Triceps Tendon Avulsion in a Soldier: A Case Report

Background

Clinical assessment of triceps brachii tendon tears is challenging, and conventional imaging methods have limitations. Timely surgical referral is important in high-grade tears to maximize patient outcomes, and musculoskeletal ultrasound (MSK US) can be used at the time of clinical examination to identify such injuries requiring advanced imaging and orthopedic referral.

Hypothesis/Purpose

The purpose of this case report is to describe how MSK US was used to facilitate advanced imaging and timely orthopedic referral for a patient presenting to a physical therapist with a high-grade triceps tendon avulsion.

Study Design

Case Report.

Case Description

A 35-year-old male soldier presented to a direct access sports physical therapist with acute-on-chronic right elbow pain. Physical examination and MSK US were used to identify a high-grade partial triceps brachii tendon tear. The MSK US findings informed the physical therapist's decision-making process to refer the subject for timely advanced imaging studies as well as referral to an orthopedic physician.

Outcomes

A high-grade partial triceps tendon avulsion was confirmed on magnetic resonance imaging (MRI). The subject was then seen by an orthopedic surgeon and underwent surgical repair of the tendon within the recommended three-week timeframe for optimal outcomes. The subject completed a post-operative rehabilitation program and returned to full physical and occupational activities.

Conclusion

MSK US can assist in the diagnosis of challenging triceps tendon injuries, facilitating timely advanced imaging and orthopedic referrals for high-grade injuries to optimize patient outcomes.

Level of Evidence

5.

The Impact of Blood Morphological Parameters on Treatment Outcomes in Tennis Elbow Patients Receiving Platelet-Rich Plasma (PRP) Therapy: A Prospective Study

Platelet-rich plasma (PRP) therapy holds substantial promise for the treatment of tennis elbow, a complex and challenging musculoskeletal condition. The aim of the study was to assess whether there are correlations between the levels of individual morphotic elements determined in whole blood and the outcomes of tennis elbow treatment with PRP injection, as measured using patient-reported outcome measures (PROMs) such as the Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE). A prospective analysis was conducted on 107 patients (132 elbows) undergoing lateral epicondylitis treatment with (PRP) injections. Patients completed VAS, PRTEE, and QDASH questionnaires on the day of PRP administration and at established checkpoints (2, 4, 8, 12, 24, 52, and 104 weeks). Minimal clinically important difference (MCID) was employed to assess the treatment effects. Then, correlations were measured within each PROM, and the impact of the concentration of individual blood parameters on the MCID outcomes was assessed. Analyzing the relationships between the MCID+ and MCID- groups, significant correlations for the VAS and QDASH scales were observed. The level of individual morphotic elements in the blood may have influenced the treatment outcome, as measured using specific patient-reported outcome measures (PROMs). Regarding the VAS scale, factors favoring a positive treatment outcome included higher values of eosinophils (EOS) and basophils (BASO). For the QDASH scale, these factors were a lower value of mean corpuscular volume (MCV) and a higher mean corpuscular hemoglobin (MCH). The levels of certain blood parameters, such as EOS and BASO, in the current study influenced the classification of patients into MCID+ or MCID- groups, based on the VAS and QDASH scales.

Novel Ultrasound-Guided Radiofrequency Ablation of the Medial Epicondylar Sensory Nerve for Recalcitrant Medial Epicondylosis: A Case-Based Technical Report

Recalcitrant medial epicondylosis (ME) is a chronic tendinopathy affecting the common flexor-pronator tendon origin which causes significant pain and functional limitations. Recalcitrant ME is difficult to manage with non-surgical treatment options. The medial epicondylar sensory nerve (MEsn) is a small sensory nerve that travels within the medial intermuscular septum to innervate the osseous-tendinous structures of the medial epicondyle. In this report, we describe a novel technique for the treatment of recalcitrant ME via radiofrequency ablation (RFA) of the MEsn under ultrasound guidance. The MEsn is localized under ultrasound in the medial distal arm, just proximal to the medial epicondyle. Patients with a positive prognostic block of the MEsn subsequently underwent RFA of the MEsn. We have performed this procedure on two patients who have demonstrated improvement in pain and function for up to nearly one year after the procedure. The relief from pain and improvement in function of these patients warrants further investigation and comparative trials with respect to conventional treatment options, as MEsn RFA may be a viable treatment option for recalcitrant ME.

A Review of Physiotherapy Techniques Used in the Treatment of Tennis Elbow

Tennis elbow, a common musculoskeletal disorder also known as lateral epicondylitis, causes pain and tenderness on the outside of the elbow. Although it is frequently linked to repetitive motions, such as those in racquet sports, it can affect people in a variety of occupations and activities. Tennis elbow can be treated conservatively with physiotherapy, which focuses on pain management, functional recovery, and recurrence prevention. The goal of this review is to give a thorough overview of the physiotherapy methods used to treat tennis elbow. In order to determine the most effective treatment options, it is crucial to comprehend the pathophysiology and etiology of tennis elbow from the outset of the study. The assessment and diagnosis of tennis elbow are next covered, emphasizing the importance of physiotherapists in correctly diagnosing the ailment and distinguishing it from other musculoskeletal problems that are comparable to it. This study primarily focuses on the numerous physiotherapy therapies for tennis elbow, which may include but are not limited to, and the section examines the use of manual treatments to treat pain and enhance joint function, including joint mobilizations, soft tissue massage, and myofascial release. Exercise rehabilitation covers the value of tailored workouts to bolster the weak muscles and enhance the elbow joint's biomechanics. Numerous workout regimens are covered, such as eccentric training and progressive resistance exercises, as well as modalities. Therapeutic agents frequently make use of modalities such as ultrasound, laser therapy, and cryotherapy. It may also make use of complementary therapeutic agents such as taping and bracing. In summary, this in-depth analysis highlights the crucial role that physical therapy plays in the treatment of tennis elbow. It seeks to give practitioners a useful tool for enhancing the care and results of patients with this common and crippling ailment by summarizing the most recent research and best practices in physiotherapy approaches.

Subperiosteal Osteoid Osteoma in the Coronoid Fossa Mimicking Early Elbow Arthropathy: A Case Report

Introduction

The elbow pain and restricted movement is a nagging problem and elbow arthropathies need to be excluded. On rare instances, uncommon etiology like a benign lesion is the culprit and the diagnosis would require judicious clinicoradiological correlation. Osteoid osteoma in the intra- or juxta-articular region is reported in the literature as rare, sporadic report.

Case Report

A 23-year-old, Indian male patient presented with a provisional diagnosis of early elbow arthropathy on account of unexplained pain and restricted elbow movement without a history of trauma. He was subjected to appropriate investigations revealing synovial hypertrophy, effusion, and bone edema suggestive of early arthropathy. Additional imaging led to an uncommon definitive diagnosis. An intra-articular osteoid osteoma was found over the medial aspect of the coronoid fossa with a thin rim of cortical rim projecting anteriorly. The lesion was diagnosed and delineated on computerized tomography and an open excision of the lesion and synovectomy was done for histopathological evaluation. Histology confirmed the presence of an osteoid osteoma at an uncommon location.

Conclusion

The careful appreciation of radiological images is critical to not miss significant etiology that may mimic non-specific elbow pain. High index of suspicion coupled with appropriate diagnostic imaging results in early diagnosis and appropriate management. Osteoid osteoma should be a differential diagnosis in cases with pain and restricted elbow movement and excision of which results in recovery of painless range of motion.

The Acute Effect of Tissue Flossing on Pain, Function, and Perception of Movement: A Pilot Study

Tissue flossing (TF) is a novel device that has been shown to cause peripheral compression and concurrent change in joint range of motion, perception of mobility and muscular performance. However, the effect of tissue flossing on pain, perception of mobility and function at the elbow joint has not been thoroughly investigated. The purpose of this pilot study was to examine the acute effect of TF on pain and upper extremity functional performance in subjects with musculoskeletal-related complaints of pain surrounding the elbow joint. We utilized a randomized crossover design. Nine resistance trained participants (8 men/1 woman) mean age 35.6 ± 10.7 took part in this study. We measured the following outcome measures; Pain Visual Analog Scale, Short Form McGill Pain Questionnaire II, pain-pressure threshold and hand grip dynamometry (HHD) pre and post and a Likert scale for movement ability questionnaire, posttest only, following a TF and placebo condition for each participant. TF resulted in significant improvement in all test measures, except HHD, pre to post (p ≤ 0.05). All pre to post changes were associated with large effect sizes for TF compared to the placebo condition applied to the elbow improves pain quality and intensity, perception of mobility and pain-pressure threshold in resistance trained individuals with a history of musculoskeletal pain for greater than 1 month. The results of this pilot study suggest that TF may function as an adjunct to treatment in the management of musculoskeletal pathologies at the elbow joint.

Lateral epicondylitis: comparing ultrasound-guided tenotomy with or without amniotic membrane allograft injection

Aim: To evaluate the clinical response to augmenting ultrasound-guided tenotomy (USGT) with an amniotic membrane (AM) allograft injection. Design: Retrospective study. Materials & methods: Subjects underwent either a USGT (N = 16) or a combined USGT plus AM injection (N = 14). Results: Both groups demonstrated a significant reduction in pain from baseline starting after 2 weeks in the USGT plus AM group (p = 0.036) and after 8 weeks in the USGT group (p = 0.021). The reduction in pain was sustained for the entire duration of the study (52 weeks). There was no significant difference in pain levels at 26- or 52-week follow-up or patient satisfaction between the two groups. Conclusion: USGT with or without AM allograft injections results in a significant reduction in pain with high patient satisfaction.

Radiographic and Ultrasonographic Evaluation of the Rare Sesamoid Bone of the Elbow: Os Subepicondylare Mediale

BACKGROUND

Sesamoids and accessory bones are generally small-sized and oval-shaped structures whose function and pathology are not fully elucidated. Despite their small size, sesamoid bones can directly or indirectly cause diagnostic problems. Sesamoid bones are less common in the elbow region and may need to be differentiated from a lot of diagnoses such as fractures, osteochondritis dissecans, calcific tendinitis, and synovial chondromatosis.

CASE PRESENTATION

A 55-year-old female patient presented with right elbow pain. An oval mass was seen near the medial epicondyle on the radiograph. A dynamic ultrasound examination was performed to reveal the relationship between the bone mass and the surrounding tissues, especially the ulnar nerve. Due to the well-circumscribed mass, a diagnosis of os subepicodlare mediale, a rare sesamoid bone, was made in light of current literature.

CONCLUSIONS

When a bone mass is seen in patients presenting with elbow pain, it will be useful to know and consider the sesamoid bones. In addition, ultrasonography should be performed in addition to radiography for a localized sesamoid bone in the medial region and adjacent to the ulnar nerve. Thus, the relationship of the sesamoid bone with existing and potential complaints can be revealed and correct diagnosis-treatment approaches can be applied.

A complete analysis of the surgical treatment for cubital tunnel syndrome: an umbrella review

BACKGROUND

Numerous original studies have been presented regarding various surgical treatments for cubital tunnel syndrome (CubTS). The results of these analyses regarding the different surgical treatments for CubTS frequently differ and, in some cases, contradict each other, creating confusion. Therefore, our umbrella review aimed to summarize the evidence from meta-analyses and systematic reviews regarding the surgical treatments of CubTS, and along with the new, more detailed outcomes, provide an evidence-based tool for surgeons performing these procedures.

MATERIALS AND METHODS

To perform this umbrella review, a systematic search was conducted for meta-analyses investigating CubTS in PubMed, Scopus, Embase, Web of Science, Google Scholar, Cochrane Library, BIOSIS, and EBSCO medical databases.

RESULTS

Detailed comparison of surgical outcomes, such as clinical improvement, complications, or reoperation rates, of different treatment methods for CubTS was performed. New risk ratios in all categories were established based on all of the primary studies available in the literature.

DISCUSSION

The goal of the present umbrella review was to gather and summarize all data about the surgical treatments for CubTS in the available literature and provide new outcomes and an evidence-based tool for surgeons performing these procedures. Each comparison of the surgical techniques has been discussed, and the present study's results were compared with the outcomes of the previous studies.

Analysis of Research Trends on Elbow Pain in Overhead Sports: A Bibliometric Study Based on Web of Science Database and VOSviewer

The publications on elbow pain (EP) in overhead sports are increasing. The results of previous studies mostly focus on the influence of EP in the ball game and throwing sports. Thus, a bibliometric analysis of these publications may show the direction of hot topics and future research trends. The purpose of this study is to identify the research trends on EP in overhead sports. For the methods, the first step is to use the main keywords of 'Elbow pain' and 'Overhead sport' merging auxiliary vocabulary to reach the relevant global publications between 1970 and 2022 in the Web of Science (WoS) database. The literature data set is imported into EndNote literature manager software to remove duplication. Secondly, the duplication-reduced articles are imported to an Excel sheet according to the inclusion and exclusion criteria of this study. In the third step, VOSviewer software is applied as the main analysis tool in extracting data for analysis from the articles. Then, the main research results for three aspects are obtained by VOSviewer software which extracted and analyzed the parameters of author name, article title, publication journal, keywords, organization, publication country/region, and the sum of times cited from 455 qualified papers. The study found that the United States of America made the most outstanding contribution to this theme study. The research on EP in overhead sports in China requires more attention from scholars. EP in swimming is a new research direction worthy of attention. In conclusion, the research results prove the growth trend of EP in overhead sports. The EP problem not only exists in the ball game and throwing sports but also swimming. Sport commercialization and the involvement of related professional sports organizations determine the degree of EP's attention in a specific sport and the development of solutions. The development of a region or country also affects the depth and scope of EP study. Clinical research development and in-depth exploration are one of the bases to solve EP problems. Non-clinical action is beneficial to EP patients, but it still needs to be explored and studied.

Local Corticosteroid Injection Versus Dry Needling in the Treatment of Lateral Epicondylitis

Background Lateral epicondylitis (LE) is an inflammation or micro-tearing of the tendons that join the forearm muscles on the lateral aspect of the elbow. Primary treatment of LE includes rest from offending activity and corticosteroid therapy for pain control. Dry needling (DN) is a relatively new therapy for LE. This study examined the results of DN therapy with corticosteroid injection. We aimed to compare pain relief and improvements in functional disability of LE patients treated via DN and corticosteroid injection in a tertiary care center. Methodology A prospective randomized control study was conducted among 54 patients in the Orthopaedics Department of R L Jalappa Hospital from January 2022 to May 2022. Patients received either DN or injectable corticosteroid therapy, and treatment groups were randomized using single-blinded randomization with sealed envelopes. Patients were evaluated using the Patient-Related Tennis Elbow Evaluation (PRTEE) score before the intervention and four and eight weeks after the intervention. Results A total of 54 patients were included in the final analysis. The mean age in the DN group was 43.96 ± 8.15 years and 44.74 ± 8.33 years in the corticosteroid group. In the DN group, 17 (62.96%) patients were male, and in the corticosteroid group, 16 (59.26%) patients were male. The differences in the PRTEE score at the fourth and eighth-week follow-up with baseline value (pre-injection) were statistically significant (p < 0.001). Conclusions DN is a low-cost, minimally invasive, and low-risk therapy whereas corticosteroid therapy is costly and produces systemic side effects in the long term. In this study, during the last follow-up visit, the PRTEE score improved in the DN group compared to the corticosteroid group.

Shoulder Range of Motion Deficits in Youth Throwers Presenting With Elbow Pain

BACKGROUND

Glenohumeral internal rotation deficit (GIRD) and total arc of motion difference (TAMD) have been associated with elbow injuries in throwing athletes.

HYPOTHESIS

Youth pitchers with elbow pain will have greater GIRD and TAMD compared with youth pitchers without elbow pain.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Glenohumeral range of motion of 25 consecutive throwing athletes presenting with elbow pain and that of a matched control group of 18 asymptomatic throwing athletes were compared. Bilateral glenohumeral internal rotation, external rotation, and horizontal adduction at 90° were measured and GIRD and TAMD were then calculated. An analysis of variance was performed to compare range of motion between throwers with and without elbow pain.

RESULTS

The average GIRD of the elbow pain group was 32.7° compared with 14.5° in the control group (P < 0.05). The average TAMD in the elbow pain group was 28.3° compared with 6.7° in the control group (P < 0.05). GIRD and TAMD were present in 88% (22 of 25) and 96% (24 of 25) of the elbow pain group versus 33.3% (6 of 18) and 55.6% (10 of 18) of the control group, respectively.

CONCLUSION

Compared with asymptomatic youth pitchers, those presenting with elbow pain have a statistically significant GIRD and TAMD.

CLINICAL RELEVANCE

This study suggests that a GIRD and TAMD may predispose youth pitchers to present with symptomatic elbow pain.

Upper Extremity Overuse Injuries and Obesity After Spinal Cord Injury

Persons with spinal cord injury (SCI) are at high risk for developing neurogenic obesity due to muscle paralysis and obligatory sarcopenia, sympathetic blunting, anabolic deficiency, and blunted satiety. Persons with SCI are also at high risk for shoulder, elbow, wrist, and hand injuries, including neuromusculoskeletal pathologies and nociceptive pain, as human upper extremities are poorly designed to facilitate chronic weight-bearing activities, including manual wheelchair propulsion, transfers, self-care, and day-to-day activities. This article reviews current literature on the relationship between obesity and increased body weight with upper extremity overuse injuries, detailing pathology at the shoulders, elbows, and wrists that elicit pain and functional decline and stressing the importance of weight management to preserve function.

The effects of counterforce brace on pain in subjects with lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Lateral elbow tendinopathy, also known as "tennis elbow" or "lateral epicondylitis," is a common disease leading to pain in the lateral side of the elbow and disability during hand gripping. A counterforce brace is one of the most conventional treatments. However, its effects on outcomes remain inconclusive.

OBJECTIVES

To investigate the effects of counterforce braces on pain in subjects with lateral elbow tendinopathy. Grip strength was reviewed as a secondary outcome.

STUDY DESIGN

Systematic review and meta-analysis of randomized controlled trials.

METHODS

PubMed, Embase, Scopus, Web of Science, CENTRAL, PEDro, ProQuest, RECAL, and RehabData were searched from January 1, 1995, through June 15, 2019.

RESULTS

Seventeen studies were included with a total of 1145 participants. A small improvement in pain over the short term (standardized mean difference -0.02; 95% confidence interval: -0.85 to 0.80) and a moderate-to-large improvement in pain in subjects 45 years or younger (standardized mean difference -0.86; 95% confidence interval: -2.45 to 0.72) in favor of the brace versus physiotherapy interventions were found. In contrast, over the long-term physiotherapy interventions (standardized mean difference 1.17; 95% confidence interval: -0.00 to 2.34), wrist splint (standardized mean difference 0.35; 95% confidence interval: -0.07 to 0.76), and laser therapy (standardized mean difference 0.58; 95% confidence interval: -0.44 to 1.59) had better effects on pain improvement versus the brace.

CONCLUSION

The results indicated that physiotherapy interventions compared to counterforce braces have better effects, especially over the long-term. However, counterforce braces may have better effects on pain in younger people (<45 years old) over the short term (<6 weeks).

CLINICAL RELEVANCE

The results suggest that counterforce bracing is a reasonable strategy to alleviate pain over the short term. However, the subgroup analysis suggests that factors such as age may have a role in their effectiveness.

Upper Extremity Pain Is Associated with Lower Back Pain among Young Basketball Players: A Cross-Sectional Study

Basketball is a major sport worldwide among different age groups that leads to a high frequency of injuries at multiple body sites. Upper and lower extremities and lower back are common pain sites in basketball players; however, there is little information about the relationship between upper or lower extremity pain and lower back pain. This study elucidated the associations between upper extremity (shoulder and elbow) pain and lower back pain (LBP) among young basketball players. We conducted a cross-sectional study using self-reported questionnaires mailed to 25,669 young athletes; the final study population comprised 590 basketball players, and their median age was 13 years (range: 6-15 years). The point prevalence rates of lower back, shoulder, elbow, and upper extremity pain among young basketball players were 12.9% (76/590), 4.6% (27/590), 2.7% (16/590), and 7.1% (42/590), respectively. Multivariate logistic regression analyses revealed that upper extremity pain was significantly associated with LBP (adjusted odds ratio [OR]: 7.86; 95% confidential interval [CI], 3.93-15.72). Shoulder pain was significantly associated with training per week (> 4 days) (adjusted OR: 4.15; 95% CI: 1.29-13.40) and LBP (adjusted OR: 13.77; 95% CI: 5.70-33.24). This study indicates that upper extremity and shoulder pain is associated with LBP among young basketball players. Assessing for lower back pain, as well as elbow and/or shoulder pain, may help prevent severe injuries in young basketball players. In conclusion, parents and coaches should be properly re-educated to help improve lower back, upper extremity, and shoulder pain among young basketball players.

Pain, function, and patient satisfaction after arthroscopic treatment of elbow in a retrospective series with minimum of 5-year follow-up

BACKGROUND

The clinical indications for elbow arthroscopic procedures have expanded through last decades. The aim of the study was to assess the functional results and patient satisfaction after arthroscopic treatment of various elbow conditions after a minimum 5-year follow-up.

METHODS

We conducted a retrospective study of a consecutive patient cohort who had undergone unilateral elbow arthroscopy between 2008 and 2010. The main outcomes were Disabilities of the Arm, Shoulder and Hand (DASH) score and a specific patient-reported outcome measure questionnaire after a minimum 5-year follow-up.

RESULTS

In total, there were 93 patients in the cohort with different diagnoses. Majority of patients were suffering from elbow osteoarthrosis. After the average follow-up of 72 months (range 60-96 months), the response rate was 67%. Eighty two percent of patients were satisfied with the pain relief and locking of the elbow was relieved in 70% of patients. Elbow range of motion (ROM) improved in 80% of the 55 patients who had a limited ROM before the operation. The overall patient satisfaction after elbow arthroscopic treatment was good. There were no differences in median DASH score between patients with or without post-traumatic condition, but the median DASH score for patients who had severe (grade 3) osteoarthrosis before the operation was significantly worse. There were no major complications reported in this cohort.

CONCLUSIONS

Arthroscopic treatment of various elbow conditions was associated with good patient satisfaction and reduced symptoms without major complications. Level of Evidence: Level IV, therapeutic case series.

Ultrasound-Guided Percutaneous Electrical Nerve Stimulation of the Radial Nerve for a Patient With Lateral Elbow Pain: A Case Report With a 2-Year Follow-up

BACKGROUND

Patients with lateral elbow pain are often diagnosed with lateral epicondylalgia. Lateral elbow pain is often associated with dysfunction of the wrist extensor muscles; however, in some cases, it can also mimic signs and symptoms of radial nerve dysfunction.

CASE DESCRIPTION

In this case report, a 43-year-old man, who was originally referred with a diagnosis of lateral epicondylalgia as a result of playing table tennis and who previously responded favorably to manual therapy and exercise, presented to the clinic for treatment. An exacerbation while participating in a table tennis match resulted in a return of his lateral epicondylalgia symptoms, which did not respond favorably to the same interventions used in his prior course of therapy. Further examination revealed sensitization of the radial nerve, which was treated with 2 sessions of ultrasound-guided percutaneous electrical nerve stimulation and 4 weeks of a low-load, concentric/eccentric exercise program for the wrist extensors.

OUTCOMES

Following this intervention, the patient experienced clinically meaningful improvement in pain intensity (numeric pain-rating scale), function (Patient-Rated Tennis Elbow Evaluation), and related disability (Disabilities of the Arm, Shoulder and Hand questionnaire). The patient progressively exhibited complete resolution of pain and function, which was maintained at 2 years.

DISCUSSION

This case report demonstrates the outcomes of a patient with lateral elbow pain who did not respond to manual therapy and exercise. Once radial nerve trunk sensitivity was identified and the intervention, consisting of ultrasound-guided percutaneous electrical nerve stimulation targeting the radial nerve combined with a low-load exercise program, was applied, a full resolution of pain and function occurred rapidly. Future clinical trials should examine the effect of percutaneous electrical nerve stimulation in the management of nerve-related symptoms associated with musculoskeletal pain conditions.

LEVEL OF EVIDENCE

Therapy, level 5. J Orthop Sports Phys Ther 2019;49(5):347-354. Epub 18 Jan 2019. doi:10.2519/jospt.2019.8570.

Comparison of extracorporeal shock-wave therapy and wrist-extensor splint application in the treatment of lateral epicondylitis: a prospective randomized controlled study

Background

Extracorporeal shock-wave therapy (ESWT) and wrist-extensor splints (WESs) are two commonly used methods in the treatment of lateral epicondylitis. In this study, the efficacy of these two methods was compared.

Methods

The study was planned as a prospective randomized controlled study. A total of 67 patients were enrolled. The patients were divided into two groups: group 1 received ESWT (32 patients) and group 2 received WES (35 patients). Patients in group 1 underwent four sessions of ESWT once every week. In each session, an ESWT device at 10–12 Hz, 2,000 pulses, and 1.6–1.8 bar pressure was used. Patients in group 2 used a wrist splint, holding the wrist at 30°–45° extension for 4 weeks. Patients were assessed for handgrip strength, pain at rest, pain while working, and quality of life. Data were collected before and after treatment (at weeks 4, 12, and 24). A visual analog scale was used to evaluate pain at rest and while working, a hand dynamometer for handgrip strength, subscales of the SF36 Health Survey to evaluate quality of life, and the Turkish version of the patient-rated tennis-elbow evaluation was used to evaluate functioning of the affected arm during various daily life activities.

Results

In both ESWT and WES groups, although there were considerably significant improvements (P<0.001) in the parameters evaluated (pain at rest and while working, handgrip strength, Patient-Rated Tennis Elbow Evaluation, Nirschl score, and SF36 subscales) were observed at 4, 12, and 24 weeks compared to pretreatment values, there was no statistically significant difference between the two groups in terms of our evaluation parameters at the three time points (P>0.05).

Conclusion

Both ESWT and WES applications were found to yield significantly superior results when compared to pretreatment values. In comparison of the two groups, on the other hand, there was no statistically significant difference.

Age-Specific Prevalence and Clinical Characteristics of Humeral Medial Epicondyle Apophysitis and Osteochondritis Dissecans: Ultrasonographic Assessment of 4249 Players

Background:

Traction apophysitis of medial epicondyle (MEC) lesions and osteochondritis dissecans (OCD) of the capitellum are common elbow injuries in adolescent baseball players. However, the age-specific prevalence of these pathologies and their influence on elbow pain remain unknown.

Purpose:

To investigate the age-specific prevalence of each MEC lesion and capitellar OCD and to identify the incidence of elbow pain in each condition.

Study Design:

Descriptive epidemiology study.

Methods:

Study participants consisted of 4249 baseball players aged 6 to 17 years. A questionnaire was used to assess history of elbow pain, and morphological changes of the elbow joint were assessed using ultrasonography.

Results:

Regarding MEC lesions, fragmented (FG) and irregular (IR) lesions both reached their greatest respective prevalence at 11 to 12 years of age. After 14 years of age, IR decreased sharply, whereas FG was maintained at approximately 10%. Hypertrophic (HT) lesions increased sharply, reaching over 50% at 16 years of age, while there was a decrease in IR and FG lesions in the same age group. The prevalence of capitellar OCD remained the same (approximately 2%) throughout all ages except for in players aged 7 to 8 years (>7%). Players with MEC lesions had significantly greater prevalence of a history of elbow pain compared with those without (68.0% vs 39.1%) and were at a significantly greater risk for FG lesions (odds ratio [OR], 4.04; 95% CI, 3.16-5.22) compared with IR (OR, 3.22; 95% CI, 2.44-4.27) and HT lesions (OR, 2.03; 95% CI, 1.75-2.36). Players with capitellar OCD also had a significantly greater risk of a history of elbow pain (OR, 2.34; 95% CI, 1.40-4.11).

Conclusion:

Controlling the amount of practice and its intensity according to the condition of each player in the preadolescent and adolescent periods may be important in accelerating bony healing and decreasing preventable elbow pain in adulthood.

A rare cause of chronic elbow pain in an adolescent baseball player: a case report

OBJECTIVE

To present a case of chronic elbow pain as a result of a hidden underlying osteochondral defect.

CLINICAL FEATURES

A 17-year old baseball player presented with chronic lateral elbow pain. Examination revealed swelling of the elbow with signs of possible ligament, muscle, and tendon injury.

DIAGNOSIS AND TREATMENT

Although there was apparent soft-tissue injury, the elbow swelling created immediate suspicion of a more serious underlying condition. Examination revealed a swollen and tender elbow, with plain x-ray confirming a subchondral bone disorder (osteochondral defect) of the capitellum. Surgical repair was performed by an orthopedic surgeon using DeNovo NT Natural Tissue Grafts: the implantation of small pieces of juvenile joint cartilage into the affected area, using glue-like fibrin. Rehabilitation of the elbow began immediately following surgery.

SUMMARY

Examination and imaging indicated that elbow pain in an adolescent baseball player could be from multiple sources, however, the chronic swelling raised suspicion of a condition requiring immediate and further investigation.

Extracorporeal shock wave therapy vs cryoultrasound therapy in the treatment of chronic lateral epicondylitis. One year follow up study

BACKGROUND

the purpose of this study is to compare the therapeutic effects of extracorporeal shock wave therapy (ESWT) to those of cryoultrasound (Cryo-US) therapy in chronic lateral epicondylitis during a 12-month period.

METHODS

single-blinded, randomized, controlled study of 80 participants treated for chronic LE with 3 ESWT sessions at 48/72-hours intervals (n=40) or 12 Cryo-US therapy sessions (4 sessions per week) (n=40). VAS and satisfactory results, considered as the sum of excellent and good scores in the Roles and Maudsley score, were used as outcome measures at baseline and 3, 6 and 12 months post-treatment.

RESULTS

the results show statistically significant differences in VAS between the two groups at 6 (p<0.001) and 12 months (p<0.001) in favour of the ESWT Group. At 12 months, a difference of more than 2 points in the VAS between the two groups is demonstrated in favour of the ESWT Group. Considering satisfactory results, significant differences between the two groups are observed at 6 (p=0.003) and 12 months (p <0.001) in favour of the ESWT Group where patients achieve a satisfactory rate over 50%.

CONCLUSIONS

ESWT has better clinical therapeutic results at 6- and 12-month follow-up as compared to Cryo-US therapy.

LEVEL OF EVIDENCE

1B.

Panner's disease: literature review and treatment recommendations

PURPOSE

To determine the most up-to-date theory on the aetiology of Panner's disease, to form a consensus on the assessment of radiographs and to evaluate clinical outcome in order to summarise the best available evidence for diagnosis and treatment.

METHODS

A review of studies to date on Panner's disease. Studies were eligible if: (1) the study provided criteria for defining Panner's disease in order to eliminate confounding data on other radiographic entities that were mistakenly grouped and presented as Panner's disease; (2) original data of at least one patient was presented; (3) manuscripts were written in English, German or Dutch; and (4) a full-text article was available. Animal studies, reviews and expert opinions were not included. Because the majority of the studies were case reports, we did not use an overall scoring system to evaluate methodological quality.

RESULTS

Twenty-three articles reporting on Panner's disease were included. Most cases of Panner's disease were unilateral in distribution and occurred in boys during the first decade of life. In general, conservative treatment is advised for Panner's disease. Panner's disease is a self-limiting disease and the majority of patients heal without clinical impairment.

CONCLUSIONS

Based on the results of this review, Panner's disease should be treated conservatively. Uniform names and descriptions of signs on radiographs would help to make the correct diagnosis. Since Panner's disease is very rare, higher quality studies are not likely to be performed and, thus, this review provides the best level of evidence on the current knowledge about Panner's disease.

Motor Cortex Reorganization and Impaired Function in the Transition to Sustained Muscle Pain

Primary motor cortical (M1) adaptation has not been investigated in the transition to sustained muscle pain. Daily injection of nerve growth factor (NGF) induces hyperalgesia reminiscent of musculoskeletal pain and provides a novel model to study M1 in response to progressively developing muscle soreness. Twelve healthy individuals were injected with NGF into right extensor carpi radialis brevis (ECRB) on Days 0 and 2 and with hypertonic saline on Day 4. Quantitative sensory and motor testing and assessment of M1 organization and function using transcranial magnetic stimulation were performed prior to injection on Days 0, 2, and 4 and again on Day 14. Pain and disability increased at Day 2 and increased further at Day 4. Reorganization of M1 was evident at Day 4 and was characterized by increased map excitability. These changes were accompanied by reduced intracortical inhibition and increased intracortical facilitation. Interhemispheric inhibition was reduced from the "affected" to the "unaffected" hemisphere on Day 4, and this was associated with increased pressure sensitivity in left ECRB. These data provide the first evidence of M1 adaptation in the transition to sustained muscle pain and have relevance for the development of therapies that seek to target M1 in musculoskeletal pain.

Use of sutures as Kirschner wire and tension-band wire for olecranon fractures: a technical note

Open reduction and internal fixation using tension-band wires for displaced olecranon fractures enables restoration of extensor function. We report on 3 elderly patients with a displaced olecranon fracture who underwent open reduction and internal fixation using sutures as the Kirschner wire and tension-band wire and achieved good outcome.

Preoperative diagnosis of bicipitoradial bursitis: a case report

Inflammation of the bicipitoradial bursa is a rare condition and only few reports can be found in literature. Several causes for a cubital bursitis have been suggested in the past. The need to include a malignant lesion in the differential diagnosis has only been mentioned in one of these reports. May main objective in reporting this case is to make this pathological entity better known.

Lateral antebrachial cutaneous nerve compression after traumatic rupture of the long head of the biceps: a case series

BACKGROUND

Lateral antebrachial cutaneous (LABC) nerve compression is a rare but debilitating injury. There are limited data on the association of LABC nerve compression and proximal biceps rupture. We theorized that because of distal migration, the biceps muscle and tendon cause compression on the nerve.

METHODS

We present 2 cases in which patients had proximal biceps ruptures with tendon retraction and developed neurologic symptoms associated with the LABC nerve. To demonstrate our theory, we performed a cadaveric experiment. After making an incision to expose the entire biceps muscle and the musculocutaneous nerve and its branch into the LABC nerve, we marked each structure in 2-cm increments with a marking pen. The long head of the biceps was then cut to simulate a proximal biceps rupture.

RESULTS

The relationship between the 3 structures was then studied, showing no change in position of the musculocutaneous nerve or LABC nerve. The biceps muscle and tendon had migrated distally toward the LABC nerve, demonstrating compression of the nerve.

CONCLUSION

Proximal biceps tears commonly occur from trauma as well as iatrogenically after a biceps tenotomy for treatment of biceps tendinopathy. However, it is unusual for neuropathy of the LABC nerve to occur. Patients who develop neuropathy associated with the LABC nerve after a proximal biceps rupture can be effectively treated with LABC nerve decompression and biceps plasty. We found that this was an effective surgical treatment of LABC neuropathy without the need for proximal biceps tenodesis.

Chiropractic management of elbow tendinopathy following a sports related trauma

OBJECTIVE

This report describes chiropractic management of a case of sub-acute elbow pain and swelling with Active Release Technique® and acupuncture.

CASE PRESENTATION

A 41-year-old male presented to a chiropractic clinic with a primary complaint of elbow pain and swelling following a fall while playing basketball five weeks prior.

INTERVENTION AND OUTCOME

Treatment consisted of two sessions of needle acupuncture and one treatment of Active Release Techniques® (ART) applied to the left elbow region.

CONCLUSIONS

The patient's outcomes indicated a quick resolution of subjective complaints and objective findings with the chosen treatment. Further research is needed to demonstrate safety, clinical effectiveness, and cost effectiveness when compared to other treatments.

A survey examining the correlations between Japanese little league baseball coaches' knowledge of and compliance with pitch count recommendations and player elbow pain

BACKGROUND

With the incidence of Little League elbow increasing, pitch limit recommendations for preventing throwing injuries have been developed in both the United States and Japan. However, levels of knowledge of and compliance with these recommendations among coaches of young baseball teams in Japan remain unknown. The relationship between these levels and elbow pain among players has not been adequately studied.

HYPOTHESIS

Knowledge of and compliance with these recommendations is similar in the United States and Japan. Greater knowledge and higher levels of compliance have a significant correlation with reduced elbow pain in Little League baseball players.

STUDY DESIGN

Cross-sectional study.

METHODS

Coaches of youth baseball teams in Kyoto, Japan, completed a questionnaire assessing knowledge of and compliance with recommendations. Team variables and coach-related factors concerning elbow pain among young baseball players were surveyed, and the questionnaire investigated demographic data and elbow pain history in the previous 12 months.

RESULTS

In total, 123 baseball coaches and 654 baseball players aged 6 to 12 years participated in this study; data were analyzed for 113 coaches and 339 players. Among coaches, 39.8% had accurate knowledge of the recommendations (similar to the US data) and 28.3% complied with them (lower than the US data). There was no correlation between elbow pain and knowledge of and compliance with the recommendations, but coaches' opinions on the number of games were indicated as a significant risk factor for elbow pain; the more coaches considered the number of games played, the fewer the number of players who experienced elbow pain.

CONCLUSION

The level of knowledge of recommendations in Japan was similar to that in the United States, but compliance levels were far lower. There was no correlation between elbow pain and knowledge and compliance.

CLINICAL RELEVANCE

The Little League elbow problem should be addressed at global and national levels.

Treatment of osteoid osteoma of the elbow by radiofrequency thermal ablation

BACKGROUND

This article presents the experience at the Rizzoli Orthopaedic Institute in the treatment of intracapsular osteoid osteoma (OO) of the elbow by computed tomography-guided percutaneous radiofrequency thermal ablation (RFA).

MATERIALS AND METHODS

Our team performed more than 800 RFA procedures to treat OO up to 2010. In 27 cases, the lesion site was the articular area of the elbow (humerus in 13 cases, ulna in 13, and radius in 1). These patients were reviewed and assessed for eradication rate, incidence of complications, and functional results measured by the Mayo Elbow Performance Score. The outcome was evaluated after a mean follow-up period of 67.4 ± 35.3 months (range, 24-128 months).

RESULTS

The mean duration of symptoms at the time of diagnosis was 31.0 ± 19.8 months (range, 5-72 months). All patients complained about pain, and in 24 of 27 cases (88.8%), the joint function was significantly impaired by the presence of OO (pretreatment score, 54.8). After RFA, the Mayo Elbow Performance Score improved by a mean of 37.7 ± 14.8 points, with 25 of 27 patients (92.5%) scoring 90 to 100 points at final follow-up. OO recurred in only 1 patient (3.7%), 5 months after the procedure. However, this was successfully retreated by RFA. No adverse effects were observed, and all patients were free of disease at the final follow-up.

DISCUSSION

The RFA procedure can be technically challenging in difficult sites such as the elbow joint. The low invasiveness of RFA compared with traditional surgery allows excellent functional recovery. RFA of elbow OO is effective and safe, and it should be considered the first-choice treatment for this disease.