The Effect of Scapular Muscle Strengthening on Functional Recovery in Patients With Lateral Elbow Tendinopathy: A Pilot Randomized Controlled Trial.

CONTEXT: There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET. OBJECTIVE: The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET. DESIGN: Prospective randomized clinical trial. SETTING: Multisite outpatient physical therapy. PATIENTS: Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS. INTERVENTIONS: Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises. MAIN OUTCOME MEASURE: The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure. RESULTS: The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05). CONCLUSION: The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

Evaluating the immediate effect of forearm and wrist orthoses on pain and function in individuals with lateral elbow tendinopathy: A systematic review.

BACKGROUND: Lateral elbow tendinopathy is associated with pain during gripping, with forearm/wrist orthoses prescribed for treatment. OBJECTIVES: To investigate the immediate effects of forearm and/or wrist orthoses on outcome measures of pain and function in individuals with lateral elbow tendinopathy. DESIGN: Systematic review METHODS: Four electronic databases were searched to identify randomised controlled trials reporting the immediate effects of forearm and/or wrist orthoses on pain and function in individuals with lateral elbow tendinopathy. The quality of evidence was rated from high to very low, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) for the primary outcomes. Where possible, standardised mean difference (SMD) and 95% confidence intervals were calculated to compare post measures between forearm and/or wrist orthoses and control/placebo conditions. RESULTS: The search revealed 1965 studies, of which, seven randomised crossover trials were included. Using the GRADE approach there was low quality evidence revealing a significant decrease in pain during contraction (SMD range -0.65 to -0.83) with forearm orthoses compared to a control/placebo condition. Low quality evidence revealed improvements in pain-free grip strength with the use of a forearm orthosis (SMD range 0.24-0.38), but not maximal grip strength (SMD range 0.14-0.15). Low quality evidence revealed a static wrist orthosis did not improve pain-free grip strength (SMD -0.08) or maximal grip strength (SMD -0.22). CONCLUSION: There is low quality evidence that forearm orthoses can immediately reduce pain during contraction and improve pain-free grip strength but not maximal grip strength in individuals with lateral elbow tendinopathy.

The Impact of Tennis and Golfer's Elbow on Shoulder External Rotators and Abductors' Peak Torque.

CONTEXT: Upper limb activities require a repetitive movement of the shoulder external rotator and abductor muscles. The malfunction of the proximal part of the upper limb kinetic chain tends to change the mechanics of the distal part and increase the risk of injuries. OBJECTIVES: To compare the normalized eccentric peak torque (NEPT) of the shoulder external rotator and abductor muscles among healthy athletes and those with tennis elbow and golfer's elbow. DESIGN: An experimental cross-sectional study. SETTING: Isokinetic laboratory, Faculty of Physical Therapy, Cairo University. PARTICIPANTS: A total of 30 male athletes participated voluntarily in this study. INTERVENTION: Participants were distributed into 3 groups: healthy group, tennis elbow group, and golfer's elbow group. MAIN OUTCOME MEASURES: NEPT of shoulder abductors and external rotators. The Biodex Isokinetic Dynamometer was used to measure the variables of interest. RESULTS: There was a significant increase in the NEPT of shoulder abductors and external rotators in healthy control group compared with both tennis elbow and golfer's elbow groups at an angular velocity of 60°/s (P < .05). Moreover, there was a significant increase in the NEPT of shoulder external rotators and abductors at an angular velocity of 120°/s in healthy control group compared with tennis elbow group and in golfer's elbow group compared with tennis elbow group (P < .05). CONCLUSION: Tennis elbow and golfer's elbow are associated with decreased NEPT of shoulder external rotators and abductors compared with those of healthy athletes. This tends to decrease the external stability of the shoulder joint and put high stress on the distal joints of the upper kinetic chain.

Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy.

PURPOSE: This study aimed to investigate the effect of unsupervised isometric exercise compared with a wait-and-see approach on pain, disability, global improvement, and pain-free grip strength in individuals with lateral elbow tendinopathy. METHODS: Forty participants with unilateral lateral elbow tendinopathy of at least 6 wk duration were randomized to either wait-and-see (n = 19) or a single supervised instruction session by a physiotherapist, followed by an 8-wk unsupervised daily program of progressive isometric exercise (n = 21). Primary outcomes were Patient-Rated Tennis Elbow Evaluation, global rating of change on a six-point scale (dichotomized to success and no success) and pain-free grip strength at 8 wk. Secondary outcomes were resting and worst pain on an 11-point numerical rating scale, and thermal and pressure pain thresholds as a measure of pain sensitivity. RESULTS: Thirty-nine (98%) participants completed 8-wk measurements. The exercise group had lower Patient-Rated Tennis Elbow Evaluation scores compared with wait-and-see at 8 wk (standardized mean difference [SMD], -0.92; 95% confidence interval [CI], -1.58 to -0.26). No group differences were found for success on global rating of change (29% exercise vs 26% wait-and-see (risk difference, 2.3%; 95% CI, -24.5 to 29.1)), or pain-free grip strength (SMD, -0.33; 95% CI, -0.97 to 0.30). No differences were observed for all secondary outcomes except for worst pain, which was moderately lower in the exercise group (SMD, -0.80; 95% CI, -1.45 to -0.14). CONCLUSIONS: Unsupervised isometric exercise was effective in improving pain and disability, but not perceived rating of change and pain-free grip strength when compared with wait-and-see at 8 wk. With only one of the three primary outcomes being significantly different after isometric exercises, it is doubtful if this form of exercise is efficacious as a sole treatment.

Ultrasound-guided tenotomy improves physical function and decreases pain for tendinopathies of the elbow: a retrospective review.

BACKGROUND: Tendinopathy is a common cause of elbow pain in the active population. Ultrasound-guided tenotomy (USGT) is a minimally invasive treatment option for cases recalcitrant to conservative management. Several case studies have shown promising preliminary results of USGT for common extensor tendinopathy and common flexor tendinopathy, but none have included USGT for triceps tendinopathy. This larger retrospective study evaluates the effectiveness and safety of USGT for all elbow tendinopathy sites at short- and long-term follow-up. METHODS: Retrospective chart review identified 131 patients (144 procedures; mean age ± standard deviation [SD], 48.1 ± 9.8 years; mean body mass index ± SD, 32.2 ± 7.7; 59% male) with elbow tendinopathy (104 common extensor tendinopathy, 19 common flexor tendinopathy, 8 triceps tendinopathy) treated with USGT over a 6-year period by a single physician. Pain and quality-of-life measures were collected at baseline. Pain, quality-of-life, satisfaction with outcome, and complications were collected at short-term (2-, 6-, and 12-week) and long-term (median 2.7 years, interquartile range = 2.0-4.0 years) follow-up. RESULTS: Overall, USGT for elbow tendinopathy decreased pain from moderate/severe at baseline to mild/occasional at short- and long-term follow-up (P < .01). Quality-of-life assessments showed significant improvement in physical function at short- and long-term follow-up (P < .01). The majority (70%) of patients were satisfied with the procedure. There was a 0% complication rate. CONCLUSION: Benefits of USGT include pain relief, improved physical function, and high patient satisfaction. USGT is a safe, minimally invasive treatment for refractory elbow tendinopathy.

Clinical rating systems in elbow research-a systematic review exploring trends and distributions of use.

BACKGROUND: Clinical rating systems are used as outcome measures in clinical trials and attempt to gauge the patient's view of his or her own health. The choice of clinical rating system should be supported by its performance against established quality standards. METHODS: A search strategy was developed to identify all studies that reported the use of clinical rating systems in the elbow literature. The strategy was run from inception in Medline Embase and CINHAL. Data extraction identified the date of publication, country of data collection, pathology assessed, and the outcome measure used. RESULTS: We identified 980 studies that reported clinical rating system use. Seventy-two separate rating systems were identified. Forty-one percent of studies used ≥2 separate measures. Overall, 54% of studies used the Mayo Elbow Performance Score (MEPS). For arthroplasty, 82% used MEPS, 17% used Disabilities of Arm, Shoulder and Hand (DASH), and 7% used QuickDASH. For trauma, 66.7% used MEPS, 32% used DASH, and 23% used the Morrey Score. For tendinopathy, 31% used DASH, 23% used Patient-Rated Tennis Elbow Evaluation (PRTEE), and 13% used MEPS. Over time, there was an increased proportional use of the MEPS, DASH, QuickDASH, PRTEE, and the Oxford Elbow Score. CONCLUSIONS: This study identified a wide choice and usage of clinical rating systems in the elbow literature. Numerous studies reported measures without a history of either a specific pathology or cross-cultural validation. Interpretability and comparison of outcomes is dependent on the unification of outcome measure choice. This was not demonstrated currently.

Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy.

STUDY DESIGN: RCT. INTRODUCTION: Lateral elbow tendinopathy is a common clinical condition. eccentric exercises. eccentric-concentric loading and, isometric exercises are indicated to reduce and manage tendon pain. PURPOSE OF THE STUDY: To compare the effectiveness of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. METHODS: A randomized clinical trial was carried out in a rheumatology and rehabilitation center. A group of 34 patients with later elbow tendinopathy was randomly allocated to Group A (n = 11) who underwent eccentric training, Group B had eccentric-concentric and Group C who had eccentric-concentric and isometric training. All patients received 5 treatments per week for 4 weeks. Pain was evaluated using a visual analog scale and function using a visual analog scale and pain-free grip strength at the end of the 4-week course of treatment (week 4) and 1 month (week 8) after the end of treatment. RESULTS: The eccentric-concentric training combined with isomentric contractions produced the largest effect in the reduction of pain and improvement of function at the end of the treatment (P < .05) and at any of the follow-up time points (P < .05). CONCLUSION: The eccentric-concentric training combined with isomentric contractions was the most effective treatment. Future well-designed studies are needed to confirm the results of the present trial. LEVEL OF EVIDENCE: III.

Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All.

Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by many proposed interventions and the condition's prognosis, ranging from immediate resolution of symptoms following simple advice in some patients to long-lasting problems, regardless of treatment, in others. This is compounded by our lack of understanding of the complexity of the underlying pathophysiology of LET. In this article, we collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears, or central sensitization, are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. A preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. Further research is needed to evaluate whether such an approach may lead to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.