Recalcitrant Lateral Epicondylitis: A Systematic Review on Current Nonoperative and Operative Treatment Modalities.

BACKGROUND: Lateral epicondylitis is a common cause of elbow pain that is generally self-limiting. For patients who have persistent symptoms refractory to conservative treatment, there is still no clear consensus on the most favorable treatment modality. The purpose of this systematic review was to synthesize the available literature regarding both nonoperative and operative treatment modalities for recalcitrant lateral epicondylitis (RLE) to provide insight into the efficacy of treatment options. METHODS: A systematic review was performed in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, where the PubMed, MEDLINE/Ovid, CINAHL, Cochrane, and Scopus databases were queried to identify studies evaluating treatment options for RLE. RESULTS: A total of 27 studies with 1,958 patients were included. Of the reviewed studies, there were a wide variety of treatments including platelet-rich plasma injections, percutaneous tenotomies, and various arthroscopic and open procedures. CONCLUSION: There are a wide variety of treatment modalities available for RLE that have promising efficacy in the short, medium, and long terms. A comprehensive approach combining evidence-based and patient-centered care is critical for effective management of refractory symptoms. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Physiotherapy practices in the clinical assessment of lateral elbow tendinopathy: An international survey.

BACKGROUND AND PURPOSE: Understanding physiotherapy practices is important to identify variations from empirical evidence and highlight requirements for training. This survey explored international physiotherapy practices for assessment of lateral elbow tendinopathy (LET). METHODS: Two hundred ninety-nine surveyed physiotherapists from eight member countries of the International Federation of Manual and Orthopaedic Physical Therapists completed the survey. Respondents rated their frequency of use (never, rarely, sometimes, often, and always) for items related to: patient history; diagnostic tests; grip and upper limb strength; cervical and neurological assessment; and medical imaging. To establish practices, the five response categories were dichotomised into routine practice (often, always) and not-routine practice (sometimes, rarely, never). A response rate of ≥70% for each dichotomy was used to determine whether an assessment item was deemed routine practice or not, with items not meeting either criterion considered neither routine nor not-routine practice. RESULTS: Most respondents were from United States (63%). The 'chair pick up test', 'cervical special tests', and 'plain radiograph' met our criteria for not routine practice (i.e., 70%, 72%, and 71%, respectively). All other assessment items did not meet the criteria to be considered routine or not-routine practice. CONCLUSION: The chair pick-up test, cervical spine special tests (e.g., Spurling's test), and plain radiography appear to not be routinely used in the assessment of LET. The finding that no assessment technique met the criteria for routine use may imply that physiotherapists adopt a nuanced approach to selecting clinical assessment items as opposed to routinely applying tests.

Effects of extracorporeal shockwave therapy versus ultrasonic therapy and deep friction massage in the management of lateral epicondylitis: a randomized clinical trial.

The study's goal was to compare and evaluate the benefits of deep friction massage and ultrasonic therapy (US) vs extracorporeal shockwave therapy (ESWT) for people with lateral epicondylitis. This double-blind, parallel-arm randomized clinical trial was conducted after ethical approval on a sample of 80 subjects with lateral epicondylitis. Participants were enrolled based on predefined eligibility criteria. They were randomly allocated to groups A and B. Group A received ESWT, while Group B received the US combined with deep friction massage. Data was collected using the Numeric Pain Rating Score (NPRS) and Patient-rated tennis elbow evaluation questionnaire (PRTEE) at baseline, at 3rd, and at 7th week of treatment. On the basis of the normality of the data, a non-parametric test was applied to evaluate between-group and within-group differences. P value ≤ 0.05 was considered significant. There was a significant difference between groups (p < 0.001). Comparisons of PRTEE scores at 3rd week and 7th week of intervention were found significant for both groups (p < 0.001). While considering between-group comparisons based on percentile scores of PRTEE at baseline, 3rd and 7th week of intervention, in group A Median (IQR) at the baseline was 24.00 (5.00), at 3rd week, 10.00 (5.00) and 7th week was 1.50 (2.50) and in group B Median (IQR) at the baseline was 25.00 (4.00), at 3rd week 19.50 (4.50) and at 7th week was 11.50 (2.50). The results were significant in both groups (p = 0.000), but between-group analysis revealed that ESWT is more effective in patients with lateral epicondylitis.

Biomechanical Examination of Wrist Flexors and Extensors with Biodex System Dynamometer-Isometric, Isokinetic and Isotonic Protocol Options.

Background and Objectives: Biodex System® is an advanced dynamometer used for testing various biomechanical parameters of muscles. Test outcomes allow for the identification of muscle pathology and consequently lead to a clinical diagnosis. Despite being widely used for the testing and rehabilitation of the human musculoskeletal system, no universal and acceptable protocol for wrist examination has been proposed for patients with wrist pathology. In this study, the authors aim to identify the most appropriate protocol for testing the biomechanical parameters of flexors and extensors of the wrist. Materials and Methods: A group of 20 patients with symptomatic tennis elbow and 26 healthy volunteers were examined using three different protocols: isokinetic, isometric and isotonic. Protocol order for each study participant was assigned at random with a minimum of a 24 h break between protocols. All protocol parameters were set according to data obtained from a literature review and an earlier pilot study. Following completion of each protocol, participants filled out a questionnaire-based protocol, assessing pain intensity during the exam, difficulty with exam performance and post-exam muscle fatigue. Results: The isotonic protocol showed the best patient tolerance and the highest questionnaire score. There was a significant difference (p < 0.05) between the three protocols in average pain intensity reported by study participants. All participants completed the isotonic protocol, but not all patients with symptomatic tennis elbow were able to complete the isometric and isokinetic protocols. The isotonic protocol was deemed "difficult but possible to complete" by study participants. Conclusions: The isotonic protocol is most suitable for testing the flexors and extensors of the wrist. It gives the most biomechanical data of all protocols, is well tolerated by patients and rarely causes pain during examination even in symptomatic participants.

Comparing autologous blood, corticosteroid, and a combined injection of both for treating lateral epicondylitis: a randomized clinical trial.

BACKGROUND: Because lateral epicondylitis is a common musculoskeletal disorder that affects the forearm's extensor tendons, an effective therapeutic approach should reverse the degeneration and promote regeneration. This study aimed to compare the efficacies of autologous blood (AB) injection, corticosteroid (CS) injection, and a combined injection of both in treating lateral epicondylitis (LE), hypothesizing that the combined approach might offer immediate symptom resolution and a lower recurrence. MATERIALS AND METHODS: A total of 120 patients diagnosed with lateral epicondylitis were systematically distributed among three distinct therapeutic injection groups. Those in the AB group were administered 1 ml of autologous venous blood mixed with 2 ml of 2% prilocaine HCl. Participants in the CS category were given 1 ml of 40 mg methylprednisolone acetate mixed with 2 ml of 2% prilocaine HCl. Meanwhile, patients in the combined group received a mixture containing 1 ml each of autologous venous blood and 40 mg methylprednisolone acetate along with 1 ml of 2% prilocaine HCl. Prior to receiving their respective injections, a comprehensive assessment of all participants was carried out. Follow-up assessments were subsequently conducted on days 15, 30, and 90 utilizing metrics of the patient-rated tennis elbow evaluation (PRTEE) and measurements of hand grip strength (HGS). RESULTS: One patient dropped out from the combined group, and 119 patients completed the trial. No complications were recorded during the course of follow-up. By day 15, all groups had demonstrated significant PRTEE improvement, with CS showing the most pronounced reduction (p = 0.001). However, the benefits of CS had deteriorated by day 30 and had deteriorated further by day 90. The AB and AB + CS groups demonstrated sustained improvement, with AB + CS revealing the most effective treatment, achieving a clinically significant improvement in 97.4% of the patients. The improved HGS parallelled the functional enhancements, as it was more substantial in the AB and AB + CS groups (p = 0.001), corroborating the sustained benefits of these treatments. CONCLUSIONS: The study concluded that while AB and CS individually offer distinct benefits, a combined AB + CS approach optimizes therapeutic outcomes, providing swift and sustained functional improvement with a lower recurrence rate. These findings have substantial clinical implications, suggesting a balanced, multimodal treatment strategy for enhanced patient recovery in LE. LEVEL OF EVIDENCE: Randomized clinical trial, level 1 evidence. TRIAL REGISTRATION: NCT06236178.

High-intensity versus low-level laser in musculoskeletal disorders.

PURPOSE: To evaluate the current evidence comparing low level to high level laser therapy to reveal any superiorities in the treatment of musculoskeletal disorders. METHODS: Five databases were searched till September 2022 to obtain relevant RCTs comparing high intensity and low-level laser therapies in the management of musculoskeletal disorders. Two authors assessed the methodological quality of the included studies using the Physiotherapy Evidence Database scale and meta-analysis was conducted for studies that showed homogeneity. RESULTS: Twelve articles were included in this systematic review with a total population of 704 participants across various musculoskeletal pathologies including tennis elbow, carpal tunnel syndrome, chronic non-specific low back pain, knee arthritis, plantar fasciitis, and subacromial impingement. There were no statistical differences between the two interventions in pain, electrophysiological parameters, level of disability, quality of life, postural sway or pressure algometer, however, Low level laser therapy showed superiority in increasing grip strength compared to high intensity laser therapy while results were significant in favour of high intensity laser therapy regarding long head of biceps diameter and cross sectional area, supraspinatus thickness and echogenicity and acromio-humeral distance. CONCLUSION: The current literature suggests no superiority of both types of laser therapy in musculoskeletal disorders, however, more RCTs with larger sample size are required to reach a definitive conclusion regarding the superiority of either form of laser therapy in musculoskeletal disorders.

The concentration of platelets in PRP does not affect pain outcomes in lateral epicondylitis: a systematic review and meta-analysis.

Aim: To investigate the analyze the relationship between concentration platelet-dose in platelet-rich plasma (PRP) injections and improvements in pain when treating lateral epicondylitis. Methods: A systematic review was conducted into five medical databases, exploring the difference in pain outcomes based on concentration of PRP. Results: Initial querying of the databases yielded 1408 articles with 20 articles ultimately included. There was no statistical significance between effect sizes of the two treatment groups (high and low platelet concentration; p = 0.976). Conclusion: Both large and small concentrations of platelets depict significant reduction in pain, however, between subgroups there was no significance. It can thus be concluded that concentration of platelets in PRP does not impact overall pain relief.

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Occupational elbow musculoskeletal disorders in Tunisia: Epidemiology and socio-professional consequences.

INTRODUCTION: Musculoskeletal disorders (MSDs) are as the primary occupational disease (OD) in Tunisia. They can touch the elbow and cause occupational disability. AIMS: Describe the epidemiological and clinical characteristics of elbow MSDs recognized in Tunisia, identify the factors associated with these MSDs and assess their socio-professional impact. METHODS: Retrospective descriptive study of elbow MSDs recognized as compensable OD by the Committees for the Recognition of Occupational Diseases of National Health Insurance Fund, in Tunisia, from 2012 to 2018. RESULTS: We collected 431 cases of elbow MSDs or 8.35% of all recognized MSDs and 11.8% of recognized MSDs during the same period. The average annual incidence was 4.3 cases. Patients had a mean age of 43.59 years and a clear female predominance (82.2%). The largest provider was the textile industry (60.6%). The average length of employment was 16.78 years. Biomechanical factors were repetitive movements (92.8%), forced movements (67.1%) and prolonged static posture (7.4%). These were lateral epicondylitis (79.1%), medial epicondylitis (14.2%) and ulnar nerve syndrome (10.7%). These pathologies were associated with other MSDs including carpal tunnel syndrome (25.8%). These MSDs were responsible for 15,342 days of lost work. The rate of permanent partial incapacity was 10.6% with a job loss in 15.63%. CONCLUSION: Elbow MSDs are responsible for heavy economic and socio-professional consequences justifying the implementation of a preventive strategy adapted within risk sectors.

Manual therapy and exercise for lateral elbow pain.

BACKGROUND: Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain. OBJECTIVES: To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain. SEARCH METHODS: We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication. SELECTION CRITERIA: We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals. MAIN RESULTS: Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials). AUTHORS' CONCLUSIONS: Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.

Comparison of local massage, steroid injection, and extracorporeal shock wave therapy efficacy in the treatment of lateral epicondylitis.

OBJECTIVES: This study aimed to compare the clinical outcomes of patients with lateral epicondylitis (LE) treated with local massage, corticosteroid (CS) injection, and extracorporeal shock wave therapy (ESWT). PATIENTS AND METHODS: This randomized prospective study included 52 patients. Patients treated with local massage in Group 1 (n=17; 9 males, 8 females; mean age: 46.1±10.9 years; range, 27 to 64 years), CS injection in Group 2 (n=17; 7 males, 10 females; mean age: 46.0±8.8 years; range, 28 to 63 years), and ESWT in Group 3 (n=18; 12 males, 6 females; mean age: 46.7±11.3 years; range, 28 to 68 years) for LE were evaluated between March 2021 and June 2022. Clinical outcomes were assessed using the Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH), and DASH-Work Model (DASH-WM) scoring systems at the initial examination at the beginning of the study and at two-week, three-month, and six-month follow-up controls. RESULTS: Similar results were observed between VAS, DASH, and DASH-WM scores measured during LE diagnosis. In the first two weeks of follow-up, statistically significant decreases were observed in VAS, DASH, and DASH-WM scores in all three groups. Compared to baseline values, Group 1 and 2 had significant difference in VAS and DASH scores at three months. Group 3 had a significant difference in all clinical evaluation scores. At six months, no significant difference was observed in Groups 1 and 2 in any of the scoring systems, while Group 3 showed significant improvements in all scoring systems. CONCLUSION: Treatment with ESWT was superior to other treatments throughout the study and at the final follow-up. In patients receiving CS injections, the clinical outcomes worsened with time, evidenced by the six-month follow-up. Further studies on combined treatment modalities are needed on this subject.

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

OBJECTIVE: The objective of the study was to evaluate the efficacy of Maitland accessory mobilization and neural mobilization in patients with tennis elbow. METHOD: Twenty-five patients meeting the selection criteria were randomly assigned to three experimental groups: Group C (conventional treatment), Group B (neural mobilization), and Group A (Maitland mobilization). Quality of life was assessed using the Patient Rated Tennis Elbow Evaluation (PRTEE), while pain, range of motion, and grip strength were evaluated using the Visual Analog Scale (VAS), a universal goniometer, and a handheld dynamometer. The interventions were administered three times per week for four weeks to the respective groups. RESULTS: Non-parametric tests were employed to analyze the results due to the non-normal distribution of the data (p < 0.05). Both the Wilcoxon signed-rank test and the Kruskal-Wallis test were utilized to assess differences within and between groups. The results of the between-group analysis demonstrated significant differences in pain (p = 0.018) and quality of life (p = 0.045) among the three groups. CONCLUSION: After a 4-week intervention, all three groups exhibited notable improvements in discomfort levels, grip strength, and quality of life. Notably, Group B demonstrated the most substantial increase in range of motion (ROM) compared to Groups A and C. Consequently, incorporating neural mobilization into the treatment plan is recommended for patients experiencing Tennis Elbow.

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 ±â€…4.24, while for the control group, it was 12.82 ±â€…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.

Association between Platelet-Derived Growth Factor Receptor Alpha Gene Polymorphisms and Platelet-Rich Plasma's Efficiency in Treating Lateral Elbow Tendinopathy-A Prospective Cohort Study.

Individual differences in the response to platelet-rich plasma (PRP) therapy can be observed among patients. The genetic background may be the cause of this variability. The current study focused on the impact of genetic variants on the effectiveness of PRP. The aim of the present study was to analyze the impact of single nucleotide polymorphisms (SNP) of the platelet-derived growth factor receptor alpha (PDGFRA) gene on the effectiveness of treating lateral elbow tendinopathy (LET) with PRP. The treatment's efficacy was analyzed over time (2, 4, 8, 12, 24, 52 and 104 weeks after the PRP injection) on 107 patients using patient-reported outcome measures (PROM) and achievement of a minimal clinically important difference (MCID). Four SNPs of the PDGFRA gene (rs7668190, rs6554164, rs869978 and rs1316926) were genotyped using the TaqMan assay method. Patients with the AA genotypes of the rs7668190 and the rs1316926 polymorphisms, as well as carriers of the T allele of rs6554164 showed greater effectiveness of PRP therapy than carriers of other genotypes. Moreover, the studied SNPs influenced the platelets' parameters both in whole blood and in PRP. These results showed that PDGFRA gene polymorphisms affect the effectiveness of PRP treatment. Genotyping the rs6554164 and the rs1316926 SNPs may be considered for use in individualized patient selection for PRP therapy.

It is time to move forward: a bibliometric analysis of top 50 cited articles in elbow arthroscopy.

OBJECTIVES: To analyze the bibliometric characteristics of the top 50 cited articles in elbow arthroscopy. METHODS: The Web of Science Core Collection was employed to systematically retrieve publications related to elbow arthroscopy. Subsequently, the top 50 cited articles meeting the predefined inclusion criteria were meticulously documented and subjected to comprehensive bibliometric analysis. RESULTS: The top 50 cited articles spanned the years 1999-2017, with the 2010s emerging as the most prolific decade. Citations per article varied from 24 to 211, and citation density ranged from 1.61 to 9.17. The United States dominated in article production and citations. Predominantly, the articles took the form of case series and expert opinions, with a notable absence of level I or II evidence. The keywords with the highest frequencies were "arthrofibrosis," "complications," and "release." These keywords formed five main clusters: stiff elbow, osteoarthritis, osteochondritis dissecans, and lateral epicondylitis. CONCLUSIONS: The majority of the top 50 cited articles in elbow arthroscopy comprised case series exhibiting Level IV or V evidence. Despite a dynamic development post-2010, elbow arthroscopy articles showed lower mean citations and citation density compared to other joints, potentially influenced by concerns about complications. However, with the increasing prevalence of elbow arthroscopy procedures, it is anticipated that higher-level articles, particularly those focusing on complications and exploring additional indications, will supersede some of the articles included in this analysis. LEVEL OF EVIDENCE: IV.

Comparison of Interventions for Lateral Elbow Tendinopathy: A Systematic Review and Network Meta-Analysis for Patient-Rated Tennis Elbow Evaluation Pain Outcome.

PURPOSE: There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET), and not all available treatment options have been compared directly with placebo/control. A network meta-analysis was conducted to compare the effectiveness of different LET treatments directly and indirectly against control/placebo based on a validated outcome, the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score. METHODS: Randomized, controlled trials comparing different treatment methods for LET were included, provided they reported outcome data using the PRTEE pain score. A network meta-analysis with random effect was used to combine direct and indirect evidence between treatments compared with placebo in the short term (up to six weeks) and midterm (more than six weeks and up to six months) after intervention. RESULTS: Thirteen studies with 12 comparators including control/placebo were eligible. The results indicated no significant improvement in PRTEE pain score in the short term across all treatments compared with control/placebo. In the midterm, physiotherapy/exercise showed benefit against placebo (mean difference: -4.32, 95% confidence interval: -7.58 and -1.07). Although steroid injections, dry needling, and autologous blood also exhibited potential treatment effects, it is crucial for the clinician to consider certain pitfalls when considering these treatments. The limited number of small studies and paucity of data call for caution in interpreting the results and need for further evidence. CONCLUSIONS: Patients should be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared with control/placebo in the short and medium terms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Percutaneous tendon dry needling and thrust manipulation as an adjunct to multimodal physical therapy in patients with lateral elbow tendinopathy: A multicenter randomized clinical trial.

OBJECTIVE: The purpose of this study was to assess the effects of adding electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization, and ultrasound in patients with lateral elbow tendinopathy. DESIGN: Randomized, single-blinded, multicenter, parallel-group trial. SETTING: Thirteen outpatient physical therapy clinics in nine different US states. PARTICIPANTS: One hundred and forty-three participants (n = 143) with lateral elbow tendinopathy were randomized. INTERVENTION: Cervical spine manipulation, extremity manipulation, and percutaneous tendon electrical dry needling plus multimodal physical therapy (n = 73) or multimodal physical therapy (n = 70) alone. MAIN MEASURES: The primary outcome was elbow pain intensity and disability as measured by the Patient-Rated Tennis Elbow Evaluation at baseline, 1 week, 4 weeks, and 3 months. Secondary outcomes included the Numeric Pain Rating Scale, Tennis Elbow Functional Scale, Global Rating of Change, and medication intake. RESULTS: The 2 × 4 analysis of covariance demonstrated that individuals with lateral elbow tendinopathy receiving electrical dry needling and thrust manipulation plus multimodal physical therapy experienced significantly greater improvements in disability (Patient-Rated Tennis Elbow Evaluation: F = 19.675; P < 0.001), elbow pain intensity (Numeric Pain Rating Scale: F = 22.769; P < 0.001), and function (Tennis Elbow Function Scale: F = 13.269; P < 0.001) than those receiving multimodal physical therapy alone at 3 months. The between-group effect size was large for pain and disability (Patient-Rated Tennis Elbow Evaluation: standardized mean difference = 1.13; 95% confidence interval: 0.78, 1.48) in favor of the electrical dry needling and thrust manipulation group. CONCLUSIONS: The inclusion of percutaneous tendon electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization and ultrasound was more effective than multimodal physical therapy alone in individuals with lateral elbow tendinopathy.Trial Registration: www.clinicaltrials.gov NCT03167710 May 30, 2017.

Exploring Symptom Responses to Upper Limb Neural Test Variations of the Radial Nerve in Patients With Lateral Epicondylalgia: An Observational Study.

OBJECTIVE: Clinical practice guidelines recommend the radial nerve mechanosensitivity evaluation in patients with lateral epicondylalgia. Despite different positions and sequences having been described, no research analyzed how each variation triggers symptoms associated with lateral epicondylalgia. The aim of this study was to explore the effects of different positions and sequences in the upper limb neural tension test 2b (ULNT2b) in symptom responses in patients with lateral epicondylalgia. METHODS: In this observational study, 66 patients underwent 4 test conditions: standard ULNT2b, ULNT2b proximal to distal, ULNT2B with resisted supination, and resisted supination isolated. Paresthesia sensations, symptom reproduction, pain intensity (measured using a visual analog scale), and distribution of painful symptoms data were collected. RESULTS: Significant differences in paresthesia sensations were observed between groups, with significant differences between the standard ULNT2B and other ULNT variations or resisted supination maneuvers. Symptom reproduction also differed significantly across groups, with significant differences between the standard ULNT2B and other ULNT or resisted supination tests. The positive/negative test and percentage of distribution of painful symptoms scores varied significantly across 4 conditions in both lateral and frontal views. Although pain intensity scores during tests were comparable among the tests, distribution of painful symptoms differed significantly. CONCLUSION: Variations in the ULNT2b test can affect symptom responses in patients with lateral epicondylalgia. The standard ULNT2b test appears more effective at reproducing symptoms, intensity of paresthesia, and distribution of painful symptoms compared to other ULNT variations and the resisted supination test. IMPACT: ULNT2b sequences have been shown to elicit varying responses concerning paresthesia, replication of familiar symptoms, positive/negative test results, and distribution of painful symptoms. Clinicians should consider specific test variations during the patients' radial nerve mechanosensitivity assessment to identify aggravating factors reproducing recognizable symptoms. A control group of asymptomatic participants and the role of presence of other comorbidities, psychological factors, or the duration of symptoms were not considered in this study and might play an important role influencing the results of the tests.