Does the ulnohumeral angle have a role in the aetiopathogenesis of lateral epicondylitis?

The pathophysiology of lateral epicondylitis (LE) remains not fully elucidated, as it involves a complex interaction of anatomical structures. The primary objective of the research is to identify a potential relationship between LE and the ulnohumeral angle (UHA), which demonstrates the coronal alignment of the elbow. Patients diagnosed with LE between September 1st, 2020, and September 1st, 2023, were retrospectively examined. Demographic information and UHA measurements of patients meeting the inclusion criteria and a control group with similar criteria were collected. Measurements were independently conducted by 2 orthopedists at a 2-week interval and compared. Among 413 patients meeting the inclusion criteria and the control group comprising 420 patients, there were no significant differences in age, gender, and side (P = .447, P = .288, P = .159, respectively). The mean UHA for the LE group was 13.49 ± 4.24, while for the control group, it was 12.82 ± 9.19, showing a significant difference (P = .026). The inter-observer and intraobserver reliability of the angle measurements were both above 0.80. We hypothesize that the increase in UHA in patients with LE reflects an adaptive change secondary to compressive forces acting on the lateral aspect of the elbow. This study is the first to describe the relationship between LE and UHA based on anatomical-biomechanical foundations, suggesting a cause-and-effect relationship. Further studies are warranted to delve deeper into this relationship.

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.

Cardiovascular Disease Risk Factors Predict the Development and Numbers of Common Musculoskeletal Disorders in a Prospective Cohort

OBJECTIVE

The aim of the study is to assess risk of common musculoskeletal disorders (MSDs) based on cardiovascular disease (CVD) risk scores.

METHODS

Data from a 9-year prospective cohort of 1224 workers in three states were analyzed. Baseline data included questionnaires, structured interviews, physical examinations, anthropometric measurements, nerve conduction studies, and individualized measurement of job physical factors. Monthly follow-ups were conducted. Framingham risk scores were calculated. A priori case definitions were constructed for carpal tunnel syndrome, lateral epicondylopathy, medial epicondylopathy, and rotator cuff tendinopathy.

RESULTS

Adjusted RRs for one or more MSDs increased to 3.90 (95% confidence interval, 2.20-6.90) among those with 10-year cardiovascular disease risk scores greater than 15% and 17.4 (95% confidence interval, 3.85-78.62) among those with more than 4 disorders.

CONCLUSIONS

Cardiovascular disease factors are strongly associated with the subsequent development of common MSDs. Risks among those with multiple MSDs are considerably stronger.

[The use of sodium hyaluronate to treat upper limb disease: A review]

The most common diseases of the upper limb are osteoarthritis (OA) of the joints of the hands, lateral epiconlitis, tendinitis of the shoulder muscles, adhesive capsulitis. OA of the shoulder and acromioclavicular joints is less common. The development of acute and subacute pain in the elbow and shoulder joints in the vast majority of cases is determined by the pathology of soft tissues: muscles, ligamentous apparatus and related synovial bags, making it difficult to diagnose. A clinical and radiological heterogeneity of OA of the joints of the hands is a very complex pathology for the study, and also to create a unified algorithms for therapy. Therapy nonsteroidal anti-inflammatory drugs are effective in the short term, but it has several side effects. Despite a variety of attempts at therapy with successful and unsuccessful outcome, the attention of researchers for several decades converted to the injection therapy with hyaluronic acid. The article presents the data of studies demonstrating the anti-inflammatory effect of hyaluronic acid in the treatment of OA, as well as the results of clinical trials and data system of meta-analysis demonstrating the effectiveness of intra-articular and extra-articular therapy tendinopathy of the upper limb. Most of the cited studies demonstrated the efficacy and good tolerance of 1% sodium hyaluronate. In the domestic market it is presented in the drug Flexotron Forte. The authors provide the results of the study results, demonstrating the efficacy and safety of using Flexotron Forte to clinical practice.

The Use of Wearable Inertial Sensors and Workplace-Based Exercises to Reduce Lateral Epicondylitis in the Workstation of a Textile Logistics Center

People whose jobs involve repetitive motions of the wrist and forearm can suffer from lateral epicondylitis, which is a significant burden on both the individual and the employer due to treatment costs, reduced productivity, and work absenteeism. This paper describes an ergonomic intervention to reduce lateral epicondylitis in the workstation of a textile logistics center. The intervention includes workplace-based exercise programs, evaluation of risk factors, and movement correction. An injury- and subject-specific score was calculated from the motion captured with wearable inertial sensors at the workplace to evaluate the risk factors of 93 workers. Then, a new working movement was adapted to the workplace, which limited the observed risk factors and took into account the subject-specific physical abilities. The movement was taught to the workers during personalized sessions. The risk factors of 27 workers were evaluated again after the intervention to validate the effectiveness of the movement correction. In addition, active warm-up and stretching programs were introduced as part of the workday to promote muscle endurance and improve resistance to repetitive stress. The present strategy offered good results at low cost, without any physical modification of the workplace and without any detriment to productivity.

Platelet-Rich Plasma Injections Decrease the Need for Any Surgical Procedure for Chronic Epicondylitis versus Conservative Treatment-A Comparative Study with Long-Term Follow-Up

Background: Platelet-rich plasma (PRP) injections may alleviate symptoms of chronic medial or lateral epicondylitis. Methods: We retrospectively analyzed a total of 55 patients with chronic ME or LE who had undergone at least 6 months of any conservative treatment before intervention. The patients were divided into two groups: the PRP group (n = 25), who received a single injection of autologous PRP to the medial or lateral epicondyle, and the PT group (n = 30), who continued with PT and pain medication. The primary outcome measures were pain and functional outcomes measured in terms of the following: Patient Related Tennis Elbow Evaluation (PRTEE), Visual Analogue Scale (VAS), and Disabilities of the Arm, Shoulder, and Hand (DASH), which were detected at preintervention, 6-, 12-, 24-, and 36-month follow-up. Secondary outcomes included complications and the need for any surgery at follow-up. Results: Primary outcome measurements showed significantly better results favoring the PRP group (6-month PRTEE total 43.2 ± 19.2 vs. 62.8 ± 24.0, p < 0.001; 12-month PRTEE total 6.9 ± 15.0 vs. 28.1 ± 24.4, p < 0.001; 24-month PRTEE total 4.8 ± 9.8 vs. 12.7 ± 14.5, p = 0.029), and significantly better results in VAS and DASH sub-scores. The PRP group required significantly fewer surgical procedures (n = 0/0% vs. n = 6/20%, p = 0.027) at follow-up (mean 38.3 ± 12.3 months), and one case of prolonged pain after injection was detected. Conclusions: Patients who underwent PRP injections for epicondylitis resulted in better pain and functional outcomes compared to physiotherapy, and this improvement lasted at least 24 months. They required fewer surgical procedures and achieved faster recovery than the PT group. We recommend PRP for chronic epicondylitis of the elbow before considering surgery when other treatments have failed.

Women's wrist and elbow at work: analysis of acute injuries and cumulative trauma disorders to improve ergonomics in female-dominated activities

The aim of this study is to analyse women's wrist and elbow acute work injuries together with cumulative trauma disorders, such as carpal tunnel syndrome (CTS) and epicondylitis. Five years records (2015-2019) on women's wrist/elbow acute work injuries and CTS/epicondilytis, from Italian National Compensation Authority, were collected and pooled all together as 'dis-ac' (disorders + acute) events. A statistical analysis was performed in comparing the different female-dominated work sectors. Results showed that hairdressing/laundry sector was associated with the highest risk for wrist acute work injuries and cleaning for elbow while manufacturing for CTS and epicondylitis. Hairdressing/laundry and manufacturing were associated with the highest risk for dis-ac events (hairdressing: wrist dis-ac OR: 4.89; CI 95% 4.22-5.67; elbow dis-ac OR: 3.70; CI 95% 2.99-4.58; manufacturing: wrist dis-ac OR: 3.39; CI 95% 3.13-3.66; elbow dis-ac OR: 2.45; CI 95% 2.20-2.73). The relationship between acute injuries and cumulative trauma disorders is discussed to preserve women's safety and health in ergonomics.Practitioner Summary: Women's wrist and elbow acute work injuries and cumulative trauma disorders (carpal tunnel syndrome and epicondylitis) were analysed and studied all together (dis-ac events) in female-dominated activities. Hairdressing and manufacturing work sectors were associated with the highest risk, showing the need to safeguard the health and safety of female workers.

Ultrasound in the Differential Diagnosis of Medial Epicondylalgia and Medial Elbow Pain-Imaging Findings and Narrative Literature Review

Medial epicondylalgia (ME), commonly known as “the golfer’s elbow”, typically develops in individuals who perform repetitive forearm movements and weight-bearing activities. It accounts for up to 20% of all epicondylitis cases and is most prevalent in particular sports and occupations. Though the diagnosis can be made based on sole clinical examination, additional imaging might be essential for confirmation of medial epicondylitis and excluding other pathologies of the medial epicondyle region. US imaging, with a sensitivity and specificity of 95% and 92%, respectively, remains a practical and accessible alternative to MRI. However, its diagnostic efficacy highly depends on the operator’s experience and requires proper technique. This article describes the ultrasound examination and technique for adequate visualization of elbow joint structures. It also discusses the differential diagnosis of other common and less-known pathologies of the medial compartment of the elbow, including snapping triceps, medial collateral ligament injury, and cubital tunnel neuropathy.

Sports injuries and risk factors for table tennis among nonprofessional collegiate athletes: A cross-sectional study

Despite the increasing popularity of table tennis worldwide, few studies have focused on table tennis injuries.This study aimed to investigate the injury profiles, including the injury rate, types, locations, and risk factors, among nonprofessional collegiate table tennis athletes in Taiwan.We performed an online investigation among collegiate table tennis athletes of the nonprofessional category in the 2019 National Intercollegiate Athletic Games in Taiwan. Participants provided general information, and data on the characteristics of their play style, training, and injuries were collected. We then categorized these participants into injured and noninjured groups. Injuries were classified as mild, moderate, and severe, based on the time loss in playing table tennis. The risk factors for table tennis-related sports injuries were then identified through between-group comparisons.In total, 150 participants responded to the questionnaire. The average participant age was 21.3 years. Gender differences existed in age categories, forehand rubber, backhand style of play, and average days of training per week. Over the 6 months before the study, 76 of 150 participants experienced at least one injury. The handedness for play was associated with the occurrence of injury. Factors associated with injury severity included using rubber other than inverted rubber for the forehand and not qualifying for the national round of the team category of the National Intercollegiate Athletic Games.With a considerably high injury rate among nonprofessional collegiate athletes, further studies are required on table tennis-related injuries. Playing styles such as handedness and type of rubber used might be associated with the injury. The lower limb was the most common site of injury. These results may provide insights into trainers and coaches for further measures on injury prevention.

Wrist flexion and extension strength in patients with work-related chronic elbow pain: the isokinetic effort factor and its implications

BACKGROUND

The validity of isokinetic strength findings relating to forearm muscles in patients with chronic elbow pain and/or epicondylitis is not well established. Furthermore, given the nature of this disorder, ensuring maximal effort in performing the tests is an essential prerequisite. The isokinetic-based DEC parameter (defined as the difference between high- and low-velocity eccentric-to-concentric ratios of a given muscle) has been shown to efficiently detect maximal effort. The purpose of this study was therefore to assess the validity of isokinetic strength tests in patients with chronic elbow pain and/or epicondylitis.

METHODS

A cohort consisting of 44 male patients with chronic elbow pain (average evolution time, 262 ± 193.04 days) was recruited. The wrist extensor and flexor concentric and eccentric isokinetic strength of the involved and uninvolved sides was measured. The involved-uninvolved and flexor-extensor (F/E) ratios, as well as the DEC (eccentric-concentric difference), were computed based on peak moment values. Work disability and relapse within the first year were registered. In maximal performers, associations between deficits, F/E ratios, work disability, and symptom relapse were explored applying multiple comparisons.

RESULTS

Of the patients, 68.2% met the maximal-effort criteria, with the involved-side muscles being significantly weaker than their uninvolved-side counterparts in most cases. Although the mean deficit in this group was not associated with either work disability or relapse, patients with a relapse of symptoms within the first year had a significantly higher F/E ratio than those without relapse.

CONCLUSION

In patients presenting with chronic elbow pain who perform at the maximal level of effort, high wrist F/E strength ratios may predict symptom relapse.

Single Assessment Numeric Evaluation Correlates with American Shoulder and Elbow Surgeons Score for Common Elbow Pathology: A Retrospective Cohort Study

BACKGROUND

There are currently a variety of patient-reported outcomes (PROs) for elbow pathology, without any established gold standard. The Single Assessment Numeric Evaluation (SANE) is a single question assessment of the patient's perceived overall function compared with normal. The SANE score has been correlated with PROs from the shoulder and knee literature.

PURPOSE

To correlate the SANE score for a variety of elbow pathologies with a traditionally reported elbow outcome measure, the American Shoulder and Elbow Surgeons-Elbow score (ASES-E).

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A retrospective review was performed of all patients identified at a single center between April 2016 and January 2019 who presented as a new patient with elbow pathology. All patients prospectively completed the ASES-E along with the SANE score for elbow (SANE-E) at the time of initial consultation. Spearman correlations (r) were performed to evaluate the correlation between the ASES-E and the SANE-E score for specific elbow pathology, along with descriptive data such as age, sex, and chronicity of the problem.

RESULTS

A total of 555 patients (166 women, 29.9%) with a mean ± SD age of 51.0 ± 11.7 years with the diagnoses of medial epicondylitis (n = 72; 13.0%), lateral epicondylitis (n = 224; 40.4%), biceps tendon rupture (n = 139; 25.0%), triceps tendon rupture (n = 21; 3.8%), and elbow arthritis (n = 99; 17.8%) were included in this analysis. There was moderate correlation between the SANE-E and the ASES-E (r = 0.623; P < .001), with strongest correlation with the visual analog scale (VAS) (r = -0.518; P < .001) compared with any individual question and moderate to strong correlations based on specific diagnoses. SANE-E and ASES-E scores for the entire cohort were 42.9 ± 26.7 and 56.9 ± 21.4, respectively (P < .001). Age (r = 0.027; P = .526), sex (r = 0.026; P = .555), VAS (r = -0.106; P = .013), and chronicity of the problem (r = -0.037; P = .384) were not found to be correlated with differences in ASES-E and SANE-E.

CONCLUSION

The SANE-E score is a simple way to assess patient-perceived function relative to normal. The findings of this study demonstrated moderate to strong correlation between the ASES-E and the SANE-E score for a variety of commonly encountered elbow conditions.

Cell-based therapies for the treatment of sports injuries of the upper limb

Introduction: The use of cell-based therapies in the management of sports injuries of the upper limb is increasingly popular despite the limited scientific evidence available for their use. We aim to evaluate the evidence for the use of cell-based therapies in these injuries and recommend areas for further research.Areas covered: In accordance with a published protocol (PROSPERO; Registration No. CRD42020193258), a comprehensive search of the literature was performed using the MEDLINE and EMBASE databases from inception to June 2020. All human studies reporting on the clinical, histological, or radiological outcomes following the use of cell-based therapies in the management of epicondylitis or rotator cuff pathology were included in this study. This resulted in 22 studies being included in this review, all of which underwent risk of bias assessments.Expert opinion: The evidence for the use of cell-based therapies in upper limb sports injuries is limited and generally of low quality. Given the heterogeneity in the cell types used, their harvesting methods and cell amounts, future research should be targeted at developing standardization of the reporting of these studies and more direct comparative studies looking at the efficacy of the different cell types.

Factors Associated With Lateral Epicondylitis of the Elbow

Background:

Metabolic factors have been linked to tendinopathies, yet few studies have investigated the association between metabolic factors and lateral epicondylitis.

Purpose:

To evaluate risk factors for lateral epicondylitis, including several metabolic factors.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We evaluated 1 elbow in each of 937 volunteers from a rural region that employs many agricultural laborers. Each participant received a questionnaire, physical examinations, blood tests, simple radiographic evaluations of both elbows, magnetic resonance imaging of bilateral shoulders, and an electrophysiological study of bilateral upper extremities. Lateral epicondylitis was diagnosed using 3 criteria: (1) pain at the lateral aspect of the elbow, (2) point tenderness over the lateral epicondyle, and (3) pain during resistive wrist dorsiflexion with the elbow in full extension. Multivariable logistic regression analysis was used to calculate the odds ratios (ORs) and 95% CIs for various demographic, physical, and social factors, including age, sex, waist circumference, dominant-side involvement, smoking habit, alcohol intake, and participation in manual labor; the comorbidities of diabetes, hypertension, thyroid dysfunction, metabolic syndrome, ipsilateral biceps tendon injury, ipsilateral rotator cuff tear, and ipsilateral carpal tunnel syndrome; and the serologic parameters of serum lipid profile, glycosylated hemoglobin A1c, level of thyroid hormone, and high-sensitivity C-reactive protein.

Results:

The prevalence of lateral epicondylitis was 26.1% (245/937 participants). According to the multivariable logistic regression analysis, female sex (OR, 2.47; 95% CI, 1.78-3.43), dominant-side involvement (OR, 3.21; 95% CI, 2.24-4.60), manual labor (OR, 2.25; 95% CI, 1.48-3.43), and ipsilateral rotator cuff tear (OR, 2.77; 95% CI, 1.96-3.91) were significantly associated with lateral epicondylitis (P < .001 for all). No metabolic factors were significantly associated with lateral epicondylitis.

Conclusion:

Female sex, dominant-side involvement, manual labor, and ipsilateral rotator cuff tear were found to be risk factors for lateral epicondylitis. The study results suggest that overuse activity is more strongly associated with lateral epicondylitis than are metabolic factors.

[Chronic pain syndrome in diseases of periarticular tissues]

The search for an effective method of treating diseases of the musculoskeletal system is a rather actual problem for a practicing physician nowadays in connection with the modern lifestyle of most people. A prolonged stay in the same position, as a rule, leads to overstrain of the capsule-joint complexes, and, as a consequence, to the development of degenerative changes in the joints and periarticular tissues. These changes can manifest themselves clinically in the form of a chronic or acute pain syndrome. One of the common diseases characterized by degenerative periarticular changes with a variety of clinical manifestations are periarthropathies. Periarthropathy or periarthrosis is still the subject of discussion by doctors of related specialties: neurologists, orthopedists, rheumatologists, etc. Pain in this case can be caused by the primary degenerative process in muscles and tendons in combination with their chronic microtraumatization, ischemia, and reactive inflammation. Periarthropathy can be considered as a «train» of any arthropathy, because pain always causes muscle spasm, a change in the motor stereotype, a limitation of motor activity in the joint, etc. In the absence of joint pathology, it should be considered as a primary disease. There is still no common understanding of this nosological unit, including pathogenesis, classification, diagnostic algorithms and therapy. Treatment is based on general recommendations: limiting the load on the damaged joint, massage (according to indications), exercise therapy, manual therapy, physiotherapy. Drug therapy includes intramuscular or intraarticular administration of glucocorticosteroids (GCS), non-steroidal anti-inflammatory drugs (NSAIDs) but these drugs have certain side-effects and contraindications. Treatment of peritropathy with chondroprotectors (chondrogard) is rapidly gaining momentum, as well as GCS and NSAIDs, they reduce pain and increase the functionality of the joints, but, unlike the latter, their safety profile is much higher. The authors summarize current findings on this issue.

Prospective Evaluation of Changes in Pain Levels, Quality of Life and Functionality After Low Dose Radiotherapy for Epicondylitis, Plantar Fasciitis, and Finger Osteoarthritis

Background: The objective benefits of low dose radiotherapy (LDRT) for non-malignant joint disorders are controversial. This study evaluated changes in pain, quality of life (QoL) and function after LDRT for epicondylitis, plantar fasciitis, and finger osteoarthritis. Materials and Methods: Patients over 40 years old with epicondylitis, plantar fasciitis, and finger osteoarthritis were had pain following at least 6 months of conservative therapy. Patients received 0.5 Gy LDRT twice weekly for 4 weeks repeated once after 8 weeks in patients who failed to achieve complete pain relief. Patients assessed their pain according to the visual analog scale. Handgrip strength was measured with an isometric dynamometer and the fast self-paced walking test was used in patients with plantar fasciitis. QoL was evaluated according to the EQ-5D and HAQ-DI questionnaires. Results: Outcomes for 157 patients (204 sites) were documented at 2, 6, and 12 months after last LDRT. Pain reduction at rest (p < 0.001), during activity (p < 0.001) and increase in handgrip strength (extension p < 0.001, flexion p = 0.002) were highly significant for patients with lateral epicondylitis. Patients with medial epicondylitis reported pain relief at rest (p = 0.041) and during activity (p = 0.041) and significant increase in handgrip strength (p = 0.022). Patients with plantar fasciitis reported pain reduction at rest (p < 0.001), during activity (p < 0.001) and faster walking times (p < 0.001). A trend toward improved QoL was observed. Patients with finger osteoarthritis reported significant pain relief during activity (p < 0.001) and a gain in handgrip strength (p = 0.004), with a trend to both pain relief at rest (p = 0.056) and stronger pinch grip (p = 0.099). Conclusions: LDRT achieved significant pain relief at rest and during activity and a corresponding objective improvement in handgrip strength in patients with epicondylitis. Pain relief at rest, during activity and improvement in walking time were demonstrated in patients with plantar fasciitis. LDRT achieved pain relief during activity, and handgrip strength was improved in patients with finger osteoarthritis. No significant effect was seen on quality of life measures for these conditions. The observed benefits were maintained 12 months after LDRT for all 3 indications and we recommend this low cost, safe intervention for patients over 40 who have failed prior conservative therapy.

Prolotherapy: Regenerative Medicine for Lateral Epicondylitis

Lateral epicondylitis (LE) is a degenerative disease of the tendons, spurred by repetitive microtrauma leading to an attempt by the body to heal by upregulating local angiogenesis and fibroblast proliferation. Prolotherapy (PT) is the injection of dextrose around the injured tissues to stimulate their spontaneous regeneration. Herein, we have described a case of lateral epicondylitis, diagnosed with clinical and ultrasound (US) examination, where local steroid injections provided relief only for a limited time. We treated the patient with US-guided PT, following which the pain disappeared and the tendon was restored.

T1ρ-Mapping for Musculoskeletal Pain Diagnosis: Case Series of Variation of Water Bound Glycosaminoglycans Quantification before and after Fascial Manipulation® in Subjects with Elbow Pain

Diagnosis and management of musculoskeletal pain is a major clinical challenge. Following this need, the first aim of our study was to provide an innovative magnetic resonance technique called T_1ρ to quantify possible alterations in elbow pain, a common musculoskeletal pain syndrome that has not a clear etiology. Five patients were recruited presenting chronic elbow pain (>3 months), with an age between 30 and 70 years old. Patients underwent two T_1ρ-mapping evaluations, one before and one after the series of Fascial Manipulation^® (FM) treatments. After the first MRI evaluation, a Disability of the Arm, Shoulder and Hand (DASH) questionnaire was administered to quantify the symptoms and pain intensity. Patients then received three sessions of FM, once a week for 40 min each. A statistically significant difference was found between bound and unbound water concentration before and after FM treatment. Our preliminary data suggest that the application of the manual method seems to decrease the concentration of unbound water inside the deep fascia in the most chronic patients. This could explain the change in viscosity perceived by many practitioners as well as the decrease of symptoms due to the restoration of the normal property of the loose connective tissue. Being able to identify an altered deep fascial area may better guide therapies, contributing to a more nuanced view of the mechanisms of pain.

Platelet-rich plasma vs corticosteroids for elbow epicondylitis: A systematic review and meta-analysis

OBJECTIVE

The aim of this meta-analysis was to compare the effectiveness of platelet-rich plasma (PRP) vs corticosteroids for treatment of patients with lateral elbow epicondylitis.

METHODS

A literature search was performed in EMBASE, Medline, the Cochrane Library and PubMed. Randomized controlled studies comparing PRP with corticosteroids for the treatment of epicondylitis were included. The Cochrane Collaboration's tool for assessing the risk of bias was used to evaluate the methodological quality of the included trials. The Cochrane Collaboration's Review Manager software was used to perform the meta-analyses. The overall effect size of each anesthetic was calculated as the weighted average of the inverse variance of the study-specific estimates.

RESULTS

Seven randomized controlled trials were included in this review. The data from 2 studies were unavailable for meta-analysis, and the systematic review criteria were just achieved. Local corticosteroid injection yielded a significantly superior Disabilities of the Arm, Shoulder and Hand (DASH) score at 4 weeks (WMD, 11.90; 95% CI: 7.72 to 16.08; P < .00001; heterogeneity, χ = 0, I = 0%, P = 1.00) and 8 weeks (WMD, 6.29; 95% CI: 2.98 to 9.60; P = .0002, χ = 0, I = 0%, P = 1.00). Otherwise, it was noteworthy that a significantly lower VAS score (WMD, -2.61; 95% CI: -5.18 to -0.04; P = .05; heterogeneity, χ = 29.85, I = 97%, P < .00001) and DASH score (WMD, -7.73; 95% CI: -9.99 to -5.46; P < .00001, χ = 0.20, I = 0%, P = .66) existed in the PRP regimen than in the steroid regimen at the 24-week follow-up. More effective treatments were achieved in the PRP-treated patients than in the patients treated with corticosteroids (WMD, 3.33; 95% CI: 1.81 to 6.14; P = .000; heterogeneity, χ = 0.43, I = 0%, P = .51).

CONCLUSIONS

Local corticosteroid injections demonstrated favorable outcomes compared with those of local PRP treatments for lateral elbow epicondylitis during the short-term follow-up period (4 weeks and 8 weeks post-treatment). Otherwise, at the long-term follow-up (24 weeks post-treatment), PRP injections had improved pain and function more effectively than corticosteroid injections.

Ultrasound-guided tenotomy improves physical function and decreases pain for tendinopathies of the elbow: a retrospective review

BACKGROUND

Tendinopathy is a common cause of elbow pain in the active population. Ultrasound-guided tenotomy (USGT) is a minimally invasive treatment option for cases recalcitrant to conservative management. Several case studies have shown promising preliminary results of USGT for common extensor tendinopathy and common flexor tendinopathy, but none have included USGT for triceps tendinopathy. This larger retrospective study evaluates the effectiveness and safety of USGT for all elbow tendinopathy sites at short- and long-term follow-up.

METHODS

Retrospective chart review identified 131 patients (144 procedures; mean age ± standard deviation [SD], 48.1 ± 9.8 years; mean body mass index ± SD, 32.2 ± 7.7; 59% male) with elbow tendinopathy (104 common extensor tendinopathy, 19 common flexor tendinopathy, 8 triceps tendinopathy) treated with USGT over a 6-year period by a single physician. Pain and quality-of-life measures were collected at baseline. Pain, quality-of-life, satisfaction with outcome, and complications were collected at short-term (2-, 6-, and 12-week) and long-term (median 2.7 years, interquartile range = 2.0-4.0 years) follow-up.

RESULTS

Overall, USGT for elbow tendinopathy decreased pain from moderate/severe at baseline to mild/occasional at short- and long-term follow-up (P < .01). Quality-of-life assessments showed significant improvement in physical function at short- and long-term follow-up (P < .01). The majority (70%) of patients were satisfied with the procedure. There was a 0% complication rate.

CONCLUSION

Benefits of USGT include pain relief, improved physical function, and high patient satisfaction. USGT is a safe, minimally invasive treatment for refractory elbow tendinopathy.

The use of biologics for the elbow: a critical analysis review

There is significant interest in biologic treatment options to improve the healing environment and more rapidly decrease symptoms in many conditions around the elbow. Despite fairly widespread use of biologic agents such as platelet-rich plasma (PRP) in the elbow, there is a lack of clear evidence in the literature to support its use. The potential impact of these biologic agents must be evaluated with evidence from high-quality studies, particularly considering the high financial burden these treatments often impose on patients. The aim of this review is to provide an evidence-based summary of the biologic augmentation options available for use by the physician treating painful conditions of the elbow and to identify areas where further research is warranted.

Iontophoresis in lateral epicondylitis: a randomized, double-blind clinical trial

BACKGROUND

Lateral epicondylitis (LE) is a painful condition typically caused by excessive use of tendons, resulting in tendinopathy, inflammation, pain, and sensitivity changes in the lateral elbow. Iontophoresis is a noninvasive method of systemic and local drug delivery by means of a current. The study aimed to evaluate the effects of iontophoresis in patients with LE.

METHODS

We performed a randomized, double-blind clinical trial. Twenty-four patients with LE, randomized into an iontophoresis group and a galvanic current group. The iontophoresis group received a solution of dexamethasone (4 mg/mL) and gel lidocaine-applied on the negative electrode by means of a continuous current at 5 mA for 15 minutes-and the positive electrode received a base gel solution. Patients in the galvanic current group received the same protocol but using a base gel solution on both electrodes.

RESULTS

Both groups showed a significant improvement in pain on exertion and rest; increased handgrip strength in elbow extension and flexion; and improved function, as evaluated by the Patient-Rated Tennis Elbow Evaluation scale (P < .05). Iontophoresis showed superior results compared with galvanic current in pain on exertion and rest and in the function of individuals with tennis elbow.

CONCLUSION

Iontophoresis proved to be an effective technique in reducing pain and improving strength and function in individuals with LE (tennis elbow).

Quantitative Measures of Physical Risk Factors Associated with Work-Related Musculoskeletal Disorders of the Elbow: A Systematic Review

Background: Work-related musculoskeletal disorders at the elbow are a common health problem, which highly impacts workers’ well-being and performance. Besides existing qualitative information, there is a clear lack of quantitative information of physical risk factors associated with specific disorders at the elbow (SDEs). Objective: To provide evidence-based quantitative measures of physical risk factors associated with SDEs. Methods: Studies were searched from 2007 to 2017 in Medline, EMBASE, and Cochrane Work. The identified risk factors were grouped in main- and sub-categories of exposure using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework for rating evidence. Results: 133 different risk-factor specifications were identified in 10/524 articles and were grouped into 5 main- and 16 sub-categories of exposure. The risk factors were significantly associated with lateral epicondylitis, medial epicondylitis, or ulnar neuropathy. Significant risk factors such as wrist angular velocity (5°/s, with increasing prevalence ratio of 0.10%/(°/s), or forearm supination (≥45° and ≥5% of time combined with forceful lifting) were found. Conclusions: This review delivers a categorization of work-related physical risk-factor specifications for SDEs with a special focus on quantitative measures, ranked for evidence. These results may build the base for developing risk assessment methods and prospective preventive measures.

Platelet-rich plasma versus Tenex in the treatment of medial and lateral epicondylitis

BACKGROUND

Medial epicondylitis and lateral epicondylitis are among the most common elbow pathologies affecting people aged between 40 and 50 years. Although epicondylitis is often a self-limiting condition that improves with conservative treatment, the condition can be difficult to eradicate. The purpose of this study was to compare the effectiveness of platelet-rich plasma (PRP) injections and ultrasound-guided percutaneous tenotomy (Tenex) for the treatment of medial or lateral epicondylitis. Our hypothesis was that the Tenex procedure would not be inferior to PRP injections in the treatment of medial or lateral epicondylitis.

METHODS

In this retrospective review, 62 of 75 patients were available for contact via phone and e-mail to complete post-procedure patient-reported outcome surveys. Subjective assessment of pain and function included a visual analog scale for pain; the Quick Disabilities of the Arm, Shoulder and Hand questionnaire; and the EuroQol-5D questionnaire. The inclusion criteria included age of 18 years or older and previous failure of nonoperative treatment.

RESULTS

The average ages in the PRP and Tenex groups were 47 years and 51 years, respectively. The PRP cohort (n = 32) included 10 female and 22 male patients, whereas the Tenex cohort (n = 30) included 12 female and 18 male patients. The PRP and Tenex groups both demonstrated clinical and statistical improvement in visual analog scale pain scores; Quick Disabilities of the Arm, Shoulder and Hand scores; and EuroQol-5D scores. No statistically significant difference was found between the 2 treatment modalities.

CONCLUSION

The PRP and Tenex procedures were both successful in producing clinically and statistically significant improvements in pain, function, and quality of life.

Diagnostics and acknowledgement of occupational diseases - topics and challenges in the Czech Republic

The causes of occupational diseases are changing, thats why a regular update of Czech List of Occupational Diseases is needed. New compensable occupational diseases, such as cancer of the larynx and ovarian cancer due to asbestos, and chronic obstructive pulmonary diseases due to black coal dust were included in the last two updates of the Czech List. The need of an early examination at the Centers of Occupational Diseases is stressed in this article, especially before a surgery or other treatment of epicondylitis and carpal tunnel syndrome. These treatments may suppress the diagnostic hallmarks requested for acknowledgements of these disorders. Extrinsic allergic alveolitis, allergic rhinitis and bronchial asthma are underdiagnosed, and isocyanates belong among the key factors. Only about 10 % patients with mesotheliomas due to asbestos are compensated. The latency in cancers due to asbestos may reach more than 50 years.

Surgical management of lateral epicondylitis combined with ligament insufficiency

BACKGROUND

Lateral collateral ligament (LCL) insufficiency may occur in patients with chronic lateral epicondylitis (LE). We report on 14 consecutive patients with chronic LE and LCL insufficiency.

METHODS

We performed a retrospective review of 14 patients with LE and LCL insufficiency diagnosed between 2006 and 2015. The patients had undergone débridement for LE and ligament reconstruction for LCL insufficiency. The study included 9 men and 5 women with an average age of 53 years (range, 41-69 years). The mean follow-up period was 36 months (range, 24-97 months). We analyzed the pain visual analog scale score; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; range of motion; and posterolateral rotatory drawer test. We compared histories of steroid injection, trauma, and surgery.

RESULTS

The pain visual analog scale score, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score were significantly improved postoperatively and improved in all patients. Three patients had mild instability on the stress test at final follow-up. All patients had a history of steroid injection, 2 had a history of trauma, and 3 had a history of surgery. The number of steroid injections and the number of cases receiving steroid injections more than 3 times were significantly higher in patients with LCL insufficiency.

CONCLUSIONS

Assessment of stability is important in patients with chronic LE and risk factors such as multiple steroid injections. Simultaneous surgical treatment including open débridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency.

Current physiotherapy practice in the management of tennis elbow: A service evaluation

BACKGROUND

Tennis elbow is a common painful condition that may affect daily function and ability to work. Physiotherapy is the most commonly used primary intervention but there is a wide range of treatment options within the umbrella of physiotherapy. Our aim was to report on the treatments that are currently used by physiotherapists in a UK National Health Service (NHS) setting.

METHODS

A retrospective service evaluation was conducted at two NHS hospital trusts by reviewing patient attendance records over a 1-year period. All patients with tennis elbow were included, except those referred for postoperative rehabilitation. Patient notes were analysed using a predefined assessment template.

RESULTS

A total of 65 patient records were identified, with patients having a mean age 48 years and mean symptom duration of 5.4 months. The mean treatment duration was 64 days, over 3.7 sessions. The most commonly used treatments were education and exercise, although the type and dosing of exercise varied greatly. Passive modalities such as ice, taping, manual therapy, acupuncture and electrotherapy were still used.

CONCLUSIONS

Wide variations in treatment approaches were identified. There was no consistency in the choice of modality used, the type of exercise or the dose of exercise prescribed. The use of passive modalities and corticosteroid injections was found to remain commonplace, despite a lack of supporting research evidence. There is a clear need for evidence-based guidance for physiotherapists treating patients with tennis elbow.

Real-time sonoelastography: principles and clinical applications in tendon disorders. A systematic review

Background

Sonoelastography (SE) is a new ultrasound-based method adopted in an increased number of scientific reports to analyse normal and pathological tendons. The aim of this study is to provide a systematic overview of clinical applications of SE in normal and pathological tendons.

Methods

A systematic research of PubMed, Ovid, and Cochrane Library electronic databases was performed according to PRISMA guideline. Two Authors searched and evaluated the articles independently; a third Author was involved to solve any disagreement. The Oxford Level of Evidence (LoE) was used to assess each article.

Results

There is an increasing interest in the application of SE in the evaluation of healthy and diseased tendons. Many different tendons are amenable for SE evaluation, such as the Achilles and patellar tendons, rotator cuff, common extensor tendons, quadriceps tendon, and the plantar fascia.

Conclusion

SE appears to be a very useful diagnostic tool, in particular in tendon pathology. This is a dynamic examination, provides an immediate evaluation of the tissue elasticity, and may be useful in recognizing tendon abnormalities and in implementing the information available with conventional US.

Level of evidence

IV.

[Local injection therapy of damage of paraarticular tissue]

AIM

To evaluate the potential of local injection therapy with Alflutop in management of paraarticular tissue lesions (PTL).

MATERIAL AND METHODS

44 patients with various localization of PTL were examined and exposed to treatment.

RESULTS

As a result of local therapy with Alflutop, the majority of patients with PTL experienced a decrease in pain syndrome and an increase in the functional capabilities. There was no negative dynamic of symptoms.

CONCLUSION

Treatment with Alflutop was well tolerated by patients, easily applied, had a small number of side effects and was accompanied by a pronounced clinical effect.

Topical polidocanol application in combination with static stretching in tendinopathies: a prospective pilot study

BACKGROUND

Highly operator-based injection therapy with vasosclerosing and anesthetic polidocanol is used for tendinopathies. This pilot-study evaluates the topical application of polidocanol gel.

METHODS

Prospective case series. 39 patients with tendinopathies (14 Achilles, 14 patella, 11 wrist extensors) with a symptom duration > 6 months were included. Polidocanol and static stretching were the therapy in the first 2 weeks, while static stretching was continuously performed for 6 months. Clinical outcome was evaluated with VISA-A, VISA-P and DASH Scores and sonographically with B-Mode (B-Mode), Power Doppler (PD) and Shearwave Elastography (SWE).

RESULTS

22 patients clinically improved (>+10 score points), 11 patients were without improvement (<+ 10) and 1 patient worsened during 6 months. The VISA-A Score increased in average 19 points from 56 to 75 (p< 0.01), VISA-P Score increased 13 points from 59 to 72 (p< 0,01) and the DASH-Score decreased 20 points from 40 to 20 (p< 0,01). SWE correlates better than B-Mode or PD with symptom improvement.

CONCLUSION

The combination of static training and topical polidocanol application seems to be successful in the treatment of tendinopathies. Further RCT studies need to evaluate the efficiency of topical polidocanol application. SWE is a more sensitive tool to describe symptom development than PD or B-Mode.

LEVEL OF EVIDENCE

IV.

Evaluation of common elbow pathologies: a focus on physical examination

Elbow tendinopathy accounts for the majority of elbow pathology in patients presenting to upper extremity and sports medicine surgeons. With increased participation in overhead sports in an aging population, the incidence of elbow injuries has risen. A comprehensive knowledge of elbow anatomy and biomechanical function of the elbow complex is prerequisite in the assessment of patients with elbow injuries; however, a thorough understanding of alternative and confounding pathologies is essential for accurate diagnosis. Because tendinopathy, tendonitis, and tendon tears have an anatomic basis for their pathology, a targeted history and meticulous physical examination often yields an accurate clinical diagnosis. The importance of physical examination and provocative examination maneuvers must be stressed in a technologically advanced era where clinical diagnosis is too commonly attained solely by advanced imaging modalities. A revived dedication to the physical examination may enhance our ability to correctly diagnose various pathologies about the elbow. Early and accurate clinical diagnosis is the first step in the proper initiation of treatment modalities and improvement in overall patient outcome.

Incidence and prevalence of upper-limb work related musculoskeletal disorders: A systematic review

BACKGROUND

Musculoskeletal disorders are one of the most common work-related diseases. Frequently this association is thought to have a temporal cause-effect relation. The absence of accessible diagnostic criteria and ethological cause-effect demonstration are probably important reasons for the lack of good evidence data on these pathologies.

OBJECTIVE

For these reasons, the authors aim to present a systematic review on prevalence and incidence of the upper limb WRMSD.

METHODS

The survey was conducted for papers published between January 1st, 2000 and July 2012, according to the PRISMA statement (2009) guidelines.

RESULTS

From the 2016 papers obtained, 94 met the qualitative selection criteria. From these 27 address upper-limb WRMSD, and 17 present data on prevalence or incidence on upper-limb musculoskeletal diseases, six of them with a control group. Annual incidence ranges from 0.08 to 6.3, and prevalence from 0.14 to 14.9. Rotator cuff syndrome among shoe industry workers, present the highest incidence, and cubital, radial or ulnar nerve entrapment, the highest prevalence among a miscellaneous group of workers.

CONCLUSIONS

More studies are needed to clarify the relation between work and WRMSD's, especially prospective investigations from different economic sectors and work activities, but with similar, reproducible and comparable methodologies.

The Three-Portal Technique in Arthroscopic Lateral Epicondylitis Release

Lateral epicondylitis, commonly referred to as tennis elbow, is a syndrome characterized by pain over the origin of the common extensor muscles of the fingers, hand and wrist at the lateral epicondyle. Reports of 70-90% response to conservative treatment at one year have been documented in the literature though refractory cases often require surgical management. Arthroscopic treatment of lateral epicondylitis allows for intra-articular visualization for concomitant pathology and localization of the Extensor Carpi Radialis Brevis tendon. Additionally, compared to the open technique, the arthroscopic technique has a lower morbidity and an earlier return to work and activity. Here we describe a three portal technique for improved visualization in arthroscopic lateral epicondylitis release.

Examining the association between musculoskeletal injuries and carpal tunnel syndrome in manual laborers

INTRODUCTION

The association between musculoskeletal injuries and carpal tunnel syndrome (CTS) has not been investigated in a large, population-based study.

METHODS

Latino manual laborers were recruited as part of a study of work-related health conditions. Each had a clinical examination, completed a hand diagram, and had nerve conduction studies.

RESULTS

A total of 512 individuals completed all testing. An association was found between rotator cuff syndrome and CTS, with an adjusted odds ratio of 2.25 (P = 0.01) for the right arm, 2.08 (P = 0.03) for the left arm, and 1.84 (P = 0.03) for all individuals. Associations between epicondylitis and CTS did not reach statistical significance.

CONCLUSIONS

Individuals with rotator cuff syndrome have a higher prevalence of CTS. Further investigations will be needed to examine for causation and to determine if 1 condition typically occurs first and leads to the other. Muscle Nerve 54: 31-35, 2016.

[Diagnostic guidlines for occupational epicondylitis]

Making final decisions on the occupational etiology of musculoskeletal diseases is often difficult and problematic at every stage of the diagnostic procedure. Taking into account the need to facilitate decision-making about the causal relationship between the diagnosed disease entity and the working conditions guidelines for the recognition of work-related musculoskeletal diseases have been developed. This paper presents the guidelines for the diagnosis of occupational etiology of humeral epicondylitis, one of the most common occupational disease of the musculoskeletal system in Poland. The developed guidelines have been based on the literature data concerning occupational risk factors of humeral epicondylitis, workload classification, including repetitive movements, awkward postures, and force. Some criteria applied in ergonomic evaluation methods were also included. The presented diagnostic guidelines define approximate benchmarks for stating (after excluding non-occupational etiology) that the identified humeral epicondylitis, is related to the way of working. Crucial work factors that should be analyzed include an operating time of movements overloading tendons connecting to the epicondyle, repetition and force used to perform occupational activities. The developed guidelines are aimed to facilitate occupational physicians diagnostic and certification procedures in case of humeral epicondylitis and determination whether there is a likelihood of its occupational etiology.

Factors associated with failure of nonoperative treatment in lateral epicondylitis

BACKGROUND

Lateral epicondylitis is a common cause of elbow pain that is treated with a variety of nonoperative measures and often improves with time. Minimal research is available on patients in whom these nonoperative treatments fail.

PURPOSE

To identify baseline patient and disease factors associated with the failure of nonoperative treatment of lateral epicondylitis, defined as surgery after a period of nonoperative treatment.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

A total of 580 patients treated for lateral epicondylitis at a tertiary center between 2007 and 2012 were analyzed. Disease-specific and patient demographic characteristics were compared between patient groups (nonoperative vs surgical treatment). A multivariable logistic regression model was created based on preliminary univariate testing to determine which characteristics were associated with failure of nonoperative treatment.

RESULTS

Of the 580 patients, 92 (16%) underwent surgical treatment at a mean of 6 months (range, 0-31 months) from their initial visit. Univariate analysis demonstrated a potential association (P < .10) between operative management and the following factors at initial diagnosis: increased age, body mass index, duration of symptoms, presence of radial tunnel syndrome, prior injection, physical therapy, splinting, smoking, workers' compensation, a labor occupation, use of narcotics, use of antidepressant medications, and previous orthopaedic surgery. In the final multivariable model, a workers' compensation claim (odds ratio [OR], 8.1), prior injection (OR, 5.6), the presence of radial tunnel syndrome (OR, 3.1), previous orthopaedic surgery (OR, 3.2), and duration of symptoms >12 months (OR, 2.5) remained significant independent predictors of surgical treatment.

CONCLUSION

This study identifies risk factors for surgical treatment for lateral epicondylitis. While these findings do not provide information regarding causal factors associated with surgery, these patient and disease-specific considerations may be helpful when counseling patients regarding treatment options and the likelihood of the success of continued nonoperative treatment.

Predicting work-related incidence of lateral and medial epicondylitis using the strain index

BACKGROUND

The Strain Index (SI) has been developed to evaluate the risk for developing a distal upper extremity disorder. The objective of this study is to determine if the SI predicts incidence cases of work-related lateral, medial, or any epicondylities (LEPI, MEPI, and EPI).

METHODS

Six hundred seven workers were followed for up to 3.5 years, 70 developed EPI on the dominant side (44 LEPI, 13 MEPI, and 13 both). Survival analyses were conducted adjusting for demographic, psychosocial, and work organizational factors, with the SI as time-dependent variable.

RESULTS

High exposure (SI > 5), older age, and self-perceived poor general health were associated with incidence of LEPI and EPI, but not MEPI. There was a significant relationship between higher scores of SI and LEPI, hazard ratio (HR) 2.00 (95% CI 1.04-3.87) for SI 5.1-12, HR 2.12 (95% CI 1.11-4.05) for SI > 12.

CONCLUSIONS

The SI can effectively identify jobs with increased risk of developing incidence of LEPI.

Adipokines as predictors of recovery from upper extremity soft tissue disorders

OBJECTIVES

To study the associations of adipokines with recovery from upper extremity soft tissue disorders (UESTDs) and to explore whether overweight or obesity modify these associations.

METHODS

In this follow-up study, patients seeking medical advice due to incipient upper extremity symptoms with symptom duration <1 month were included (n = 163). The outcome of the study was full or substantial recovery from UESTDs, assessed at 2, 8 and 12 weeks of follow-up. We studied the associations of four adipokines (leptin, adiponectin, resistin and visfatin) with recovery using the generalized estimating equation.

RESULTS

Of the study population, 27.5% reported full or substantial recovery at the 8-week follow-up and 32% at 12 weeks. Higher levels of resistin [odds ratio (OR) = 1.58, 95% CI 1.18, 2.11 for 1 s.d. increase] and visfatin (OR = 1.29, 95% CI 0.94, 1.78 for 1 s.d. increase) at baseline predicted a higher recovery rate at the 8-week follow-up. Moreover, higher levels of leptin predicted a lower rate of recovery (OR = 0.73, 95% CI 0.51, 1.02 for 1 s.d. increase). Adipokines did not predict recovery at 12 weeks. In subgroup analyses, high levels of resistin and visfatin at baseline predicted a higher recovery rate during follow-up in non-overweight patients.

CONCLUSION

The adipokines resistin and visfatin predicted recovery from UESTDs and the associations may be related to stimulation of anti-inflammatory response mechanisms. A higher level of leptin may prevent recovery from UESTDs.

Medium-Term Results After Treatment of Recalcitrant Lateral Epicondylitis: A Prospective, Randomized Study Comparing Open Release and Radiofrequency Microtenotomy

BACKGROUND

Recalcitrant lateral epicondylitis (elbow extensor-origin tendinosis) is a common cause of elbow pain with many treatment options. In the present study, the medium-term results after open release and radiofrequency microtenotomy are reported.

HYPOTHESIS

Microtenotomy would provide long-term pain relief that was as good as the open release method.

STUDY DESIGN

Prospective, randomized trial.

METHODS

Twenty-four patients randomized to either open release or microtenotomy were assessed after 5 to 7 years. Clinical examination and dynamic infrared thermography (DIRT) of both elbows were performed preoperatively and at the medium-term follow-up. Magnetic resonance imaging (MRI) of both elbows was performed at the medium-term follow-up.

RESULTS

Significant pain reduction was found using a visual analog scale (VAS) at the medium-term follow-up in both groups compared with the preoperative assessment (P < .005). The Mayo Elbow Performance Score (MEPS) increased significantly in both groups (P < .01). The improvement in grip strength was not significant in either group. There was no significant difference between the groups in terms of VAS, strength, and the MEPS. On the DIRT examinations, there were significantly fewer hot spots at the medium-term follow-up than preoperatively (P = .0067, both study groups together). The MRI examinations revealed grade II changes in the operated elbow in 1 patient in each group at the medium-term follow-up, while all the other MRI examinations revealed a normal tendon.

CONCLUSION

In this prospective, randomized trial with a medium-term follow-up, the results were similar after surgical release and microtenotomy in patients with recalcitrant lateral epicondylitis. The hypothesis was thus verified.

Self-reported physical exposure association with medial and lateral epicondylitis incidence in a large longitudinal study

INTRODUCTION

Although previous studies have related occupational exposure and epicondylitis, the evidence is moderate and mostly based on cross-sectional studies. Suspected physical exposures were tested over a 3-year period in a large longitudinal cohort study of workers in the USA.

METHOD

In a population-based study including a variety of industries, 1107 newly employed workers were examined; only workers without elbow symptoms at baseline were included. Baseline questionnaires collected information on personal characteristics and self-reported physical work exposures and psychosocial measures for the current or most recent job at 6 months. Epicondylitis (lateral and medial) was the main outcome, assessed at 36 months based on symptoms and physical examination (palpation or provocation test). Logistic models included the most relevant associated variables.

RESULTS

Of 699 workers tested after 36 months who did not have elbow symptoms at baseline, 48 suffered from medial or lateral epicondylitis (6.9%), with 34 cases of lateral epicondylitis (4.9%), 30 cases of medial epicondylitis (4.3%) and 16 workers who had both. After adjusting for age, lack of social support and obesity, consistent associations were observed between self-reported wrist bending/twisting and forearm twisting/rotating/screwing motion and future cases of medial or lateral epicondylitis (ORs 2.8 (1.2 to 6.2) and 3.6 (1.2 to 11.0) in men and women, respectively).

CONCLUSIONS

Self-reported physical exposures that implicate repetitive and extensive/prolonged wrist bend/twisting and forearm movements were associated with incident cases of lateral and medial epicondylitis in a large longitudinal study, although other studies are needed to better specify the exposures involved.

Acupuncture for lateral epicondylitis (tennis elbow): study protocol for a randomized, practitioner-assessor blinded, controlled pilot clinical trial

BACKGROUND

Lateral epicondylitis is the most frequent cause of pain around the elbow joint. It causes pain in the region of the elbow joint and results in dysfunction of the elbow and deterioration of the quality of life. The purpose of this study is to compare the effects of ipsilateral acupuncture, contralateral acupuncture and sham acupuncture on lateral epicondylitis.

METHODS/DESIGN

Forty-five subjects with lateral epicondylitis will be randomized into three groups: the ipsilateral acupuncture group, contralateral acupuncture group and the sham acupuncture group. The inclusion criteria will be as follows: (1) age between 19 and 65 years with pain due to one-sided lateral epicondylitis that persisted for at least four weeks, (2) with tenderness on pressure limited to regions around the elbow joint, (3) complaining of pain during resistive extension of the middle finger or the wrist, (4) with average pain of NRS 4 or higher during the last one week at a screening visit and (5) voluntarily agree to this study and sign a written consent. Acupuncture treatment will be given 10 times in total for 4 weeks to all groups. Follow up observations will be conducted after the completion of the treatment, 8 weeks and 12 weeks after the random assignment. Ipsilateral acupuncture group and contralateral acupuncture group will receive acupuncture on LI4, TE5, LI10, LI11, LU5, LI12 and two Ashi points. The sham acupuncture group will receive treatment on acupuncture points not related to the lateral epicondylitis using a non-invasive method. The needles will be maintained for 20 minutes. The primary outcome will be differences in the visual analogue scale (VAS) for elbow pain between the groups. The secondary outcome will be differences in patient-rated tennis elbow evaluation (PRTEE), pain-free/maximum grip strength (Dynamometer), pressure pain threshold, clinically relevant improvement, patient global assessment, and the EQ-5D. The data will be analyzed with the paired t-test and ANCOVA (P <0.05).

DISCUSSION

The results of this study will allow evaluation of contralateral acupuncture from two aspects. First, if the contralateral acupuncture shows the effects similar to ipsilateral acupuncture, this will establish clinical basis for contralateral acupuncture. Second, if the effects of contralateral acupuncture are not comparable to the effects of ipsilateral acupuncture, but are shown to be similar to the effects of the sham acupuncture, we can establish the basis for using the same acupoints of the unaffected side as a control in acupuncture clinical studies.

TRIAL REGISTRATION

This trial has been registered with the 'Clinical Research Information Service (CRIS)', Republic of Korea: KCT0000628.

Role of diagnostic ultrasound in the assessment of musculoskeletal diseases

The wide availability and recent improvement in technology coupled with portability, low cost and safety makes ultrasound the first choice imaging investigation for the evaluation of musculoskeletal diseases. Diagnostic use of ultrasound findings is greatly enhanced by knowledge of the clinical presentation. Conversely, ultrasound skills with its prerequisite anatomical knowledge make the clinical diagnosis more precise and reduce uncertainty in the choice of therapy. Therefore, it is essential for rheumatologists to acquire ultrasonography skills in order to improve patient care. Ultrasound examination provides an excellent opportunity for patient education and to explain the rationale for therapy. This review summarizes the indications for musculoskeletal ultrasound and describes its role in diagnosis, monitoring and prognosis.

Two cases of work-related lateral epicondylopathy treated with Graston Technique® and conservative rehabilitation

OBJECTIVE

To chronicle the conservative treatment and management of two work-related cases of lateral elbow pain diagnosed as lateral epicondylopathy.

CLINICAL FEATURES

PATIENT 1: A 48-year old female presented with gradual onset of right lateral elbow pain over the course of six weeks related to work activities of repetitive flexion/extension movements of the wrist and finger keying. PATIENT 2: A 47-year old female presented with gradual onset of left lateral elbow pain over the course of four weeks related to work activities of repetitive squeezing and gripping.

INTERVENTION AND OUTCOME

The conservative treatment approach consisted of activity modification, bracing, medical acupuncture with electrical stimulation, Graston Technique®, and rehabilitative exercise prescription. Outcome measures included verbal pain rating scale (VPRS), QuickDASH Work Module Score (QDWMS), and a return to regular work activities. Both patients attained resolution of their complaints, and at eight month follow-up reported no recurrence of symptoms.

CONCLUSION

A combination of conservative rehabilitation strategies may be used by chiropractors to treat work-related lateral epicondylopathy and allow for individuals to minimize lost time related to this condition.

The prevalence of medial epicondylitis among patients with c6 and c7 radiculopathy

Background:

Medial epicondylitis, or golfer’s/pitcher’s elbow, develops as a result of medial stress overload on the flexor muscles at the elbow and presents as pain at the medial epicondyle. Cervical radiculopathy has been associated with lateral epicondylitis, but few associations between the cervical spine and medial epicondylitis have been made. Researchers propose that there is an association, suggesting that the weakness and imbalance in the elbow flexor and extensor muscles from C6 and C7 radiculopathy allow for easy onset of medial epicondylitis.

Hypothesis:

Medial epicondylitis will present in over half the patients diagnosed with C6 and C7 radiculopathy.

Methodology:

A total of 102 patients initially presenting with upper extremity or neck symptoms were diagnosed with cervical radiculopathy. They were then examined for medial epicondylitis. Data were collected by referring to patient charts from February 2008 until June 2009.

Results:

Fifty-five patients were diagnosed with medial epicondylitis. Of these, 44 had C6 and C7 radiculopathy whereas 11 presented with just C6 radiculopathy.

Conclusion:

Medial epicondylitis presented with cervical radiculopathy in slightly more than half the patients. Weakening of the flexor carpi radialis and pronator teres and imbalance of the flexor and extensor muscles from the C6 and C7 radiculopathy allow for easy onset of medial epicondylitis. Patients with medial epicondylitis should be examined for C6 and C7 radiculopathy to ensure proper treatment. Physicians dealing with golfers, pitchers, or other patients with medial epicondylitis should be aware of the association between these 2 diagnoses to optimize care.

Effect of repetition rate on the formation of microtears in tendon in an in vivo cyclical loading model

We reported previously the formation of microtears in an in vivo loaded Flexor Digitorum Profundus (FDP) rabbit tendon with a repetition rate of 60 repetitions per minute and a peak force of 15% of maximum peak tetanic force for 80 cumulative hours. Tear area as a percent of tendon area, tear density (tears/mm(2)), and mean tear size (microm(2)) were higher in tendons from the loaded limb compared to the unloaded control limb. The purpose of the present study was to compare those results to results obtained with a repetition rate of 10 while maintaining the same peak force and force-time integral (n = 8). Due to a strain gradient between the inner and outer sides of the FDP tendon, microtears were quantified in four regions, two regions each along the inner and outer sides of the tendon. The tear area as a percent of total tendon area and the mean tear size were significantly greater in the loaded limb compared to the unloaded limb (p < 0.03). However, the effects were less than those observed at 60 repetitions/min. The higher repetition loading pattern resulted in an increase in tear measures in all four regions, while the lower rate produced changes only in the outer regions of the tendon. This finding may establish where the initial sites of damage occur in tendons that insert into bone in a similar arrangement as the FDP. The results suggest that repetition rate or number of loading cycles is associated with increased tendon microtears or fragility in a dose-response pattern.

Repetitive Strain in Nonrepetitive Work: A Case Study

In a Québec factory, a woman in a nontraditional job suffered from epicondylitis whereas her male coworkers were unaffected. A study was undertaken in order to enumerate the operations at risk for epicondylitis. Workers were interviewed in order to identify difficult operations and systematic observations were done over 4 work days. Although tasks were extremely varied, certain movements at risk for epicondylitis were repeated many times. Fifty-three valves were turned against resistance as part of this job, and one valve requiring a particularly difficult movement was turned 20 times in one day. There were at least 61 operations at risk for epicondylitis per day over a 4-day period. Strain on the elbow joint was particularly intense for the woman worker because the design of the workplace gave an advantage to taller workers with larger hands. Although this case study does not permit us to conclude that the worker's epicondylitis was due to her job, it enables us to suggest that it would be wise to adapt the dimensions of relevant equipment and worksites to a wider range of potential worker sizes. We also raise some questions about the definition of repetitive strain in epidemiological studies. We suggest that it may be necessary to consider not only the cycle time but also the total of forces exerted on a joint in order to study workplace injuries to the musculoskeletal system.