Minimal important difference, patient acceptable symptom state and longitudinal validity of oxford elbow score and the quickDASH in patients with tennis elbow

BACKGROUND

The Oxford Elbow Score (OES) and the short version of Disabilities of Arms, Shoulder and Hand (QuickDASH) are common patient-reported outcomes for people with elbow problems. Our primary objective was to define thresholds for the Minimal Important Difference (MID) and Patient-Acceptable Symptom State (PASS) for the OES and QuickDASH. The secondary aim was to compare the longitudinal validity of these outcome measures.

METHODS

We recruited 97 patients with clinically-diagnosed tennis elbow for a prospective observational cohort study in a pragmatic clinical setting. Fifty-five participants received no specific intervention, 14 underwent surgery (11 as primary treatment and 4 during follow-up), and 28 received either botulinum toxin injection or platelet rich plasma injection. We collected OES (0 to 100, higher is better) and QuickDASH (0 to 100, higher is worse), and global rating of change (as an external transition anchor question) at six weeks, three months, six months and 12 months. We defined MID and PASS values using three approaches. To assess the longitudinal validity of the measures, we calculated the Spearman's correlation coefficient between the change in the outcome scores and external transition anchor question, and the Area Under the Curve (AUC) from a receiver operating characteristics (ROC) analysis. To assess signal-to-noise ratio, we calculated standardized response means.

RESULTS

Depending on the method, MID values ranged from 16 to 21 for OES Pain; 10 to 17 for OES Function; 14 to 28 for OES Social-psychological; 14 to 20 for OES Total score, and - 7 to -9 for QuickDASH. Patient-Acceptable Symptom State (PASS) cut offs were 74 to 84 for OES Pain; 88 to 91 for OES Function; 75 to 78 with OES Social-psychological; 80 to 81 with OES Total score and 19 to 23 with Quick-DASH. OES had stronger correlations with the anchor items, and AUC values suggested superior discrimination (between improved and not improved) compared with QuickDASH. OES also had superior signal-to-noise ratio compared with QuickDASH.

CONCLUSION

The study provides MID and PASS values for OES and QuickDASH. Due to better longitudinal validity, OES may be a better choice for clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02425982 (first registered April 24, 2015).

Evaluation of lateral epicondylopathy, posterior interosseous nerve compression, and plica syndrome as co-existing causes of chronic tennis elbow

PURPOSE

A great number of patients that suffer from lateral epicondylitis, commonly called tennis elbow (TE), are not successfully treated, meaning, not getting adequate therapeutic effects and the main origin of the pain not being handled appropriately. The hypothesis of the present study is that the inefficiency of the treatment of the chronic TE may often be due to underdiagnosis of posterior interosseous nerve (PIN) entrapment or and plica syndrome, as the authors believe that those pathologies can often occur simultaneously.

METHODS

A prospective cross sectional study was conducted. A total of 31 patients met the required criteria.

RESULTS

Thirteen (40.7%) of the patients had more than one source of the lateral elbow pain. Five patients (15.6%) had all three examined pathologies. Six patients (18.8%) had TE and PIN syndrome. Two patients (6.3%) had TE and plica syndrome.

CONCLUSION

The present study demonstrated concomitant potential sources of lateral elbow pain in patients diagnosed with chronic TE. Our analysis shows how important it is to systematically diagnose patients that present with lateral elbow pain. The clinical characteristics of the three most common causes of chronic lateral elbow pain, meaning, TE, PIN compression, and plicae syndrome were also analyzed. Having adequate knowledge about the clinical aspects of these pathologies can help with a more effective differentiation of the etiology of chronic lateral elbow pain, and with that, a more efficient and cost-effective treatment plan.

Is blood group a risk factor in lateral epicondylitis?

OBJECTIVE

Lateral epicondylitis is a common disorder in the community. Identification of risk factors plays an important role in the prevention and treatment of the disease. In our study, the relationship between risk factors in lateral epicondylitis and blood group, which has not been mentioned before in the literature, will be examined.

PATIENTS AND METHODS

In our study, patients' age, height, weight, body mass index (BMI), dominant upper extremity, affected upper extremity, duration of symptoms, duration between onset of symptoms and hospital admission, occupation, number of children and youngest child age (if the patient is a mother), smoking, alcohol use, presence of additional diseases, sports activities, job requiring repetitive movements and strength in the upper extremities in daily life, marital status, where he/she lives and his/her blood type were questioned. In our study, there were 304 patients in the patient group and 304 patients in the control group.

RESULTS

In our study, blood type 0 was significantly more common in the patient group (p<0.001).

CONCLUSIONS

In our study, it was concluded that there is a relationship between 0 blood group and lateral epicondylitis.

Radial Tunnel Syndrome: Case Report and Comprehensive Critical Review of a Compression Neuropathy Surrounded by Controversy

Radial tunnel syndrome (RTS) is an uncommon controversial entity thought to cause chronic lateral proximal forearm pain due to compression of the deep branch of the radial nerve, without paralysis or sensory changes. Diagnostic confusion for pain conditions in this region results from inconsistent definitions, terminology, tests, and descriptions in the literature of RTS and "tennis elbow," or lateral epicondylitis. A case of bilateral RTS with signs discordant with traditionally used clinical diagnostic tests was successfully relieved with surgical decompression and led us to perform a comprehensive critical review of the condition. We delineate the controversy surrounding its diagnosis and aim to facilitate appropriate management and identify other areas for further study in this controversial condition. Clinical validity and evidence of anatomical rationale for the traditionally used Maudsley's provocative test is unclear in diagnosis of RTS or in chronic lateral elbow pain, if at all. Neither imaging nor electrophysiological studies contribute to a clinical diagnosis which is supported by short-term improvement after an injection with long-acting local anesthetic and corticosteroid. Accurate diagnosis and treatment of RTS can significantly improve quality of life, but validity and evidence for traditional clinical tests and definitions must be clarified.

[MEDIAL EPICONDYLITIS (GOLFER'S ELBOW) - CLINICAL PRESENTATION AND TREATMENT]

Medial epicondylitis, which is also called "Golfer's Elbow" is a pathology which typically presents as medial elbow pain. It affects 1% of the general population, yet affects 3.8% to 8.2% of work-related complaints. Golfer's elbow is common in the 40 to 60-year-old age group so those suffering from it are part of the workforce and hence, its economic impact. Women and men alike suffer from golfer's elbow, and microtrauma combined with attritional changes in the common flexor tendon origin at the medial aspect of the elbow are the culprit of this pathology. The first line of treatment is conservative therapy and only when it fails is an open surgical approach utilized. New approaches to treating this ailment such as use of Extra Corporeal Shock Wave therapy and the use of injectable blood derivatives, as well as new surgical techniques are also being applied.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BACKGROUND

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

METHODS

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

CONCLUSIONS

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis

BACKGROUND

Tennis elbow is a common painful enthesopathy of the lateral elbow that limits upper limb function and frequently results in lost time at work. Surgeons often recommend surgery if symptoms persist despite nonsurgical management, but operations for tennis elbow are inconsistent in their efficacy, and what we know about those operations often derives from observational studies that assume the condition does not continue to improve over time. This assumption is largely untested, and it may not be true; meta-analyzing results from the control arms of tennis elbow studies can help us to evaluate this premise, but to our knowledge, this has not been done.

QUESTIONS/PURPOSES

The aims of this systematic review were to describe the course of (1) global improvement, (2) pain, and (3) disability in participants who received no active treatment (placebo or no treatment) in published randomized controlled trials (RCTs) on tennis elbow. We also assessed (4) whether the duration of symptoms or placebo effect is associated with differences in symptom trajectories.

METHODS

We searched MEDLINE, Embase, and CENTRAL from database inception to August 12, 2019, for trials including participants with tennis elbow and a placebo or a no-treatment arm and a minimum follow-up duration of 6 months. There were no language restrictions or exclusion criteria. We extracted global improvement, pain, and disability outcomes. We used the Cochrane Risk of Bias tool to assess the risk of bias of included trials. To estimate the typical course of tennis elbow without active treatment, we pooled global improvement (the proportion of participants who reported feeling much better or completely recovered), mean pain, and mean disability using baseline, 1-month, 3-month, 6-month, and 12-month follow-up data. We transformed pain and disability data from the original papers so that at each timepoint the relevant outcome was expressed as change relative to baseline to account for different baseline values. We used meta-regression to assess whether the placebo effect or duration of symptoms before enrollment was associated with differences in symptom trajectories. We included 24 trials with 1085 participants who received no active treatment.

RESULTS

The number of patients who were not improved decreased exponentially over time. The half-life of global improvement was between 2.5 and 3 months (that is, every 2.5 to 3 months, 50% of the remaining symptomatic patients reported complete recovery or greatly improved symptoms). At 1 year, 89% (189 of 213; 95% CI 80% to 97%) of patients experienced global improvement. The mean pain and disability followed a similar pattern, halving every 3 to 4 months. Eighty-eight percent of pain (95% CI 70% to 100%) and 85% of disability (95% CI 60% to 100%) had resolved by 1 year. The mean duration of symptoms before trial enrollment was not associated with differences in symptom trajectories. The trajectories of the no-treatment and placebo arms were similar, indicating that the placebo effect of the studied active treatments likely is negligible.

CONCLUSION

Based on the placebo or no-treatment control arms of randomized trials, about 90% of people with untreated tennis elbow achieve symptom resolution at 1 year. The probability of resolution appears to remain constant throughout the first year of follow-up and does not depend on previous symptom duration, undermining the rationale that surgery is appropriate if symptoms persist beyond a certain point of time. We recommend that clinicians inform people who are frustrated with persisting symptoms that this is not a cause for apprehension, given that spontaneous improvement is about as likely during the subsequent few months as it was early after the symptoms first appeared. Because of the high likelihood of spontaneous recovery, any active intervention needs to be justified by high levels of early efficacy and little or no risk to outperform watchful waiting.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Management of Lateral Epicondylitis: A Narrative Literature Review

Lateral epicondylitis, also termed as "tennis elbow," is the most common cause of elbow pain and dysfunction, mainly resulting from repetitive gripping or wrist extension during various activities. The exact pathogenesis remains largely elusive with putative tendinosis, a symptomatic degenerative process of the local tendon. It is usually diagnosed by clinical examinations. Sometimes, additional imaging is required for a specific differential diagnosis. Although most cases can be self-healing, the optimal treatment strategy for chronic lateral epicondylitis remains controversial. This article presents a landscape of emerging evidence on lateral epicondylitis and focuses on the pathogenesis, diagnosis, and management, shedding light on the understandings and treatment for healthcare professionals.

[Not a Chronic Tennis Elbow]

Not a Chronic Tennis Elbow Abstract. Lateral elbow pain is a highly unspecific finding and may be caused by one of several possible differential diagnoses. Unfortunately, it is often assumed to be epicondylitis, commonly referred to as tennis elbow, although instability is a frequent cause in chronic cases. In the presented case, it is the less frequent nerve compression of the radial nerve which must also be considered, together with plica syndrome, osteochondritis dissecans and arthrosis of the radiocapitellar joint, as a differential diagnosis of lateral elbow pain.

The effects of KinesioTape on the treatment of lateral epicondylitis

STUDY DESIGN

Randomized clinical trial.

INTRODUCTION

KinesioTape (KT) is a noninvasive method to treat pain and muscular dysfunction.

PURPOSE

To investigate the effect of KT with and without tension on pain intensity, pain pressure threshold, grip strength and disability in individuals with lateral epicondylitis, and myofacial trigger points in forearm muscles.

METHODS

Thirty women with lateral epicondylitis and myofacial trigger point in forearm muscles were randomly assigned to KT with tension and placebo (KT without tension). The treatment was provided 3 times in one week, and outcome measures were assess pre-post treatment.

RESULTS

The mean score of visual analogue scale (VAS) during activity decreased significantly from 6.4 and 6 pretest to 2.53 and 4.66 posttest, respectively, for the KT with and without tension groups. The mean score of Disabilities of the Arm, Shoulder and Hand decreased significantly from 16.82 and 22.79 pretest to 8.65 and 8.29 posttest, respectively, for the KT with and without tension groups. A paired t-test revealed a significant reduction in VAS during activity and Disabilities of the Arm, Shoulder and Hand before and after treatment in both groups (P < .05). Pain pressure threshold, grip strength, and VAS using an algometer revealed no significant differences. The study showed no significant difference in variables immediately after intervention.

DISCUSSION

Improvements in functional disability were superior when KT was used with tension, than obtained with a placebo-no tension application.

CONCLUSION

The application of KT produces an improvement in pain intensity and upper extremity disability in subjects with LE and MTP in forearm muscles, and KT with tension was more effective than placebo group.

LEVEL OF EVIDENCE

NA.

TRIAL REGISTRATION NUMBER

100-216.

MSK injury? Make splinting choices based on the evidence

Which devices do-and don't-have evidence to support their use when it comes to injuries like carpal tunnel syndrome, "tennis elbow," or an ankle sprain? Read on.

Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis

OBJECTIVE

The aim of this study was to compare the efficacy of extracorporeal shock wave therapy (ESWT) and therapeutic ultrasound (US) in the treatment of lateral epicondylosis (LE).

METHODS

Our study enrolled 50 patients with LE. Patients were randomized into two groups. Group 1 underwent therapeutic US (n = 24; 5 males and 15 females; mean age: 43.75 ± 4.52) Group 2 underwent ESWT (n = 20; 8 males and 16 females; mean age: 46.04 ± 9.24). Patients were evaluated at baseline, after treatment,and 1 month following treatment. The outcome measures were the visual analog scale (VAS), algometer, grip dynamometer, quick-disability of the arm,shoulder,and hand (QDASH), patient-rated tennis elbow evaluation (PRTEE), and Short Form-36 (SF-36) health survey questionnairre.

RESULTS

Both groups showed significant improvements in terms of VAS (all p values < 0.0001), dynamometer (p = 0.001 vs p = 0.015), algometer (all p values < 0.0001), PRTEE (all p values < 0.0001), QDASH (all p values < 0.0001), and SF-36 scores (p = 0.001 vs p = 0.005) within time. There was no significant difference between the two groups, except algometer scores in favor of ESWT (p = 0.029).

CONCLUSION

ESWT and therapeutic US are equally effective in treating LE. ESWT is an alternative therapeutic intervention and as effective as US.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Ultrasonography versus magnetic resonance imaging in detecting and grading common extensor tendon tear in chronic lateral epicondylitis

OBJECTIVES

To investigate the diagnostic performance and reliability of ultrasonography (US) in detecting and grading common extensor tendon (CET) tear in patients with chronic lateral epicondylitis (LE), using magnetic resonance imaging (MRI) as the reference standard.

MATERIALS AND METHODS

The study comprised fifty-eight chronic LE patients. Each patient underwent US and MRI. CET status was classified as: high-grade tear (≥50% thickness), low-grade tear (<50% thickness), suspected tear (possible but not evident tear), no tear. Additionally, the following dichotomous scale was used: confirmed or unconfirmed CET tear. Relative US parameters (versus MRI) for detecting CET tear included: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy. The agreement between US and MRI findings was measured using the weighted Cohen kappa coefficient (κ).

RESULTS

US showed moderate agreement with MRI in detecting and grading CET tear (κ = 0.49). Sensitivity, specificity, and accuracy in CET tear detecting by US were 64.52%, 85.19%, and 72.73%, respectively. PPV and NPV of US were 83.33% and 67.65%, respectively. No patient with unconfirmed CET tear on US had high-grade CET tear on MRI.

CONCLUSION

Ultrasonography is a valuable imaging modality that can be used as a screening tool to exclude high-grade CET tear in chronic LE patients. Once a tear is evident on US, MRI should be considered to assess precisely the extent of tendon injury.

No abatement of steroid injections for tennis elbow in Australian General Practice: A 15-year observational study with random general practitioner sampling

Objective

Evaluate general practitioner (GP) management of tennis elbow (TE) in Australia.

Methods

Data about the management of TE by GPs from 2000 to 2015 were extracted from the Bettering the Evaluation of Care of Health program database. Patient and GP characteristics and encounter management data were classified by the International Classification of Primary Care, version 2, and reported using descriptive statistics with point estimates and 95% confidence intervals.

Results

TE was managed by GPs 242,000 times per year on average. Patients were mainly female (52.3%), aged between 35 and 64 years (mean: 49.3 yrs), had higher relative risks of concomitant disorders (e.g. carpal tunnel syndrome and other tendonitis) and their TE was 10 times more likely to be work related than problems managed for patients who did not have TE. Use of diagnostic tests was low, implying a clinical examination based diagnosis of TE. Management was by procedural treatments (36 per 100 TE problems), advice, education or counselling (25 per 100), and referral to other health care providers (14 per 100, mainly to physiotherapy). The rate of local injection did not change over the 15 years and was performed at similar rates as physiotherapy referral.

Conclusion

The high risk of comorbidities and work relatedness and no abatement in the reasonably high rate of local injections (which is contrary to the evidence from clinical trials) provides support for the development and dissemination of TE clinical guidelines for GPs.

[Not Available]

Zusammenfassung. Obwohl der laterale Ellbogenschmerz viele mögliche Ursachen hat, wird er immer noch zu oft reflexartig mit dem Tennisarm gleichgesetzt. Zwei aktuelle Studien zeigen jedoch, dass 75 % der Patienten mit chronischem, lateralem Ellbogenschmerz unter einer Ellbogeninstabilität und nicht einem Tennisarm leiden. Der vorliegende Mini-Review soll die wichtigsten Differenzialdiagnosen des lateralen Ellbogenschmerzes in Ursache, Diagnostik, Behandlungsansatz sowie «pitfalls» und «red flags» beleuchten.

Percutaneous Needle Tenotomy for the Treatment of Lateral Epicondylitis: A Systematic Review of the Literature

OBJECTIVE

To analyze the literature to determine whether controlled studies on percutaneous tenotomy have been published, and if so, to systematically assess the efficacy of percutaneous tenotomy for the treatment of tendinosis at the lateral epicondyle of the elbow.

DESIGN

Systematic review of the available literature.

METHODS

Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, and Web of Science databases were searched in November 2015, unrestricted by date. After the initial search, we excluded conference proceedings, theses, reviews, expert opinions, and publications written in languages other than English. Next, 2 independent reviewers screened all of the remaining records with regard to their titles and abstracts, and subsequently, the full texts of identified publications potentially relevant to the present study.

RESULTS

Six articles focused on percutaneous tenotomy, none of which were controlled against a placebo or conservative treatment group. The absence of true randomized controlled trials created a great deal of heterogeneity between the studies; thus we could not include any of our studies in the intended final quantitative analysis with meta-analysis tools. We describe all 6 studies identified by this systematic review with a detailed analysis of the procedural methods, outcome measures, and conclusions of each study.

CONCLUSIONS

Percutaneous tenotomy presents an alternative to surgical release of the common extensor tendon for the treatment of chronic tendinosis at the lateral epicondyle of the elbow. Current research supporting the efficacy of this procedure, however, is of low quality (level II to level IV).

LEVEL OF EVIDENCE

III.

MR findings in humeral epicondylitis: A systematic review

Purpose: To highlight the importance of meta-analysis in diagnostic imaging by presenting a systematic search of the literature on the accuracy of MR imaging in epicondylitis.

Material and Methods: The literature was comprehensively reviewed to identify studies on MR findings in epicondylitis. Reviewers blind to the clinical diagnoses screened the data according to predetermined inclusion criteria. Data were collected and validity and relevance were assessed on structured forms.

Results: Seven studies including 148 patients with epicondylitis were accepted for the analysis. Eleven asymptomatic contralateral elbows and 29 elbows of healthy volunteers served as controls. The volunteers were distinctly younger than the patients. The MR technique was divergent, and the observed pathological changes also varied. The most frequent alteration was a change in the common extensor tendon signal (90%, 95% confidence interval 84-94%); 14% of the healthy volunteers and 50% of the contralateral elbows displayed the similar alteration.

Conclusion: Small sample size and methodological shortcomings in the original studies make the assessment of MR findings in epicondylitis questionable. There is a need for well-designed studies in which clinical features and occupational backgrounds as well as imaging parameters are carefully documented.

You're the Flight Surgeon: lateral epicondylitis

Wolf SJ. You're the flight surgeon: lateral epicondylitis. Aerosp Med Hum Perform. 2015; 86(12):1077-1080.

Posterolateral Rotatory Apprehension Test in Tennis Elbow

BACKGROUND

Tennis elbow is a syndrome that commonly diagnosed in patient who comes with lateral elbow pain. Instability pain in tennis elbow patient was observed and reported in many previous literatures. Posterolateral rotatory apprehension test was proposed for diagnosis of posterolateral rotatory instability of elbow. However, no review literatures that studied about posterolateral rotatory apprehensions test in tennis elbow.

OBJECTIVE

To find out the relationship between posterolateral rotatory apprehension test and tennis elbow.

MATERIAL AND METHOD

There were 44 patients that were recruited in this study. We examined the posterolateral rotatory apprehension test in tennis elbow patients. The examination was done in our outpatient clinic from March 2012 to April 2012. The data was collected to find out the ratio of negative test in tennis elbow patient.

RESULTS

The results from the posterolateral rotatory apprehension test were negative in 43 patients. The ratio of the negative test result was 98%.

CONCLUSION

A result from posterolateral rotatory apprehension test should be negative in general tennis elbow patients. If this test is used in a tennis elbow patients who are suspected with hidden instability and the result is positive, further evaluation is strongly suggested.

Epicondylitis and corticosteroid injection: fewer cures at one year

Corticosteroid injection provides short-term relief for patients with epicondylitis. However, in a trial lasting one year, corticosteroid injection resulted in a lower complete recovery rate and higher recurrence rate. Physiotherapy appears to improve symptoms in the short-term without affecting outcome at one year.

[Elbow tendinopathy]

The lateral and medial epicondylitis is often manifested in a professional or in a sport context leading to repetitive wrist movements. The diagnosis is primarily clinical. Additional tests are indicated in chronic evolution and in searching for differential diagnoses. Elbow X-ray can be completed with ultrasound or MRI, the most efficient but expensive diagnostic procedure. There is no consensus on treatment. After a period of rest, stretching then strengthening exercises are recommended. Corticosteroid injections may provide a short-term beneficial effect. Platelet-Rich Plasma injections have recently gained notoriety. In case of failure of treatment, surgery is possible, but only in a minority of patients.

Lateral Epicondylitis and Tobacco Use: A Case-Control Study

BACKGROUND

Although lateral epicondylitis (LE) is a very common tendinopathy, we understand little about the etiology of the disease. Tobacco use has been associated with other tendinopathies, and the purpose of this study is to determine if there is an association between the incidence of lateral epicondylitis and tobacco use.

METHODS

We performed a retrospective cohort study of adult patients diagnosed with lateral epicondylitis. Patients from a single orthopaedic surgeon's practice with LE were matched to control patients with other common upper extremity conditions based on age, gender, and occupation. A total of 65 case patients and 217 control patients were included in the study. The incidence of smoking in patients with lateral epicondylitis was compared to the incidence of smoking in the control group.

RESULTS

Of the LE patients, 30/65 (46.2%) were non-smokers, 23/65 (35.4%) were former smokers, and 12/65 (18.5%) were current smokers. Of the control patients, 121/217 (55.8%) were non-smokers, 45/217 (20.7%) were former smokers, and 51/217 (23.5%) were current smokers. The odds of LE patients being former or current smokers compared to control patients were 1.45 times higher, but this was not statistically significant. Among people who did not smoke at the time of presentation, the odds of being a former smoker were 2.28 times higher in LE patients than in controls, which was statistically significant.

CONCLUSIONS

The odds of being a former smoker were significantly higher in patients with lateral epicondylitis compared to patients with other upper extremity conditions. Although it did not reach statistical significance, the odds of being former or current smokers were also higher in the LE group. These results suggest a relationship between smoking history and incidence of lateral epicondylitis, though more research is needed to determine the exact nature of the relationship.

LEVEL OF EVIDENCE

Prognostic, Level III.

Effects of extracorporeal shock wave therapy on functional and strength recovery of handgrip in patients affected by epicondylitis

Extracorporeal shock wave therapy (ESWT) is effective in the treatment of tendinopathy. We designed a prospective observational clinical study to assess the correlation between clinical and functional measures and recovery of strength after ESWT for epicondylitis. We analyzed 26 patients. We measured progressive improvement in visual analogue scale values (p < 0.0005) and Mayo Elbow Performance Index scores (p = 0.004) for the pathologic limb. Monitoring of handgrip failed to reveal changes in values at any follow-up (p > 0.05). We found no correlation between degree of clinical function and muscle deficit during follow-up. After ESWT, there was a tendency toward a decrease in grip strength, especially in the dominant limb. This could be related to the effects of ESWT, which reduces spasticity in painful hypertonic muscles. These data may be useful in defining the expectations for function during ESWT for epicondylitis, particularly for elite athletes.

Elbow tendinopathy

Overuse injuries of the lateral and medial elbow are common in sport, recreational activities, and occupational endeavors. They are commonly diagnosed as lateral and medial epicondylitis; however, the pathophysiology of these disorders demonstrates a lack of inflammation. Instead, angiofibroblastic degeneration is present, referred to as tendinosis. As such, a more appropriate terminology for these conditions is epicondylosis. This is a clinical diagnosis, and further investigations are only performed to rule out other clinical entities after conventional therapy has failed. Yet, most patients respond to conservative measures with physical therapy and counterforce bracing. Corticosteroid injections are effective for short-term pain control but have not demonstrated long-term benefit.

Diagnostic confidence of sonoelastography as adjunct to greyscale ultrasonography in lateral elbow tendinopathy

BACKGROUND

Conventional ultrasonography or magnetic resonance (MR) imaging is commonly performed to obtain information about the severity of the disease, location of the injury, and differential diagnosis. The aim of this research was to investigate the diagnostic confidence of sonoelastography as an adjunct to greyscale ultrasonography in lateral elbow tendinopathy.

METHODS

A single experienced physiatrist performed greyscale ultrasonography and sonoelastography in 28 patients (9 men, 19 women; mean age, 48.5 years; age range, 36-67 years) with unilateral symptoms of lateral elbow tendinopathy; the asymptomatic elbows were used as controls. Greyscale images were described as normal, tendinosis, partial-thickness tear, and full-thickness tear. Sonoelastographic images of the common extensor tendon were analyzed qualitatively (scoring of the elastic spectrum) and quantitatively (based on a color histogram).

RESULTS

Both the imaging methods had high sensitivity, specificity, and accuracy for diagnosing lateral elbow tendinopathy. Considering the clinical diagnosis of lateral elbow tendinopathy, sonoelastography showed significantly higher diagnostic accuracy (96.4%) than ultrasonography (89.5%, P < 0.01). Quantitative analysis showed objective interpretation of the sonoelastographic images that revealed greater intensity of green and blue pixels in symptomatic elbows (P < 0.01).

CONCLUSION

Sonoelastography increases diagnostic confidence in tennis elbow pathology over greyscale ultrasonography alone and may be an additional powerful diagnostic tool in cases of lateral elbow tendinopathy with inconclusive greyscale ultrasonographic findings.

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.

[Treatment of refractory lateral epicondylitis with modified Nirschl surgical technique]

OBJECTIVE

To investigate the clinical effects of modified Nirschl surgical techniique in treating refractory lateral epicondylitis.

METHODS

From March 2009 to January 2011,21 patients (21 elbows) with refractory lateral epicondylitis were treated in our hospital. There were 8 males and 13 females,ranged in age from 25 to 59 years with an average of (48.3+/-13.4) years and the duration time from 8 to 33 months with an average of (17.1+/-7.7) months;affected position in dominant sides of 16 cases and non-dominant sides of 5 cases. The patients had already received multiple non-operative treatments. Modified Nirschl surgical technique was performed,and operative origination from origin of musculus extensor carpi radialis brevis to discard process with small incision, the process place of extensor digitorum communis would be removed. The incisions were nursed by ice compress for 2 days after operation. Range of motion (ROM) and strengthening exercise of elbow joints started at the 1 week after plaster slab fixation; ROM and strengthening exercise of wrist joints also started at the 2 week after fixation. The pain, power of gripping and patient staisfaction were recorded after operation. Verhaar scaling were used to estimate the recovery.

RESULTS

Seventeen patients were followed up from 13 to 22 months with an average of 16.3 months. According to Verhaar standard, 15 cases obtained excellent results and 2 good. No postoperative complication such as instability was found.

CONCLUSION

Modified Nirschl surgical technique is an effective method in treating refractory lateral epicondylitis but correct to diagnosis and exclusion the coexisting diseases,accurate removal the process are important guarantee.

Prevalence of epicondylitis, rotator cuff syndrome, and low back pain in Latino poultry workers and manual laborers

BACKGROUND

The goal of this study is to improve understanding of immigrant Latino manual workers' occupational health, focusing on upper body musculoskeletal injury.

METHODS

Physical exams were conducted with a representative sample of 516 Latino poultry workers and manual laborers in western North Carolina; outcome measures were prevalence of epicondylitis, rotator cuff syndrome, and low back pain.

RESULTS

Low back pain (n = 89; 17.2%) and rotator cuff syndrome (n = 76; 14.7%) indicated by physical exam was common. Epicondylitis was less common, but still frequent (n = 30; 5.8%). Prevalence of each outcome did not differ between poultry processing workers and other manual workers. Workers >40 years old had greater incidence of rotator cuff syndrome and epicondylitis.

CONCLUSIONS

Epicondylitis, rotator cuff syndrome, and low back pain are common in immigrant Latino workers, and may negatively impact long-term health and contribute to occupational health disparities.

[Update in Current Care guidelines: repetitive strain injuries of the hand and forearm]

Repetitive strain injuriesof the upper extremities refer to pain in the forearm, wrist and hand, caused by excessive strain. Diagnoses include tenosynovitis, epicondylitis and carpal tunnel syndrome. Treatment is aimed at alleviating pain, restoring normal physical functioning and maintain ability to work. Preventive interventions have shown some attenuation of discomfort but no effects on disease prevalance or sick leave days. Return to work interventions seem to decrease length of sickness absences. Part time work has hastened return to work and decreased sickness absences in musculoskeletal disorders.

Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial

OBJECTIVE

To compare the effectiveness of supervised exercise program and Cyriax physiotherapy in the treatment of tennis elbow (lateral epicondylitis).

DESIGN

Randomized clinical trial.

SETTING

Physiotherapy and rehabilitation centre.

SUBJECTS

This study was carried out with 20 patients, who had tennis elbow (lateral epicondylitis).

INTERVENTION

Group A (n = 10) had received supervised exercise program. Group B (n = 10) was treated with Cyriax physiotherapy. All patients received three treatment sessions per week for four weeks (12 treatment sessions).

OUTCOME MEASURES

Pain was evaluated using a visual analogue scale (VAS), and functional status was evaluated by completion of the Tennis Elbow Function Scale (TEFS) which were recorded at base line and at the end of fourth week.

RESULTS

Both the supervised exercise program and Cyriax physiotherapy were found to be significantly effective in reduction of pain and in the improvement of functional status. The supervised exercise programme resulted in greater improvement in comparison to those who received Cyriax physiotherapy.

CONCLUSION

The results of this clinical trial demonstrate that the supervised exercise program may be the first treatment choice for therapist in managing tennis elbow.

Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical-radiologic correlation

The diagnosis of lateral epicondylitis is often straightforward and can be made on the basis of clinical findings. However, radiological assessment is valuable where the clinical picture is less clear or where symptoms are refractory to treatment. Demographics, aspects of clinical history, or certain physical signs may suggest an alternate diagnosis. Knowledge of the typical clinical presentation and imaging findings of lateral epicondylitis, in addition to other potential causes of lateral elbow pain, is necessary. These include entrapment of the posterior interosseous and lateral antebrachial cutaneous nerves, posterolateral rotatory instability, posterolateral plica syndrome, Panner's disease, osteochondritis dissecans of the capitellum, radiocapitellar overload syndrome, occult fractures and chondral-osseous impaction injuries, and radiocapitellar arthritis. Knowledge of these potential masquerades of lateral epicondylitis and their characteristic clinical and imaging features is essential for accurate diagnosis. The goal of this review is to provide an approach to the imaging of lateral elbow pain, discussing the relevant anatomy, various causes, and discriminating factors, which will allow for an accurate diagnosis.

MRI and arthroscopy correlations of the elbow: a case-based approach

The number of elbow arthroscopies and indications for the procedure have increased significantly since the advent of modern elbow arthroscopy in the 1980s. In addition to the patient history, physical examination, and plain radiography, MRI is an important tool for the clinician in diagnosing several pathologies within and around the elbow. Understanding the pathophysiology and clinical presentation and being familiar with the MRI characteristics of a variety of elbow conditions will assist the physician in making an accurate diagnosis and help guide appropriate treatment.

Tennis elbow

INTRODUCTION

Lateral pain in the elbow affects up to 3% of the population, and is considered an overload injury of the extensor tendons of the forearm where they attach at the lateral epicondyle. Although usually self-limiting, symptoms may persist for over 1 year in up to 20% of people.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for tennis elbow? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, autologous whole blood injections, corticosteroid injections, combination physical therapies, exercise, extracorporeal shock wave therapy, iontophoresis, low-level laser therapy, manipulation, non-steroidal anti-inflammatory drugs (oral and topical), orthoses (bracing), platelet-rich plasma injections, pulsed electromagnetic field treatment, surgery, and ultrasound.

[Epicondylitis--diagnostics and treatment]

Shortcomings of tennis elbow treatment have raised medical interest in pathomechanics of this condition. In 2009, a new theoretic model was proposed, one that has integrated the current knowledge about tennis elbow pathophysiology, with aim to improve the effectiveness of therapeutic methods. It was suggested that tennis elbow patients should be grouped by severity of local tendon pathology, change in pain perception and degree of motor apparatus malfunction when deciding on the most suitable treatment method or when designing scientific research on the subject. It is believed that by employing detailed diagnostics of these lesions (either separate or clustered) in order to confirm or eliminate their presence, the effectiveness of their treatment should increase.

Elbow arthroscopy: setup, portal placement, and simple procedures

Elbow arthroscopy has become an accepted treatment for numerous elbow conditions, including loose bodies, lateral epicondylitis, contractures, painful osteophytes, synovitis, osteochondritis dissecans, synovial plica, and osteoarthritis. It is absolutely necessary that the treating surgeon have complete knowledge of elbow anatomy. Three options exist for patient positioning: supine, prone, and lateral decubitus. Standard arthroscopic probes, grasping forceps, punches, and motorized shavers and burrs are used in the procedure. Retractors are essential for visualizing, exposing, and protecting nerves. Specially designed capsular biters can be used to develop a plane between the capsule and the surrounding soft tissues to facilitate capsulotomy and capsulectomy. Among elbow arthroscopists, the sequence of portal placement varies; however, there is little variation in the exact location of portal placement because of neurovascular constraints. Loose body removal and extensor carpi radialis brevis release for lateral epicondylitis are common procedures suitable for the beginning arthroscopist. For beginning and advanced procedures, the surgeon's skill and competence must be at a level consistent with the procedure to avoid complications.