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.

Epicondilalgias laterales del codo

Introducción: La epicondilitis es la causa más frecuente de dolor en el codo y afecta anualmente entre un 1 y 3 % de los adultos. Se produce debido a la tracción sobre los tendones extensores de la muñeca y la mano en actividades laborales y deportivas. Objetivos: Actualizar los conceptos fundamentales sobre el diagnóstico, cuadro clínico y tratamiento de las epicondilalgias laterales del codo. Métodos: Se revisaron las publicaciones de los años 2011-2021 con los términos "epicondilitis lateral del codo", "codo de tenista", "epicondilalgias laterales del codo" y "tratamiento de la epicondilitis lateral del codo". Desarrollo: Los músculos epicondíleos laterales se originan de un tendón común, la lesión primaria se origina en el músculo supinador corto, pero también en el extensor común de los dedos. Los síntomas son causados por movimientos repetitivos de extensión de la muñeca y el dolor se localiza en la cara anterodistal del epicóndilo. La radiografía, resonancia magnética y ultrasonido contribuyen al diagnóstico. El 90 % de los casos resuelven con tratamiento conservador. Conclusiones: Los métodos no quirúrgicos para las epicondilalgias laterales del codo aportan resultados satisfactorios; mientras que los tratamientos quirúrgicos, incluido el artroscópico, están indicados en pacientes con síntomas persistentes después de seis y hasta doce meses de tratamientos conservadores.

Introduction: Epicondylitis is the most common cause of elbow pain and it affects between 1 and 3% of adults yearly. It occurs due to traction on the extensor tendons of the wrist and hand in work and sports activities. Objectives: To bring up-to-date the fundamental concepts on the diagnosis, clinical condition and treatment of lateral epicondylalgia of the elbow. Methods: 2011-2021 publications with the terms "lateral epicondylitis of the elbow", "tennis elbow", "lateral epicondylalgias of the elbow" and "treatment of lateral epicondylitis of the elbow" were reviewed. Finding: The lateral epicondylar muscles originate from a common tendon, the primary lesion is at the origin of the short brachial muscle, as well in the common extensor of the fingers. The symptoms are caused by repetitive wrist extension movements and the pain is localized to the anterodistal aspect of the epicondyle. Radiography, magnetic resonance imaging and ultrasound contribute to the diagnosis. 90% of cases resolve with conservative treatment. Conclusions: Non-surgical methods for lateral epicondylalgia of the elbow provide satisfactory results; while surgical treatments, including arthroscopic treatment, are indicated in patients with persistent symptoms after six and up to twelve months of conservative treatment.

Efectividad de la terapia por ondas de choque en lesiones de tendones y ligamentos del sistema osteomioarticular / Effectiveness of Shock Wave Therapy in Tendon and Ligament Injuries of the Osteomioarticular System

Introducción: Por más de 20 años la litotricia extracorpórea se ha aplicado con éxito en el mundo. Objetivo: Evaluar la efectividad de la terapia por ondas de choque en el tratamiento a pacientes que presentan lesiones en los tendones y ligamentos del sistema osteomioarticular. Métodos: Se realizó un estudio descriptivo, de corte transversal, con 107 pacientes diagnosticados con lesiones en los tendones y ligamentos del sistema osteomioarticular, los cuales fueron tratados con el equipo Well Wave (ondas de choque extracorpóreas) en el Complejo Científico Ortopédico Internacional Frank País, en el período comprendido entre marzo de 2019 y abril de 2020. Se realizó el análisis de las variables edad, sexo, dolor y discapacidad. Se obtuvieron frecuencias absolutas y relativas, y con ellas se confeccionaron las tablas que resumen la información estadística de la investigación. Resultados: Predominó el sexo femenino (71,9 por ciento), de 51 - 60 años (28 por ciento). El 40,2 por ciento de los pacientes fueron atendidos por presentar una tendinitis del supraespinoso. Todos los pacientes presentaban dolor antes de la aplicación de la terapia. Luego del tratamiento el 78,5 por ciento de los enfermos dejaron de sentirlo y el 71 por ciento presentó ausencia de discapacidad según escala de DASH. Según los criterios de evaluación de la respuesta al tratamiento los resultados fueron satisfactorios en el 56 por ciento de los pacientes. Conclusiones: La terapia con las ondas de choque posibilitó una rápida recuperación de los pacientes atendidos y su incorporación a las actividades diarias(AU)

ABSTRACT Introduction: Over more than 20 years, extracorporeal lithotripsy has been successfully used worldwide. Objective: To evaluate the effectiveness of shock wave therapy in the treatment of patients with injuries to the tendons and ligaments of the osteomioarticular system. Methods: A descriptive, cross-sectional study was carried out with 107 patients diagnosed with injuries to the tendons and ligaments of the osteomioarticular system. These subjects were treated with the Well Wave equipment (extracorporeal shock waves) at Frank País International Orthopedic Scientific Center, from March 2019 to April 2020. The variables age, sex, pain and disability were analyzed. Absolute and relative frequencies were obtained, and the results of statistical information of the investigation was shown in summarizing tables. Results: The female sex prevailed (71.9percent), 51 - 60 years old (28 percent). 40.2 percent of the patients were treated for supraspinatus tendinitis. All patients had pain before the use of therapy. After treatment, 78.5 percent of the patients stopped feeling pain and 71 percent showed no disability according to DASH scale. According to the treatment response evaluation criteria, the results were satisfactory in 56percent of the patients. Conclusions: This therapy enabled rapid recovery of the patients treated and their integration into daily activities(AU)

In vitro effect of triamcinolone and platelet-rich plasma on cytokine levels of elbow lateral epicondylitis-derived cells.

BACKGROUND: The pathogenesis and treatment of lateral elbow epicondylitis (LEE) are still controversial. The purpose of the current study was to evaluate the production of inflammatory cytokines by LEE-derived cells and to compare the anti-inflammatory effect of triamcinolone acetonide with platelet-rich plasma (PRP) on cytokines production in primary culture of these cells. METHODS: Third passage cells from primary cultures of LEE were assessed for the production of the cytokines IL-1ß, IL-6, IL-8, IL-10 and TNF-α by immune-enzymatic assay (ELISA), after the treatment with 1, 10 and 100 µM triamcinolone compared to no treated controls at the time points 6, 12, 18, 24, 48, 72 and 96 h, and to PRP at 48, 72 and 96 h. RESULTS: The cytokines IL-6 and IL-8 were produced in high concentrations by LEE cells. One, 10 and 100 µM triamcinolone induced significant decrease in the production of IL-6 and IL-8 at 48, 72 and 96 h, adding the time point 12 h for IL-8. Compared to controls, PRP caused a significant increase in the production of IL-6 and IL-8 and there was a significant increase in IL-10 production with the use of 100 µM triamcinolone at 48 h. The production of IL1-ß and TNF-α was very low and did not change when the cultures were treated with triamcinolone or PRP. CONCLUSION: LEE-derived cells produce IL-6 and IL-8, confirming the inflammatory nature of this condition. While triamcinolone inhibited the production of IL-6 and IL-8 by LEE cells, PRP induced an increase in these cytokines compared with controls.

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.

Epicondilitis: Revisión bibliográfica desde una perspectiva médico legal / Epicondylitis: Literature review from a legal medical perspective

Resumen La valoración médico legal implica establecer un nexo de causalidad entre lo denunciado por los usuarios y los hallazgos encontrados clínica y radiológicamente, esto implica tener un conocimiento amplio de la biomecánica que permita interrelacionar de manera objetiva un mecanismo de trauma que se relacione en su génesis con el movimiento denunciado. En este artículo se realizará una revisión bibliográfica de la epicondilitis, tomando en consideración todos los aspectos de importancia médico legal.

Abstract The forensic evaluation implies establishing the causality between the story and the clinical and radiologic findings, this implies having a broad knowledge of biomechanics that allows an objective interrelation of a trauma mechanism. This article consists in a bibliographical revision about the etiopathogenesis of the epicondylitis and the interpretation of this patology in relation to medico legal analysis.

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.

Ulnar nerve subluxation and dislocation: a review of the literature.

The pathogenesis of ulnar nerve subluxation and dislocation is widely debated. Upon elbow flexion, the ulnar nerve slips out of the groove for the ulnar nerve, relocates medial or anterior to the medial epicondyle, and returns to its correct anatomical position upon extension. This chronic condition can cause neuritis or neuropathy; however, it has also been suggested that it protects against neuropathy by reducing tension along the nerve. This article reviews the extant literature with the aim of bringing knowledge of the topic into perspective and standardizing terminology.

La epicondilitis medial en los lanzadores de la Isla de la Juventud / Epicondilite medial em lançadores da Ilha da Juventude / Medial epicondylitis in pitchers of La Isla de la Juventud

Resumen La tendinopatía es una causa importante de morbilidad musculo-esquelética. Tiene una alta incidencia en el ámbito deportivo de 30 a 50 % de las lesiones, en atletas profesionales y recreativos, que pueden comprometer el rendimiento deportivo y causar discapacidad. En gran medida, es causada por una alteración en los orígenes músculo-tendinosos, en los cóndilos humerales. En la mayoría de los casos, se encuentra en población laboralmente activa, por lo cual tiene alto impacto en la reducción de la productividad por ausencias laborales, que de acuerdo con la severidad pueden ser días o semanas. El objetivo general de la investigación consiste en proponer un complejo de ejercicios físicos que contribuyan a la recuperación de dicha lesión en lanzadores de béisbol. Se emplearon los métodos teóricos, empíricos y se determinaron los fundamentos teóricos que componen la rehabilitación de la epicondilitis medial. Se analizó la información obtenida luego de aplicar una entrevista a los entrenadores, con la finalidad de caracterizar el estado actual del proceso de rehabilitación de esta lesión. A partir de los resultados obtenidos, se diseñó un conjunto de ejercicios físicos para rehabilitar dicha lesión en el área de entrenamiento. Los ejercicios diseñados se clasifican en pasivos, activos asistidos, activos libres, activos resistidos; este último dividido en dos grupos. Para facilitar la labor de los entrenadores, se describen la forma de ejecución de los ejercicios, así como las indicaciones metodológicas, músculos implicados, organización y variantes.

Resumo A Tendinopatia é uma das principais causas de morbidade músculo-esquelética. Tem uma alta incidência no ambiente desportivo de 30-50% das lesões em atletas profissionais e recreativos, o que pode comprometer o desempenho desportivo e causar incapacidade. Em grande medida, é causada por uma alteração na origem músculo-tendão nos côndilos umerais. Na maioria dos casos, encontra-se na população ativa, pelo que tem um elevado impacto na redução da produtividade por faltas ao trabalho, que de acordo com a gravidade pode variar de dias a semanas. O objetivo geral da pesquisa é propor um complexo de exercícios físicos que contribuam para a recuperação desta lesão em arremessadores de beisebol. Os métodos teóricos e empíricos foram utilizados e os fundamentos teóricos que compõem a reabilitação da Epicondilite medial foram determinados. As informações obtidas após a entrevista com os treinadores foram analisadas a fim de caracterizar o estado atual do processo de reabilitação para esta lesão. Com base nos resultados obtidos, um conjunto de exercícios físicos foi concebido para reabilitar esta lesão na área de treino. Os exercícios concebidos são classificados em passivos, ativos assistidos, ativos livres e ativos resistidos; sendo estes últimos divididos em dois grupos. Para facilitar o trabalho dos treinadores, é descrita a forma de execução dos exercícios, assim como as indicações metodológicas, músculos envolvidos, organização e variantes.

Abstract Tendinopathy is a major cause of musculoskeletal morbidity. A high incidence of sports-related injuries of 30-50 % in professional and recreational athletes, which can compromise sports performance and cause disability. Mostly, it is caused by an alteration in the muscle-tendontium origins in the humeral condyles. In most cases, it is in the working population, so it has a high impact on reducing productivity due to absences from work, which, depending on the severity, can range from days to weeks. The general objective of the research is to propose a complex of physical exercises that will contribute to the recovery of such injury in baseball pitchers. Theoretical and empirical methods were used and the theoretical foundations for the rehabilitation of medial epicondylitis were determined. The information obtained after interviewing the coaches was analyzed in order to characterize the current state of the rehabilitation process for this injury. Based on the results obtained, a set of physical exercises was designed to rehabilitate this injury in the training area. The exercises designed are classified into passive, assisted active, free active, and resisted active; the latter being divided into two groups. In order to facilitate the work of the trainers, the form of execution of the exercises is described, as well as the methodological indications, muscles involved, organization and variants.

Lesión del nervio cubital secundario a terapia de ondas de choque extracorpóreas radiales identificada con ultrasonografía de alta resolución: Reporte de caso / Ulnar Nerve Injury After Radial Extracorporeal Shock Wave Therapy Identified With High­Resolution Ultrasonography: Case Report

Mujer de 49 años fue evaluada por desarrollar dolor súbito a nivel de los epicóndilos mediales conjuntamente con entumecimiento y sensación de hormigueo en el cuarto y quinto dedos después de recibir terapia de ondas de choque extracorpóreas radiales (rESWT) como tratamiento para epicondilitis medial bilateral. El examen neurológico reveló signo de Tinel positivo, parestesia y una prueba de discriminación de dos puntos alterada sobre la región cubital del cuarto y quinto dedos. La ultrasonografía de alta resolución demostró hallazgos de lesión nerviosa periférica tales como hipoecogenicidad y aumento del diámetro de ambos nervios cubitales. La paciente mejoró únicamente tras recibir tratamiento conservador, demostrando así una aparente neuropatía compresiva bilateral aguda como resultado de la terapia. ESWT se utiliza como una alternativa prometedora para el tratamiento de diversos trastornos musculoesqueléticos; sin embargo, existe evidencia limitada con respecto a sus efectos secundarios, en particular la mononeuropatía periférica. Según el conocimiento de los autores, este es el primer reporte que demuestra un daño nervioso estructural después de rESWT con el uso de ultrasonografía de alta resolución.

A 49-year old woman was evaluated for developing bilateral acute medial elbow pain, numbness, and tingling sensation in the fourth and fifth fingers after receiving radial extracorporeal shock wave therapy (rESWT) for bilateral medial epicondylitis. Neurologic examination revealed the presence of Tinel's sign, paresthesia and impaired two-point discrimination testing over the ulnar side of the fourth and fifth fingers bilaterally. High-resolution ultrasonography demonstrated findings of nerve injury, such as hypoechogenicity and increased diameter of both ulnar nerves. After conservative treatment, the patient improved her condition demonstrating an apparently acute compressive nerve injury as a result of the therapy. ESWT is used as a promising alternative for the treatment of various musculoskeletal disorders; however, there is limited evidence regarding its side effects, in particular peripheral mononeuropathy. To the authors' knowledge, this is the first report demonstrating structural damage of a nerve after rESWT with the use of high-resolution ultrasonography.

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.

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

BACKGROUND: Lateral epicondylitis (LE) is a painful condition typically caused by excessive use of tendons, resulting in tendinopathy, inflammation, pain, and sensitivity changes in the lateral elbow. Iontophoresis is a noninvasive method of systemic and local drug delivery by means of a current. The study aimed to evaluate the effects of iontophoresis in patients with LE. METHODS: We performed a randomized, double-blind clinical trial. Twenty-four patients with LE, randomized into an iontophoresis group and a galvanic current group. The iontophoresis group received a solution of dexamethasone (4 mg/mL) and gel lidocaine-applied on the negative electrode by means of a continuous current at 5 mA for 15 minutes-and the positive electrode received a base gel solution. Patients in the galvanic current group received the same protocol but using a base gel solution on both electrodes. RESULTS: Both groups showed a significant improvement in pain on exertion and rest; increased handgrip strength in elbow extension and flexion; and improved function, as evaluated by the Patient-Rated Tennis Elbow Evaluation scale (P < .05). Iontophoresis showed superior results compared with galvanic current in pain on exertion and rest and in the function of individuals with tennis elbow. CONCLUSION: Iontophoresis proved to be an effective technique in reducing pain and improving strength and function in individuals with LE (tennis elbow).

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.

Efectividad de la acupuntura en pacientes con epicondilalgia lateral: un resumen de revisiones sistemáticas / Effectiveness of Acupuncture in Patients with Lateral Epicondylalgia: An Overview of Systematic Reviews / Efetividade da acupuntura em pacientes com epicondilalgia lateral: um resumo de revisões sistemáticas

La epicondilalgia lateral es una condición músculoesquelética bastante común, que se caracteriza por la presencia de dolor, disminución en la fuerza de prensión y pérdida progresiva de la funcionalidad de la mano. La acupuntura es un método terapéutico derivado de la medicina china tradicional, en donde se realiza estimulación de puntos corporales mediante agujas, con fines terapéuticos o preventivos. Algunos estudios han reportado que la acupuntura produce un beneficio a corto plazo sobre el dolor localizado en el epicóndilo lateral del codo; sin embargo, los beneficios que informan los estudios asociados a esta patología no logran ser concluyentes. Objetivo: resumir la evidencia existente en revisiones Cochrane y no Cochrane, buscando los efectos y beneficios de la acupuntura para el tratamiento del dolor en sujetos que presenten epicondilalgia lateral. Materiales y métodos: se realizó una búsqueda en el registro especializado Cochrane del grupo músculo-esquelético (1980-junio 2015) y en las bases de datos: Medline (1980-septiembre 2015), Pedro (1980- septiembre 2015), Metabuscador Epistemonikos (1980- septiembre 2015), se buscó literatura gris y actas de congresos. La calidad metodológica de las revisiones sistemáticas incluidas fueron evaluadas con AMSTAR y la calidad global de la evidencia mediante GRADE. Resultados: La búsqueda preliminar identificó 92 revisiones sistemáticas, de las cuales 2 cumplieron con los criterios de elegibilidad. Las 2 revisiones sistemáticas fueron categorizadas como de alta calidad metodológica. Conclusión: a pesar de lo poco común de la prescripción y su aplicación en sujetos que presentan epicondilalgia lateral, la acupuntura ha demostrado ser eficaz en el alivio del dolor a corto plazo

Introduction: Epicondylalgia lateral skeletal muscle is a fairly common condition, characterized by the presence of pain, decreased grip strength and progressive loss of function of the hand. Objective: To summarize the evidence in Cochrane and non-Cochrane, looking at the effects and benefits of acupuncture for the treatment of pain in patients who may be le. Methods: A search was conducted in the specialized registry of the Cochrane musculoskeletal group (1980- September 2015) and databases: Medline (1980- September 2015), Pedro (1980- September 2015), Metasearcher Epistemonikos (1980- September 2015), gray literature, conference proceedings was sought. The methodological quality of systematic reviews was evaluated including AMSTAR and the overall quality of the evidence using GRADE. Results: The search identified 92 preliminary systematic reviews, of which two met the eligibility criteria. 2 systematic reviews were categorized as high methodological quality. Conclusion: Despite the rarity of prescription and their application in subjects with lateral epicondylalgia, acupuncture has been proven effective in relieving pain in the short term

A epicondilalgia lateral é uma condição musculoesquelética bastante comum, que se caracteriza pela presença de dor, diminuição na força de preensão e perda progressiva da funcionalidade da mão. A acupuntura é um método terapêutico derivado da medicina chinesa tradicional, onde se realiza estimulação de pontos corporais mediante guias, com fins terapêuticos ou preventivos. Alguns estudos têm reportado que a acupuntura produz um benefício a curto prazo sobre a dor localizada no epicôndilo lateral do cotovelo; no entanto, os benefícios que informam os estudos associados a esta patologia não conseguem ser concluintes. Objetivo: Resumir a evidência existente em revisões Cochrane e não Cochrane, buscando os efeitos e benefícios da Acupuntura para o tratamento da dor em sujeitos que apresentem Epicondilalgia lateral. Materiais e métodos: Realizou-se uma busca no registro especializado Cochrane do grupo musculoesquelético (1980-Junho 2015) e nas bases de dados: Medline (1980-Setembro 2015), PEDro (1980- Setembro 2015), Metabuscador Epistemonikos (1980- Setembro 2015), se buscou literatura cinzenta e atas de congressos. A qualidade metodológica das revisões sistemáticas incluídas foi avaliada com AMSTAR e a qualidade global da evidência mediante GRADE. Resultados: A busca preliminar identificou 92 revisões sistemáticas, das quais 2 cumpriram com os critérios de elegibilidade. As 2 revisões sistemáticas foram categorizadas como de alta qualidade metodológica. Conclusão: Apesar da prescrição e a sua aplicação em sujeitos que apresentam epicondilalgia lateral, a acupuntura tem demonstrado ser eficaz no alívio da dor a curto prazo

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.