Differences in Clinical Tests for Assessing Lateral Epicondylitis Elbow in Adults Concerning Their Physical Activity Level: Test Reliability, Accuracy of Ultrasound Imaging, and Relationship with Energy Expenditure.

BACKGROUND: Physical activity (PA) can generate physical stress on the musculoskeletal system. Thus, the aim of the current study was to assess the influence of the level of physical activity on clinical tests used in the diagnosis of lateral epicondylitis in adults, intertest reliability and accuracy based on ultrasound imaging, and relationship with energy expenditure. METHODS: 102 adults with lateral epicondylitis were assessed via an International Physical Activity Questionnaire and divided according to PA level: low (n = 19) moderate (n = 42) or high (n = 41). Pain (visual analog scale), Cozen's and Mill's clinical tests and ultrasound exams were performed. RESULTS: The Cozen's and Mill's tests differed among PA levels. Excellent reliability was found for Mill's test for PA levels and the ultrasound exam (low ICC = 1.0, moderate ICC = 0.82 and high ICC = 0.99). Good reliability was found for Cozen's test (low ICC = 0.80, moderate ICC = 0.74 and high ICC = 0.73), but with significant differences between the ultrasound exams. The Cozen's and Mill's clinical tests had no relationship to the level of energy expenditure for PA levels. CONCLUSION: Mill's test was reliable and accurate for the PA levels. Intertest reliability was poor for the PA levels. Mill's test proved to be accurate based on the ultrasound exam. The pain caused by the tests was not related to the level of energy expenditure.

How one treats lateral epicondylitis - a survey among Brazilian orthopedists.

BACKGROUND: Lateral epicondylitis (LE), also known as tennis elbow, is the most common painful elbow condition. It affects approximately 1-3% of adults. There are various possible treatments described in the literature, but evidence to support a gold standard management protocol is lacking. Therefore, the objective of this study was to evaluate how Brazilian orthopaedists diagnose and treat lateral epicondylitis and compare these results with the available evidence. METHODS: This is an observational, analytical, cross-sectional study. A questionnaire was prepared to obtain information from the participants with eight specific questions (2 on diagnosis and 6 on treatment). These questions were answered voluntarily by participants at 3 major congresses of orthopaedists in Brazil in 2018. The results were analysed in accordance with the overall number of responses and were evaluated among groups according to subspecialty. RESULTS: We obtained a total of 501 questionnaires. Of these, 33 were excluded. The mean age was 38.67 years. The majority of respondents (91%) were male. We obtained 26.7% from specialists in hand surgery (Hand group), 36.5% from subspecialists in shoulder and elbow (Shoulder and Elbow group), and 36.8% from generalists in orthopaedics or from other subspecialties (General Orthopaedists group). For diagnosis, 24.4% did not initially request any imaging method. The most requested exam was ultrasonography (54.9%). The most prominent indication for initial treatment was physical therapy. For refractory cases, 78.3% of the respondents preferred doing a local infiltration. The most commonly used substance for local infiltrations was corticosteroids (89.6%). With respect to the surgical treatment option, 75.8% of those who recommend it prefer open techniques, and 24.2% prefer arthroscopic treatment. Of the total respondents, 12.8% did not recommend surgical treatment for LE. CONCLUSION: Among Brazilian orthopaedists, the Cozen test is most frequently chosen, and ultrasound is the most commonly used imaging tool. Nonsurgically, oral nonsteroidal anti-inflammatory drugs (NSAIDs) plus physiotherapy is the most popular initial therapy, and corticosteroids are the most popular type of infiltration agent. Most surgeons recommended surgery after 6 months of nonsurgical treatment, and 75.8% preferred the open technique.

Promising improvement of chronic lateral elbow tendinopathy by using adipose derived mesenchymal stromal cells: a pilot study.

PURPOSE: Study the effect of Adipose derived stromal cells (ASCs) injection as therapeutic procedure on the common extensor tendinopathy. METHODS: Eighteen Tennis players with chronic, recalcitrant LET (who have previously been unsuccessfully treated with nonoperative treatments) underwent clinical evaluation and magnetic resonance imaging (MRI) before intervention. Stromal vascular fraction cells (SVF) were expanded by in vitro culture and ASCs were obtained and characterized by flow cytometry. ASCs were injected into the site of tendinopathy (identified by ultrasound imaging at the origin of the common extensor tendon) on a single occasion followed by physiotherapy. Players underwent serial clinical evaluations during a 12-month period and repeated MRI at 6-month post-injection. RESULTS: At 6-month clinical evaluation revealed significant improvements compared to baseline in mean Visual Analog Scale (VAS) scores for: (1) maximum pain score (from 6.28 ± 1.65, to 1.0 ± 0.43; p < .001); (2) Mean quick Disabilities of the Arm, Shoulder and Hand (QuickDASH-Compulsory score: 51.38 ± 12.02 to 12.33 ± 4.66; p < .001); (3) QuickDASH-Sport score: 56.94 ± 15.44 to 8.68 ± 8.86; p < .001). Validated MRI scoring system grade of tendinopathy also improved significantly: 4.22 ± 0.26 to 2.22 ± 0.10 (p < .001). At 12-month from injection, VAS maximun pain score further decreased to 0.74 ± 0.44 (p < .001) and QuickDASH-Compulsory score to 5.56 ± 3.58 (p < .001). Average time to return to play tennis was 3,31 ± 0,61 month post-intervention. CONCLUSION: Tennis players with recalcitrant LET showed significant clinical improvement and structural repair at the origin of the common tendon origin after injection of autologous ASCs. Results of this study are promising and open a new biological therapeutic modality to treat LET. Even if the results of this pilot study are positive, future well-designed studies, i.e. prospective randomized trials are needed to define the role of cell therapy in treating LET.

Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: a systematic review and meta-analysis of randomized placebo-controlled clinical trials.

To compare the effects of platelet-rich plasma (PRP) injection versus placebo (saline injection) on pain and joint function in lateral epicondylitis in randomized placebo-controlled trials. Randomized controlled trials that evaluated pain (visual analog scale [VAS] and patient-rated tennis elbow evaluation [PRTEE]) and/or functional improvement (PRTEE; disability of the arm, shoulder, and hand [DASH]; and Roles-Maudsley score [RMS]) in patients diagnosed with lateral epicondylitis and compared PRP with placebo injections were considered. The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched from inception to October 2019. The assessment of bias was performed using the Cochrane Risk of Bias Tool version 1. The meta-analysis was conducted with a random effects model and generic inverse variance method. Five trials involving a total of 276 individuals were included. They used a parallel study design and saline solution as placebo. The mean age of participants was 48.0 ± 9.3 years. Follow-up varied from 2 months to 1 year. No significant changes were noted for pain (standardized mean difference [SMD], - 0.51 [95% confidence interval (CI), - 1.32 to - 0.30]) nor functional scores (SMD, - 0.07 [95% CI, - 0.46 to 0.33]) between PRP and placebo injections. The most frequent adverse reaction reported in two of the five studies was transient post-injection pain for a few days (from 16 to 20% in the PRP group and from 8 to 16% in the placebo group). PRP injection was not superior to placebo for relieving pain and joint functionality in chronic lateral epicondylitis. However, patients reported improvement after both interventions in such clinical parameters. Further randomized trials are required to determine whether PRP injection is clinically more effective than placebo (saline injection).

Effect of Normal Saline Injections on Lateral Epicondylitis Symptoms: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

BACKGROUND: Lateral epicondylitis, or tennis elbow, is a painful degenerative disorder that commonly occurs in adults between 40 and 60 years of age. Normal saline (NS) injections have been used as placebo through a large number of randomized controlled trials (RCTs) focused on the treatment of lateral epicondylitis. PURPOSE: This meta-analysis of RCTs aimed to assess the therapeutic effect of NS injections on lateral epicondylitis symptoms and compare results with established minimal clinically important difference criteria. STUDY DESIGN: Systematic review and meta-analysis. METHODS: MEDLINE, Embase, Web of Science, and Scopus databases were searched for clinical trials reporting pain and joint function with the visual analog scale, Patient-Rated Tennis Elbow Evaluation, and Disabilities of the Arm, Shoulder and Hand in patients with lateral epicondylitis. The meta-analysis was conducted with a random effects model and generic inverse variance method. Heterogeneity was tested with the I2 statistic index. RESULTS: A total of 15 RCTs included in this meta-analysis revealed a significant improvement in pain (mean difference, 3.61 cm [95% CI, 2.29-4.92 cm]; P < .00001; I2 = 88%; visual analog scale) and function (mean difference, 25.65 [95% CI, 13.30-37.99]; P < .0001; I2 = 82%; Patient-Rated Tennis Elbow Evaluation / Disabilities of the Arm, Shoulder and Hand) after NS injection (≥6 months). CONCLUSION: NS injections yielded a statistically significant and clinically meaningful improvement in pain and functional outcomes in patients with lateral epicondylitis. New research should focus on better methods to diminish the potential confounders that could lead to this effect because NS injections could mask the real effect of an active therapeutic intervention in RCT. REGISTRATION: CRD42019127547 (PROSPERO).

Analysis of Muscle Load-Sharing in Patients With Lateral Epicondylitis During Endurance Isokinetic Contractions Using Non-linear Prediction.

The aim of this paper is to analyze muscle load-sharing in patients with Lateral Epicondylitis during dynamic endurance contractions by means of non-linear prediction of surface EMG signals. The proposed non-linear cross-prediction scheme was used to predict the envelope of an EMG signal and is based on locally linear models built in a lag-embedded Euclidean space. The results were compared with a co-activation index, a common measure based on the activation of a muscle pair. Non-linear prediction revealed changes in muscle coupling, that is load-sharing, over time both in a control group and Lateral Epicondylitis (p < 0.05), even when subjects did not report pain at the end of the exercise. These changes were more pronounced in patients, especially in the first part of the exercise and up to 50% of the total endurance time (p < 0.05). By contrast, the co-activation index showed no differences between groups. Results reflect the changing nature of muscular activation strategy, presumably because of the mechanisms triggered by fatigue. Strategies differ between controls and patients, pointing to an altered coordination in Lateral Epicondylitis.

ARTHROSCOPIC TREATMENT FOR LATERAL EPICONDYLITIS: OUTCOMES IN 104 CASES OF A SINGLE INSTITUTION.

OBJECTIVE: To evaluate the outcomes of patients that underwent arthroscopic surgery for lateral epicondylitis (LE), after failed conservative treatment. METHODS: One hundred four patients with LE treated with arthroscopic debridement of the extensor carpi radialis brevis (ECRB) tendon were enrolled in this retrospective study. They were evaluated using Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) and Short Form Health Survey (SF-36) scale. Mean age at surgery was 46.9 years. Duration of symptoms was 2.1 years (range: 6 m to 10 yrs.). Mean follow-up was 34.4 months (range: 6 to 68 m). RESULTS: Mean postoperative scores were: 20.67 points on the DASH; 1.8 points on the VAS at rest, with 48 cases (46%) without pain, 40 (38%) with mild pain, 13 (13%) with moderate pain and 4 (4%) with severe pain; 4.7 points on the VAS in activity, with 21 (20%) without pain, 21 (20%) with mild pain, 35 (34%) with moderate pain and 27 (26%) with severe pain; and SF-36 was 66.8 points. Of the 23 patients who practiced sports regularly or with higher physical demand from the upper limbs, 17 (74%) were able to return to the same activity at the same level. No significant complications were observed postoperatively, except for 3 (2.8%) cases of postoperative superficial infection. CONCLUSION: Surgical treatment with arthroscopy for recalcitrant LE is effective and safe, presenting positive outcomes in the studied patients. Level of evidence IV, Case Series.

OBJETIVO: Avaliar os resultados dos pacientes submetidos a tratamento cirúrgico artroscópico da epicondilite lateral (EL) refratária depois da falha no tratamento conservador. MÉTODOS: Estudo retrospectivo que incluiu 104 pacientes submetidos a desbridamento artroscópico do tendão extensor radial curto do carpo (ERCC) para tratamento de EL. Os pacientes foram avaliados pelo escore de DASH, pela classificação visual analógica de dor (EVA) e pelo Short-Form 36 (SF36). A média da idade foi de 46,9 anos (variação de 30 a 69 anos). O tempo de sintomas foi de 2,1 anos (variação de 6 meses a 10 anos). O seguimento médio foi de 34,4 meses (variação de 6 ­ 68 meses). RESULTADOS: A média dos escores pós-operatórios foi de: 20,67 pontos no DASH; 1,8 pontos no EVA de repouso, sendo 48 (46%) sem dor, 40 (38%) com dor leve, 13 casos (13%) com dor moderada e 4 (4%) com dor intensa; 4,7 pontos no EVA em atividade, sendo 21 (20%) sem dor, 21 (20%) com dores leves, 35 (34%) com dores moderadas e 27 (26%) com dores intensas; e SF-36 de 66,8. Dos 23 pacientes em prática constante de esporte ou com maior demanda física nos membros superiores, 17 (74%) conseguiram retornar ao mesmo nível. Não observamos complicações significativas exceto por 3 (2,8%) casos de infecção pós-operatória superficial. CONCLUSÃO: O tratamento artroscópico para EL recalcitrante do cotovelo é eficaz e seguro, apresentando resultados positivos. Nível de Evidencia IV, Série de Casos.

Arthroscopic treatment for lateral epicondylitis: outcomes in 104 cases of a single institution / Tratamento artroscópico para epicondiliote lateral: resultados em 104 casos de uma única intituição

ABSTRACT Objective: To evaluate the outcomes of patients that underwent arthroscopic surgery for lateral epicondylitis (LE), after failed conservative treatment. Methods: One hundred four patients with LE treated with arthroscopic debridement of the extensor carpi radialis brevis (ECRB) tendon were enrolled in this retrospective study. They were evaluated using Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) and Short Form Health Survey (SF-36) scale. Mean age at surgery was 46.9 years. Duration of symptoms was 2.1 years (range: 6 m to 10 yrs.). Mean follow-up was 34.4 months (range: 6 to 68 m). Results: Mean postoperative scores were: 20.67 points on the DASH; 1.8 points on the VAS at rest, with 48 cases (46%) without pain, 40 (38%) with mild pain, 13 (13%) with moderate pain and 4 (4%) with severe pain; 4.7 points on the VAS in activity, with 21 (20%) without pain, 21 (20%) with mild pain, 35 (34%) with moderate pain and 27 (26%) with severe pain; and SF-36 was 66.8 points. Of the 23 patients who practiced sports regularly or with higher physical demand from the upper limbs, 17 (74%) were able to return to the same activity at the same level. No significant complications were observed postoperatively, except for 3 (2.8%) cases of postoperative superficial infection. Conclusion: Surgical treatment with arthroscopy for recalcitrant LE is effective and safe, presenting positive outcomes in the studied patients. Level of evidence IV, Case Series.

RESUMO Objetivo: Avaliar os resultados dos pacientes submetidos a tratamento cirúrgico artroscópico da epicondilite lateral (EL) refratária depois da falha no tratamento conservador. Métodos: Estudo retrospectivo que incluiu 104 pacientes submetidos a desbridamento artroscópico do tendão extensor radial curto do carpo (ERCC) para tratamento de EL. Os pacientes foram avaliados pelo escore de DASH, pela classificação visual analógica de dor (EVA) e pelo Short-Form 36 (SF36). A média da idade foi de 46,9 anos (variação de 30 a 69 anos). O tempo de sintomas foi de 2,1 anos (variação de 6 meses a 10 anos). O seguimento médio foi de 34,4 meses (variação de 6 - 68 meses). Resultados: A média dos escores pós-operatórios foi de: 20,67 pontos no DASH; 1,8 pontos no EVA de repouso, sendo 48 (46%) sem dor, 40 (38%) com dor leve, 13 casos (13%) com dor moderada e 4 (4%) com dor intensa; 4,7 pontos no EVA em atividade, sendo 21 (20%) sem dor, 21 (20%) com dores leves, 35 (34%) com dores moderadas e 27 (26%) com dores intensas; e SF-36 de 66,8. Dos 23 pacientes em prática constante de esporte ou com maior demanda física nos membros superiores, 17 (74%) conseguiram retornar ao mesmo nível. Não observamos complicações significativas exceto por 3 (2,8%) casos de infecção pós-operatória superficial. Conclusão: O tratamento artroscópico para EL recalcitrante do cotovelo é eficaz e seguro, apresentando resultados positivos. Nível de Evidencia IV, Série de Casos.

Pragmatic Combinations of Acupuncture Points for Lateral Epicondylalgia are Unreliable in the Physiotherapy Setting.

This study describes the reliability of pragmatic combinations of acupuncture points for lateral epicondylalgia (LE) as prescribed by physiotherapists who were experts in acupuncture. Raters (n = 14; 33-59 years) independently prescribed acupuncture points for 30 simulated human patients with LE who were surveyed via a printed questionnaire. The frequency and cooccurrence of acupuncture points prescribed for patients with lateral epicondylitis were assessed. Absolute agreement and Light's kappa (κLight) with 95% confidence interval (CI) were used to quantify the interrater agreement. Raters prescribed 103 unique acupuncture points in different combinations with a median (min-max) of 5 (0-11) acupuncture points. The most prescribed acupuncture point was LI-11 (297 of 420; 71%), and the most common cooccurring acupuncture points were LI-11 and LI-4 (160 of 420; 38%). The absolute agreement for prescribing the acupuncture points ranged from 70% (point GB-20) to 0% (points LI-10, SP-6, LI-11, GB-34, LI-12, and LI-4). Point LR-3 showed the highest interrater reliability for prescribing the acupuncture points [κLight = 0.112, 95% CI = (0.055-0.194)], whereas point LI-4 showed the lowest reliability [κLight = -0.003, 95% CI = (-0.024 to 0.024)]. These findings suggest that pragmatic prescriptions of acupuncture points for LE are unreliable among physiotherapists who are experts in acupuncture. Explicit, high-level evidence-based rules for prescribing and teaching combinations of acupuncture points for LE are warranted.

Asociación de la eficacia de la terapia Cyriax en pacientes con epicondilitis: metaanálisis / Association of the efficacy of Cyriax therapy in patients with epicondylitis: meta-analysis

Resumen Introducción La epicondilitis o codo de tenista es una enfermedad frecuente en el codo, tiene un perfil ocupacional claro, al igual que otras tendinopatías crónicas de las extremidades superiores, y puede aparecer asociada a ellas simultáneamente. La fricción transversal profunda (o Cyriax) ha sido una de las intervenciones fisioterapéuticas sugeridas para el tratamiento de la tendinopatía. Sin embargo, las conclusiones de las investigaciones han sido inconsistentes. Por lo tanto, este estudio intentó aclarar la asociación entre el tratamiento con Cyriax y el codo de tenista a través de un metaanálisis. Material y métodos Se recuperaron las bases de datos de PubMed y EBSCO para recopilar todas las publicaciones sobre la asociación entre el tratamiento con Cyriax y la epicondilitis. Resultados La búsqueda bibliográfica consistió en 10 artículos (que incluyeron 240 casos y 227 controles) para un análisis cualitativo y seis más (que incluyeron 121 casos y 122 controles) para el cuantitativo. Conclusión Este metaanálisis no pudo apoyar una asociación significativa entre la terapia con Cyriax y la epicondilitis. Por lo tanto, se sugiere implementar esta fisioterapia sólo como un tratamiento complementario.

Abstract Introduction Epicondylitis or tennis elbow is a common disease of the elbow that has a clear occupational profile, like other upper extremity chronic tendinopathies, and can appear associated with them simultaneously. Deep transverse friction (or Cyriax) has been one of the physiotherapy interventions suggested for the management of tendinopathy. However, the conclusions of the investigations have been inconsistent. Therefore, this study aimed to clarify the association between Cyriax treatment and tennis elbow through a meta-analysis. Material and methods The PubMed and EBSCO databases were retrieved to collect all publications on the association between Cyriax treatment and epicondylitis. Results The literature search consisted of 10 articles (that included 240 cases and 227 controls) for a qualitative analysis and six more (that included 121 cases and 122 controls) for the quantitative one. Conclusion This meta-analysis could not support a significant association between Cyriax therapy and epicondylitis. Therefore, it is suggested to implement this physical therapy only as a complementary treatment.

The influence of different non-articular proximal forearm orthoses (brace) widths in the wrist extensors muscle activity, range of motion and grip strength in healthy volunteers.

PURPOSE: The purpose this study was perform a biomechanical evaluation to compare the influence of commercial models of different non-articular proximal forearm orthoses widths (2.5 cm, 5.5 cm, 7.5 cm and 12.0 cm) in the extensor muscle activation, range of motion and grip strength in healthy subjects. METHODS: Was analyzed data from extensor carpi radialis, extensor carpi ulnares and extensor digitorum comunis using surface electromyography, simultaneous with a wrist electrogoniometer MiotecTM and a hydraulic dynamometer JamarTM. The sequence of tests with all the commercial orthoses models was randomized. Statistics analyses were performed by linear model with mixed effects. RESULTS: According to our findings the non-articular proximal forearm orthoses (2.5 cm - narrowest) positioned close to lateral epicondyle provided lesser muscle activation on extensor carpi radialis brevis/longus and extensor digitorum comunis, decreased wrist extension and grip strength during submaximal grip task (p< 0.01). CONCLUSIONS: A narrow non-articular proximal forearm orthosis positioned close to the lateral epicondyle might decrease the extensor muscle activation and therefore could reduce mechanical stress on its insertion, based on this sample. Clinical studies must be conducted to confirm these findings.