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

BACKGROUND: The Oxford Elbow Score (OES) and the short version of Disabilities of Arms, Shoulder and Hand (QuickDASH) are common patient-reported outcomes for people with elbow problems. Our primary objective was to define thresholds for the Minimal Important Difference (MID) and Patient-Acceptable Symptom State (PASS) for the OES and QuickDASH. The secondary aim was to compare the longitudinal validity of these outcome measures. METHODS: We recruited 97 patients with clinically-diagnosed tennis elbow for a prospective observational cohort study in a pragmatic clinical setting. Fifty-five participants received no specific intervention, 14 underwent surgery (11 as primary treatment and 4 during follow-up), and 28 received either botulinum toxin injection or platelet rich plasma injection. We collected OES (0 to 100, higher is better) and QuickDASH (0 to 100, higher is worse), and global rating of change (as an external transition anchor question) at six weeks, three months, six months and 12 months. We defined MID and PASS values using three approaches. To assess the longitudinal validity of the measures, we calculated the Spearman's correlation coefficient between the change in the outcome scores and external transition anchor question, and the Area Under the Curve (AUC) from a receiver operating characteristics (ROC) analysis. To assess signal-to-noise ratio, we calculated standardized response means. RESULTS: Depending on the method, MID values ranged from 16 to 21 for OES Pain; 10 to 17 for OES Function; 14 to 28 for OES Social-psychological; 14 to 20 for OES Total score, and - 7 to -9 for QuickDASH. Patient-Acceptable Symptom State (PASS) cut offs were 74 to 84 for OES Pain; 88 to 91 for OES Function; 75 to 78 with OES Social-psychological; 80 to 81 with OES Total score and 19 to 23 with Quick-DASH. OES had stronger correlations with the anchor items, and AUC values suggested superior discrimination (between improved and not improved) compared with QuickDASH. OES also had superior signal-to-noise ratio compared with QuickDASH. CONCLUSION: The study provides MID and PASS values for OES and QuickDASH. Due to better longitudinal validity, OES may be a better choice for clinical trials. TRIAL REGISTRATION: ClinicalTrials.gov NCT02425982 (first registered April 24, 2015).

The "Selfie Test": A Novel Test for the Diagnosis of Lateral Epicondylitis.

Background: Lateral epicondylitis (LE) is one of the most diagnosed elbow pathologies. The purpose of this study was to determine the diagnostic test accuracy of a new test (selfie test) for the diagnosis of LE. Methods: Medical data were collected from adult patients who presented with LE symptoms and ultrasound findings that supported the diagnosis. Patients underwent a physical examination, including provocative tests for diagnosis as well as the selfie test, and were asked to fill out the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire and subjectively rate the activity of their affected elbow. Results: Thirty patients were included in this study (seventeen females, 57%). The mean age was 50.1 years old (range of 35 to 68 years). The average duration of symptoms was 7 ± 3.1 months (range of 2 to 14 months). The mean PRTEE score was 61.5 ± 16.1 (range of 35 to 98), and the mean subjective elbow score was 63 ± 14.2 (range of 30 to 80). Mill's, Maudsley's, Cozen's, and the selfie tests had sensitivities of 0.867, 0.833, 0.967, and 0.933, respectively, with corresponding positive predictive values of 0.867, 0.833, 0.967, and 0.933. Conclusions: The selfie test's active nature, which allows patients to perform the assessment themselves, could be a valuable addition to the diagnostic process, potentially improving the accuracy of the diagnosis of LE (levels of evidence: IV).

Is blood group a risk factor in lateral epicondylitis?

OBJECTIVE: Lateral epicondylitis is a common disorder in the community. Identification of risk factors plays an important role in the prevention and treatment of the disease. In our study, the relationship between risk factors in lateral epicondylitis and blood group, which has not been mentioned before in the literature, will be examined. PATIENTS AND METHODS: In our study, patients' age, height, weight, body mass index (BMI), dominant upper extremity, affected upper extremity, duration of symptoms, duration between onset of symptoms and hospital admission, occupation, number of children and youngest child age (if the patient is a mother), smoking, alcohol use, presence of additional diseases, sports activities, job requiring repetitive movements and strength in the upper extremities in daily life, marital status, where he/she lives and his/her blood type were questioned. In our study, there were 304 patients in the patient group and 304 patients in the control group. RESULTS: In our study, blood type 0 was significantly more common in the patient group (p<0.001). CONCLUSIONS: In our study, it was concluded that there is a relationship between 0 blood group and lateral epicondylitis.

[MRI or ultrasound-which imaging technique do we need?] / MRT oder Sonographie ­ welche Bildgebung brauchen wir?

Diagnostic imaging of epicondylitis is primarily performed using widely available, radiation-free ultrasound. The dynamic examination allows a rapid point-of-care assessment. Typical imaging findings of epicondylitis include intratendinous hypoechogenic foci at the humeral origin, ossification at the enthesis, intratendinous calcifications, or (partial) rupture. In particular, Doppler sonography increases sensitivity by assessing possible neovascularization within the tendon. When sonographic findings are unclear or extensive, or when ultrasound machines or the required expertise in elbow examinations are not available, magnetic resonance imaging is indicated. Here, the use of proton density-weighted sequences is appropriate for assessing bone marrow and soft tissue edema and tendon tears, while ossifications are best delineated in T1weighted sequences. Projection radiography and computed tomography can be helpful for larger ossifications, although they are not part of the standard imaging protocol.

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

PURPOSE: A great number of patients that suffer from lateral epicondylitis, commonly called tennis elbow (TE), are not successfully treated, meaning, not getting adequate therapeutic effects and the main origin of the pain not being handled appropriately. The hypothesis of the present study is that the inefficiency of the treatment of the chronic TE may often be due to underdiagnosis of posterior interosseous nerve (PIN) entrapment or and plica syndrome, as the authors believe that those pathologies can often occur simultaneously. METHODS: A prospective cross sectional study was conducted. A total of 31 patients met the required criteria. RESULTS: Thirteen (40.7%) of the patients had more than one source of the lateral elbow pain. Five patients (15.6%) had all three examined pathologies. Six patients (18.8%) had TE and PIN syndrome. Two patients (6.3%) had TE and plica syndrome. CONCLUSION: The present study demonstrated concomitant potential sources of lateral elbow pain in patients diagnosed with chronic TE. Our analysis shows how important it is to systematically diagnose patients that present with lateral elbow pain. The clinical characteristics of the three most common causes of chronic lateral elbow pain, meaning, TE, PIN compression, and plicae syndrome were also analyzed. Having adequate knowledge about the clinical aspects of these pathologies can help with a more effective differentiation of the etiology of chronic lateral elbow pain, and with that, a more efficient and cost-effective treatment plan.

[RADIAL TUNNEL SYNDROME].

INTRODUCTION: The radial tunnel syndrome (RTS) is an entrapment of the radial nerve in the forearm. It is characterized by pain focused on the trapping area in the proximal forearm as well as pain radiated down the forearm. The syndrome is more common in men and in our estimation, there is a circumstantial connection to the continuous use of the computer keyboard. Radial tunnel syndrome is a consequence of nerve entrapment in the tunnel, which is formed from a covering consisting of the supinator muscle and the distal margins of this muscle. There is a clear association between radial tunnel syndrome and the occurrence of tennis elbow. The sensitivity in nearby locations along with the lack of familiarity of some of the clinicians with RTS lead to misdiagnosis and therefore, even to mistreatment in some cases. The physical examination is the most important means of making the correct diagnosis. The treatment of radial tunnel syndrome is divided into the conservative one in which emphasis is placed on physiotherapy and mobilizations of the nerve and the surgical one during which decompression of the radial canal is performed and in fact release of pressure at the exact anatomical location.

Tennis Elbow: What Is It? How Do I Get Back to My Regular Activities?

You do not have to play tennis to get tennis elbow-a very common problem for people who do lots of repetitive movements of the wrist, forearm and elbow, such as carpentry, painting or racquet sports. Most people with tennis elbow feel pain on the outside of their elbow and upper forearm. Experts in managing elbow pain developed a guideline for rehabilitation clinicians to use to help you understand more about tennis elbow. Here, we explain what the guidelines say about how to diagnose tennis elbow (sometimes called lateral elbow pain or lateral elbow tendinopathy), the specific treatments your physical therapist might offer you to help manage pain and improve the mobility of your elbow, and the types of exercises you could do to strengthen the muscles in your wrist and forearm.

Effects of multidirectional elastic tape on pain and function in individuals with lateral elbow tendinopathy: A randomised crossover trial.

OBJECTIVE: To investigate the effects of multidirectional elastic tape on pain and function in individuals with lateral elbow tendinopathy. STUDY DESIGN: Randomised crossover trial. SETTING: Biomechanics laboratory. SUBJECTS: 27 participants (11 females, mean (SD) age: 48.6 (11.9) years) with clinically diagnosed lateral elbow tendinopathy of at least six weeks' duration. INTERVENTIONS: Tensioned multidirectional elastic tape applied over the wrist, compared to control tape (untensioned), and no tape conditions. MAIN MEASURES: Pain-free grip strength and pressure pain threshold were recorded at three timepoints for each condition: baseline, post-application, and following an exercise circuit. Change scores were calculated as the post-application or post-exercise value minus baseline. Repeated-measure analyses of variance were used to examine differences between conditions. RESULTS: There were no statistically significant differences in pain-free grip strength between conditions (flexed position: F2,52 = 0.02, p = 0.98; extended position: F2,52 = 2.26, p = 0.12) or across timepoints (post-application vs post-exercise) (flexed position: F1,26 = 0.94, p = 0.34; extended position: F1,26 = 0.79, p = 0.38). Seven participants (26%) increased pain-free grip strength above the minimal detectable change following application of multidirectional elastic tape. There were no statistically significant differences in pressure pain threshold between conditions (affected lateral epicondyle: F1.51,39.17 = 0.54, p = 0.54) or across timepoints (affected lateral epicondyle: F1,26 = 0.94, p = 0.34). CONCLUSION: Tensioned multidirectional elastic tape may not immediately improve pain-free grip strength or pressure pain threshold in our lateral elbow tendinopathy population; however, individual variation may exist.

Lateral Epicondylitis: Critical Analysis Review of Current Nonoperative Treatments.

¼: Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm. ¼: The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time. ¼: Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments. ¼: In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

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

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

Evaluation of short-term and residual effects of Kinesio taping in chronic lateral epicondylitis: A randomized, double-blinded, controlled trial.

BACKGROUND: Lateral epicondylitis is degenerative tendinosis of the extensor carpi radialis brevis muscle and is the most common work/sports-related chronic musculoskeletal problem affecting the elbow. PURPOSE: This study aimed to evaluate the short term and residual effectiveness of the Kinesio taping method on pain, grip force, quality of life, and functionality. STUDY DESIGN: Randomized, double-blinded, controlled study. METHODS: Subjects were 50 patients diagnosed with chronic unilateral lateral epicondylitis with a symptom duration of at least 12 weeks. During the first four weeks, the study group received a true inhibitor Kinesio taping while the control group received sham taping. In both groups, progressive stretching and strengthening exercises were given as a home program for six weeks. The primary outcome measure was the Numerical Rating Scale (NRS) for self-report of pain intensity; secondary outcome measures were Cyriax resistive muscle test evaluation, maximal grip strength, Patient- Rated Tennis Elbow Evaluation (PRTEE), and Short Form-36 (SF-36). After the treatment, patients were evaluated by the first assessor who was blinded to taping types. RESULTS: There was a significant decrease in NRS scores overtime during the first four weeks in both groups (P < .001,) and effect sizes were large. There was no significant difference in Cyriax muscle resistance test maximal grip strength between groups (P > .05). However, there was a significant improvement in muscle strength of elbow extension and pronation in the study group detected in the intragroup analysis. Intragroup comparisons also showed a significant improvement in all subunits of the PRTEE and SF-36 except energy/vitality, social functioning, and pain in both groups (P < .05) with moderate to high effect sizes. PRTEE pain scores were significantly decreased in the study group compared to the placebo group (P < .05, d = 0.48). CONCLUSION: The effects of Kinesio taping on muscle strength, quality of life, and function in chronic lateral epicondylitis are not superior to placebo. However, NRS scores showed that in the two weeks after Kinesio taping treatment, pain reduction persisted as a residual effect which may improve the exercise adherence and functionality.

Clinical Outcomes of Arthroscopic Debridement for Lateral Epicondylitis with Partial Injury of the Lateral Collateral Ligament Complex.

Background: Lateral collateral ligament injuries may occur in patients with chronic lateral epicondylitis. The present study aimed to compare the clinical outcomes of arthroscopic debridement between patients with chronic lateral epicondylitis combined with a partial ligament injury and those without a ligament injury. Methods: Between 2016 and 2018, patients who underwent arthroscopic debridement for lateral epicondylitis were evaluated. Partial injury to the lateral collateral ligament was defined as discontinuity or thinning with increased signal of the lateral ligament on magnetic resonance imaging and laxity with a firm endpoint in the varus or posterolateral rotatory stress test. Arthroscopic debridement was performed when there was no apparent instability in the stress test under fluoroscopic guidance after anesthesia. Patients with a ligament injury were compared with those without a ligament injury in terms of physical examination (varus stress test and posterolateral rotatory drawer test), pain visual analog scale, Mayo elbow performance score, and quick disabilities of the arm, shoulder and hand score. Results: There were 38 patients in the intact ligament group and 15 patients in the partial ligament injury group. There were 23 men and 30 women, and the mean patient age was 50 years (range, 27-77 years). The mean follow-up period was 30 months (range, 24-49 months). Instability was not observed in both groups at the last follow-up, and clinical scores improved significantly after surgery. Postoperative results did not show significant difference between the two groups. One patient in the partial injury group underwent revision open debridement owing to persistent pain. Conclusions: The clinical outcomes of arthroscopic debridement for lateral epicondylitis did not show significant differences between patients with a partial ligament injury and those without a ligament injury.

The Effect of Elbow and Forearm Position on the Resisted Wrist Extension Test and Incidence of Sensory Disturbance of the Superficial Radial Nerve in Patients with Lateral Epicondylitis.

Background: The aim of this study is to determine the effect of elbow and forearm position on the resisted wrist extension test (RWET) in patients with lateral epicondylitis. We also looked at the incidence of associated sensory disturbance of the superficial radial nerve (SRN) and the effect of treatment of lateral epicondylitis on sensory disturbance. Methods: Sixty-three consecutive patients (68 limbs) with lateral epicondylitis and an equal number of age and gender matched volunteers were investigated. Patients with lateral epicondylitis were subdivided into two groups based on history of corticosteroid injection. We performed the RWET in four limb positions namely elbow extended and forearm pronated (EP), elbow flexed and forearm pronated (FP), elbow extended and forearm supinated (ES), elbow flexed and forearm supinated (FS). Sensory disturbance in the SRN was assessed using a Wartenberg pin wheel. Results: The positivity rate of the RWET was significantly higher in the EP position (100%) compared to the FP (66%), ES (62%) and the FS (24%) positions in limbs with lateral epicondylitis. The RWET was positive only in one subject in the EP position in the control group (1.5%). Sensory disturbance in the SRN territory was present in 63.2% of limbs and only two subjects (2.9%) in the control group. The incidence of sensory disturbance was significantly higher (74.5% vs. 48.3%, p < 0.05) in patients who did not have a corticosteroid injection. Conclusions: The sensitivity and specificity of the RWET is better when it is performed with the elbow in extension with the forearm pronated (EP); 63.2% of limbs with lateral epicondylitis were noted to have an associated sensory disturbance of the SRN and a corticosteroid injection seems to decrease the incidence of sensory disturbances. Level of Evidence: Level II (Diagnostic).

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

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

Development of a core outcome set for lateral elbow tendinopathy (COS-LET) using best available evidence and an international consensus process.

OBJECTIVES: To develop a core outcome set for lateral elbow tendinopathy (COS-LET) and to provide guidance for outcome evaluation in future studies. METHODS: We implemented a multi-stage mixed-methods design combining two systematic reviews, domain mapping of outcome measurement instruments to the core domains of tendinopathy, psychometric analysis of instruments, two patient focus groups and a Delphi study incorporating two surveys and an international consensus meeting. Following the OMERACT guidelines, we used a 70% threshold for consensus. RESULTS: 38 clinicians/researchers and 9 patients participated. 60 instruments were assessed for inclusion. The only instrument that was recommended for the COS-LET was Patient Rated Tennis Elbow Evaluation (PRTEE) for the disability domain. Interim recommendations were made to use: the PRTEE function subscale for the function domain; PRTEE pain subscale items 1, 4 and 5 for the pain over a specified time domain; pain-free grip strength for the physical function capacity domain; a Numerical Rating Scale measuring pain on gripping for the pain on activity/loading domain; and time off work for the participation in life activities domain. No recommendations could be made for the quality-of-life, patient rating of condition and psychological factors domains. CONCLUSIONS: The COS-LET comprises the PRTEE for the disability domain. Interim-use recommendations included PRTEE subscales, time off work, pain-free grip strength and a Numerical Rating Scale measuring pain on gripping. Further work is required to validate these interim measures and develop suitable measures to capture the other domains.