Lateral elbow tendinopathy: Evidence of physiotherapy management

Efficacy of neural mobilization and Maitland accessory mobilization in patients with tennis elbow- randomized controlled trial

OBJECTIVE

The objective of the study was to evaluate the efficacy of Maitland accessory mobilization and neural mobilization in patients with tennis elbow.

METHOD

Twenty-five patients meeting the selection criteria were randomly assigned to three experimental groups: Group C (conventional treatment), Group B (neural mobilization), and Group A (Maitland mobilization). Quality of life was assessed using the Patient Rated Tennis Elbow Evaluation (PRTEE), while pain, range of motion, and grip strength were evaluated using the Visual Analog Scale (VAS), a universal goniometer, and a handheld dynamometer. The interventions were administered three times per week for four weeks to the respective groups.

RESULTS

Non-parametric tests were employed to analyze the results due to the non-normal distribution of the data (p < 0.05). Both the Wilcoxon signed-rank test and the Kruskal-Wallis test were utilized to assess differences within and between groups. The results of the between-group analysis demonstrated significant differences in pain (p = 0.018) and quality of life (p = 0.045) among the three groups.

CONCLUSION

After a 4-week intervention, all three groups exhibited notable improvements in discomfort levels, grip strength, and quality of life. Notably, Group B demonstrated the most substantial increase in range of motion (ROM) compared to Groups A and C. Consequently, incorporating neural mobilization into the treatment plan is recommended for patients experiencing Tennis Elbow.

Chronic lateral elbow tendinopathy with a supervised graded exercise protocol

STUDY DESIGN

Prospective Case Series.

BACKGROUND

Variety of studies inquired the effectiveness of exercise treatment in LET (Lateral Elbow Tendinopathy). The research on the effectiveness of these approaches are still ongoing and very much needed due to the uncertainty of the subject.

PURPOSE

We aimed to understand how the application of exercises in a graded manner affect the treatment outcomes in terms of pain and function.

METHODS

This study is completed by 28 patients with LET and it was planned as a prospective case series. Thirty participants were included to participate in the exercise group. Basic Exercises (Grade 1) were performed for four weeks. Advanced Exercises (Grade 2) were performed for another four weeks. The VAS (Visual Analog Scale), pressure algometer, the PRTEE (Patient-Rated Tennis Elbow Evaluation) and a grip strength dynamometer were used to measure outcomes. The measurements were performed at baseline, at the end of four weeks and at the end of eight weeks.

RESULTS

Investigation of the pain scores revealed that all VAS scores (p < 0.05, ES = 1.35; 0.72; 0,73 activity, rest, and night respectively) and pressure algometer results were improved both during basic (p < 0.05, ES = 0.91) and advanced exercises (p < 0.05, ES = 0,41). PRTEE scores were found to be improved in patients with LET after basic and advanced exercises (p > 0.001, ES = 1.15; p > 0.001, ES = 1.56 respectively). The grip strength only changed after basic exercises (p = 0.003, ES = 0.56).

CONCLUSIONS

The basic exercises were beneficial for both pain and function. However, advanced exercises are required for obtaining further improvements in terms of pain, function, and grip strength.

Bracing or kinesio taping in the management of lateral elbow tendinopathy: A prospective, randomized single-blinded trial

OBJECTIVE

The aim of the study was to compare the effects of forearm counter force brace (FCB) and kinesio taping (KT) on pain severity, grip strength and functionality of patients with lateral elbow tendinopathy (LET).

METHODS

The study was planned as a prospective, randomized and assessor-blinded study with 1-month follow-up period. Seventy-two patients, diagnosed as LET were randomly assigned to FCB (n = 41) or KT (n = 31) groups. In the FCB group, the patients were informed and instructed to wear the brace for three weeks continuously. In the KT group, tape was applied once a week for four weeks with muscle inhibition and fascia correction techniques. The outcome measures were pain pressure threshold (PPT), maximal pain-free hand grip strength measurement and patient-rated tennis elbow evaluation questionnaire (PRTEE). The assessments were performed at the baseline, immediately after treatment and one month later after treatment.

RESULTS

PPT and grip strength were significantly increased over time in both groups. Pain, function and total scores of PRTEE were significantly decreased in both FCB and KT groups. The effect size of the improvement in PRTEE function score was within acceptable clinical significance in the KT group. However, there was no significant difference between groups.

CONCLUSIONS

Pain severity, grip strength and functionality of patients with LET improved over time in both FCB and KT groups. However, neither was superior in the management of LET.

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.

Evaluation of short-term and residual effects of Kinesio taping in chronic lateral epicondylitis: A randomized, double-blinded, controlled trial

BACKGROUND

Lateral epicondylitis is degenerative tendinosis of the extensor carpi radialis brevis muscle and is the most common work/sports-related chronic musculoskeletal problem affecting the elbow.

PURPOSE

This study aimed to evaluate the short term and residual effectiveness of the Kinesio taping method on pain, grip force, quality of life, and functionality.

STUDY DESIGN

Randomized, double-blinded, controlled study.

METHODS

Subjects were 50 patients diagnosed with chronic unilateral lateral epicondylitis with a symptom duration of at least 12 weeks. During the first four weeks, the study group received a true inhibitor Kinesio taping while the control group received sham taping. In both groups, progressive stretching and strengthening exercises were given as a home program for six weeks. The primary outcome measure was the Numerical Rating Scale (NRS) for self-report of pain intensity; secondary outcome measures were Cyriax resistive muscle test evaluation, maximal grip strength, Patient- Rated Tennis Elbow Evaluation (PRTEE), and Short Form-36 (SF-36). After the treatment, patients were evaluated by the first assessor who was blinded to taping types.

RESULTS

There was a significant decrease in NRS scores overtime during the first four weeks in both groups (P < .001,) and effect sizes were large. There was no significant difference in Cyriax muscle resistance test maximal grip strength between groups (P > .05). However, there was a significant improvement in muscle strength of elbow extension and pronation in the study group detected in the intragroup analysis. Intragroup comparisons also showed a significant improvement in all subunits of the PRTEE and SF-36 except energy/vitality, social functioning, and pain in both groups (P < .05) with moderate to high effect sizes. PRTEE pain scores were significantly decreased in the study group compared to the placebo group (P < .05, d = 0.48).

CONCLUSION

The effects of Kinesio taping on muscle strength, quality of life, and function in chronic lateral epicondylitis are not superior to placebo. However, NRS scores showed that in the two weeks after Kinesio taping treatment, pain reduction persisted as a residual effect which may improve the exercise adherence and functionality.

Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: A narrative review

Tendinopathy is a chronic degenerative musculoskeletal disorder that is common in both athletes and the general population. Exercise and extracorporeal shockwave therapy (ESWT) is among the most common treatments used to mediate tendon healing and regeneration. The review presents the current understanding of mechanisms of action of ESWT and exercise in isolation and briefly synthesises evidence of their effectiveness for various tendinopathies. The central purpose of the review is to synthesize research findings investigating the combination of ESWT and exercise for five common tendinopathies (plantar heel pain, rotator cuff, lateral elbow, Achilles, and patellar tendinopathy) and provide recommendations on clinical applicability. Collectively, the available evidence indicates that ESWT combined with exercise in the form of eccentric training, tissue-specific stretching, or heavy slow resistance training are effective for specific tendinopathies and can therefore be recommended in treatment. Whilst there are at present a limited number of studies investigating combined EWST and exercise approaches, there is evidence to suggest that the combination improves outcomes in the treatment of plantar heel pain, Achilles, lateral elbow, and rotator cuff tendinopathy. However, despite overall positive outcomes in patellar tendinopathy, the combined treatment has not been shown at present to offer additional benefit over eccentric exercise alone.

The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review

Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

How one treats lateral epicondylitis - a survey among Brazilian orthopedists

BACKGROUND

Lateral epicondylitis (LE), also known as tennis elbow, is the most common painful elbow condition. It affects approximately 1-3% of adults. There are various possible treatments described in the literature, but evidence to support a gold standard management protocol is lacking. Therefore, the objective of this study was to evaluate how Brazilian orthopaedists diagnose and treat lateral epicondylitis and compare these results with the available evidence.

METHODS

This is an observational, analytical, cross-sectional study. A questionnaire was prepared to obtain information from the participants with eight specific questions (2 on diagnosis and 6 on treatment). These questions were answered voluntarily by participants at 3 major congresses of orthopaedists in Brazil in 2018. The results were analysed in accordance with the overall number of responses and were evaluated among groups according to subspecialty.

RESULTS

We obtained a total of 501 questionnaires. Of these, 33 were excluded. The mean age was 38.67 years. The majority of respondents (91%) were male. We obtained 26.7% from specialists in hand surgery (Hand group), 36.5% from subspecialists in shoulder and elbow (Shoulder and Elbow group), and 36.8% from generalists in orthopaedics or from other subspecialties (General Orthopaedists group). For diagnosis, 24.4% did not initially request any imaging method. The most requested exam was ultrasonography (54.9%). The most prominent indication for initial treatment was physical therapy. For refractory cases, 78.3% of the respondents preferred doing a local infiltration. The most commonly used substance for local infiltrations was corticosteroids (89.6%). With respect to the surgical treatment option, 75.8% of those who recommend it prefer open techniques, and 24.2% prefer arthroscopic treatment. Of the total respondents, 12.8% did not recommend surgical treatment for LE.

CONCLUSION

Among Brazilian orthopaedists, the Cozen test is most frequently chosen, and ultrasound is the most commonly used imaging tool. Nonsurgically, oral nonsteroidal anti-inflammatory drugs (NSAIDs) plus physiotherapy is the most popular initial therapy, and corticosteroids are the most popular type of infiltration agent. Most surgeons recommended surgery after 6 months of nonsurgical treatment, and 75.8% preferred the open technique.

Ultrasound-Guided Percutaneous Neuromodulation in Patients with Chronic Lateral Epicondylalgia: A Pilot Randomized Clinical Trial

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.

Comparing the efficiency of ultrasound, ketoprofen, and mucopolysaccharide polysulfate phonophoresis in the treatment of lateral epicondylitis: A randomized-controlled clinical study

Objectives

In this study, we aimed to compare the efficiency of ultrasound, mucopolysaccharide polysulfate phonophoresis, ketoprofen phonophoresis and exercise combinations in terms of pain, functionality, disability, and strength in patients with lateral epicondylitis (LE).

Patients and methods

This prospective, parallel-group, randomized-controlled clinical study included a total of 60 patients (42 males, 18 females; mean age 38.08 years; range, 21 to 50 years) with LE between April 2016 and October 2017. The patients were equally randomized into four groups based on the time of admission to the outpatient clinic. The Visual Analog Scale (VAS), painless weight lifting, the Patient- Rated Tennis Elbow Evaluation (PRTEE), and Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) were used to measure the outcomes. The measurements were performed at baseline, at the end of 10 daily sessions, and after a six-week follow-up period.

Results

The resting VAS scores in the ketoprofen phonophoresis group and lifted weights in the MPS and ketoprofen phonophoresis groups showed a significant improvement both after 10 days of treatment and at six-week follow-up visits (p<0.001). In the QuickDASH model, there was no significant improvement in the control group after 10 days of treatment (p>0.05); however, a significant improvement was observed after six weeks (p<0.001). Except for these variables, significant improvements were found in all groups for all variables at six-week follow-up (p<0.05). However, improvements were similar in all groups (p>0.05).

Conclusion

Based on our study results, for LE patients who are unable to adhere to exercise and splint use and are given a physical treatment plan, inclusion of ketoprofen and MPS phonophoresis in the treatment program may yield additional benefits in their daily living activities, functionality, and working life.

Clinical comparative effectiveness of acupuncture versus manual therapy treatment of lateral epicondylitis: feasibility randomized clinical trial

Background

Lateral epicondylitis (LE) is a challenging condition for clinicians, and research has yet not proven the superiority of one specific treatment approach. However, manual therapy (elbow mobilization) in addition to eccentric exercise has been found to be superior to exercise alone. As well, acupuncture is effective in short-term pain relief when compared with sham treatment, but there is little knowledge on the comparative effectiveness of manual therapy and acupuncture treatment of LE in terms of pain relief. The primary objective of this pilot trial was to assess the feasibility (retention and adherence rates) of performing a randomized controlled trial (RCT) to explore the clinical effectiveness of acupuncture and manual therapy treatment of LE.

Methods

This pilot trial took place in an outpatient interdisciplinary institute of sports medicine and rehabilitation in Oslo, Norway. Thirty-six adults with clinically diagnosed LE were randomly allocated into one of three groups: eccentric exercise alone, eccentric exercise plus acupuncture, or eccentric exercise plus manual therapy for a 12-week treatment period. Primary outcomes were patient retention and adherence rates. Secondary outcomes included patient-reported pain (NRS), level of disability (Quick-DASH), and participant’s satisfaction with treatment and global perceived effect.

Results

Nine (69%) patients in the acupuncture group completed the 1-year follow-up, compared to eight (67%) in the manual therapy group and five (45%) in exercise alone. Our goal was to demonstrate a retention rate above 80% to avoid serious threats to validity, but the result was lower than expected. The majority of participants (64%) in both treatment groups received only three-treatment sessions; the reasons included non-attendance or recovery from pain. Secondary outcomes support the rationale for conduction of an RCT. There were no adverse advents related to study participation.

Conclusions

Based on differences in pain relief between groups, patient retention, and adherence rates, an RCT seems to be feasible to assess treatment effectiveness more precisely. In a future definitive trial, greater dropout may be reduced by maintaining contact with the participants in the exercise alone group throughout the intervention, and objective assessments might be considered.

Trial registration

ClinicalTrials.gov, NCT02321696

TREATMENT OF SPORT INJURIES WITH ACUPUNCTURE: A LITERATURE REVIEW

ABSTRACT As acupuncture is growing in popularity in Brazil and worldwide, it is necessary to study the benefits and possibilities of this type of treatment more in depth, especially as it is believed to produce fast results with few side effects and does not involve substances banned in sports. Thus, it seems like a good option to be considered as main or adjuvant therapy in sports-related injuries. In order to gain more knowledge about this subject, this article is an integrative review analyzing the publications of the period between January 2012 and January 2017 on the Cochrane and Pubmed platforms that analyzed acupuncture in the treatment of sports injuries. We found 49 articles, 11 of which fulfilled the inclusion criteria: two case reports, three clinical trials and six literature reviews. Although all the articles analyzed produced favorable results with the use of the therapeutic technique in question, flaws in the designs of the studies and the difficulty of creating a placebo control group in acupuncture hinder the qualification of the articles on evidence rating scales. Therefore, it is suggested to the researchers that further studies be published with experimental animal models and observational studies, and that STRICTA recommendations be followed to improve the level of evidence of acupuncture research. Level of Evidence II; Systematic review of level II studies.