group (65.72; SD, 15.28; P = .0003). Twenty-seven patients were deemed to have failed the CSI treatment at 16 to 24 weeks, with an exit score of 59.22 (SD, 11.54), and then had treatment with LR-PRP. The crossover group improved with the LR-PRP: from 59.22 (SD, 11.22) at baseline to 75.55 (SD, 16.05) at 12 weeks, 77.69 (SD, 15.30) at 24 weeks, and 77.53 (SD, 14.54) at 104 weeks. The LR-PRP group retained 38 of 39 patients to 52 weeks and continued to improve. Their baseline scores of 53.77 (SD, 12.08) improved to 82.59 (SD, 9.71) at 104 weeks ( P < .0001).

CONCLUSION

Among patients with chronic gluteal tendinopathy and a length of symptoms >15 months, a single intratendinous LR-PRP injection performed under ultrasound guidance results in greater improvement in pain and function than a single CSI. The improvement after LR-PRP injection is sustained at 2 years, whereas the improvement from a CSI is maximal at 6 weeks and not maintained beyond 24 weeks.

REGISTRATION

ACTRN12613000677707 (Australian New Zealand Clinical Trials identifier).

Tendon neuroplastic training for lateral elbow tendinopathy: 2 case reports

OBJECTIVE

To report 2 cases of lateral elbow tendinopathy treated with a novel adaptation of tendon neuroplastic training (TNT).

CLINICAL FEATURES

Patient 1: A 61-year-old male machine operator presented with one year of bilateral lateral elbow pain related to his occupation of using torque wrenches.Patient 2: A 37-year-old male electrician presented with two months of recurrent left lateral elbow pain related to repetitive motions of gripping and pulling at work.

INTERVENTION AND OUTCOME

Both patients underwent 8 weeks of a novel rehabilitation program, including TNT, which involved pacing their resistance exercises to a metronome. Both patients experienced clinically meaningful improvements in pain and functional outcome scores that were sustained at the 3-month follow-up.

SUMMARY

Recent evidence suggests that the central nervous system may play a role in chronic tendinopathies. It is possible that TNT may address the central nervous system component of chronic/recurrent tendinopathy that is not addressed by traditional passive therapies. However, further research is needed.

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

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

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

Background:

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

Purpose:

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

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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