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Background: Tennis elbow is a common condition that is estimated to affect 1% to 5% of the population in their lifetime. Despite its name, it is mainly work related, presenting with overuse pathology at the origin of extensor carpi radialis brevis (ECRB). Multiple treatment modalities are in common use, including the use of a forearm brace. Aim: To review the current knowledge of treating tennis elbow with forearm bracing, using biomechanical studies and clinical practice. Methods: A search was performed using Medline, Embase, and CINAHL libraries, using the terms tennis elbow or lateral epicondylitis, combined with the terms brace or strap or band. Articles related to forearm bracing were then limited to human studies, English language, published since 1991. The resulting studies were then further selected if comparing bracing to other physical therapy. Results: Biomechanical studies show that forearm bracing reduces the forces acting at the origin of ECRB, especially with braces that incorporate a pad directly over the belly of ECRB. This may come at a cost, however, with bracing reducing the grip and wrist extension strength during prolonged fatiguing exercise. The clinical studies present mixed results, with some showing a benefit of bracing over standard therapy, whereas others have found no difference or even a greater improvement with physical therapy without bracing. Systematic reviews have been unable to come to any conclusions with regard to the benefit of forearm bracing in tennis elbow. Conclusion: Although biomechanical studies show that forearm bracing has a direct effect on reducing the stresses at the origin of ECRB, clinical studies are more equivocal, and further trials are required to determine the usefulness of forearm bracing for tennis elbow in clinical practice.
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|TECHNIQUE |
Tennis Elbow Counterforce Bracing
Martin Kroslak, BSc(Med), MBBS and George A. C. Murrell, MD, DPhil
Sports Medicine and Shoulder Service
Orthopaedic Research Institute
St George Hospital Campus
University of New South Wales
Sydney, New South Wales, Australia
|ABSTRACT
Background: Tennis elbow is a common condition that
is estimated to affect 1% to 5% of the population in
their lifetime. Despite its name, it is mainly work
related, presenting with overuse pathology at the origin
of extensor carpi radialis brevis (ECRB). Multiple
treatment modalities are in common use, including the
use of a forearm brace.
Aim: To review the current knowledge of treating
tennis elbow with forearm bracing, using biomechanical
studies and clinical practice.
Methods: A search was performed using Medline,
Embase, and CINAHL libraries, using the terms tennis
elbow or lateral epicondylitis, combined with the terms
brace or strap or band. Articles related to forearm
bracing were then limited to human studies, English
language, published since 1991. The resulting studies
were then further selected if comparing bracing to other
physical therapy.
Results: Biomechanical studies show that forearm
bracing reduces the forces acting at the origin of ECRB,
especially with braces that incorporate a pad directly
over the belly of ECRB. This may come at a cost,
however, with bracing reducing the grip and wrist
extension strength during prolonged fatiguing exercise.
The clinical studies present mixed results, with some
showing a benefit of bracing over standard therapy,
whereas others have found no difference or even a
greater improvement with physical therapy without
bracing. Systematic reviews have been unable to come
to any conclusions with regard to the benefit of forearm
bracing in tennis elbow.
Conclusion: Although biomechanical studies show that
forearm bracing has a direct effect on reducing the stresses
at the origin of ECRB, clinical studies are more equivocal,
and further trials are required to determine the usefulness
of forearm bracing for tennis elbow in clinical practice.
Keywords: tennis elbow, lateral epicondylitis, brace,
treatment
Tennis elbow, also known as lateral epicondylitis or
epicondylosis, was first described in the late 19th
century by Runge.
1
The structure most commonly
affected in this condition is the origin of the extensor
carpi radialis brevis (ECRB) and, in some instances,
also the origin of extensor digiti communis.
2Y4
The
mechanism of injury is associated with overuse, not just
through racquet sports but any repetitive manual tasks
involving forceful gripping or rotation at the wrist.
2
The
main histological features of the enthesis of ECRB at
the humerus are immature fibroblasts and disorganized
matrix.
3,5,6
Many therapeutic modalities have been tried,
from exercises to steroid injections to surgery.
2
A
popular and noninvasive treatment strategy is the use
of a proximal forearm brace, also called a counterforce
brace (Fig. 1).
Despite its popularity during the last 30 years, it still
is not completely clear how counterforce bracing
actually worksVor whether it works. The general
principle behind many proposed treatments of tennis
elbow is to reduce the forces acting on the ECRB origin,
giving it time to recover. The forearm brace may
achieve this through several mechanisms. By compress-
ing the extensor bundle, the brace works by dispersing
and dampening some of the force away from the muscle
attachment, in effect creating a ‘‘secondary^origin
further distally. Also, by restricting the full muscular
expansion during the contraction, these braces may
diminish the potential force developed by the muscles at
the ECRB origin.
3
Some authors suggest that the brace
acts to enhance proprioception around the elbow, thus
improving the biomechanics at the joint.
7
The aim of
this article is to review the current literature in regard to
treating tennis elbow using forearm bracing.
|METHODS
Using Medline, Embase, and CINAHL libraries, the
combination of tennis elbow or lateral epicondylitis and
Techniques in Shoulder and Elbow Surgery 8(2):75–79, 2007 Ó2007 Lippincott Williams & Wilkins, Philadelphia
Address correspondence and reprint requests to George A. C. Murrell,
MD, DPhil, Department of Orthopaedic Surgery, St George Hospital
Campus, Kogarah, Sydney, New South Wales 2217, Australia (e-mail:
admin@ori.org.au).
Volume 8, Issue 2 75
Copyr ight © Lippincott Williams & Wilkins. Unauthoriz ed reproduction of this article is prohibited.
brace or strap or band was searched for. The results
were further limited to human studies in English,
published in the last 15 years. Those studies that did
not compare forearm bracing to other physical modal-
ities were discarded.
|RESULTS
Biomechanical Studies
To determine the biomechanical properties of the
various brace designs, several studies have been
performed on cadavers and healthy volunteers.
Chan and Ng
7
studied the effect of simple bracing
on unaffected volunteers with the brace set at different
tensions, from no brace to 5 kg of tension (free weights
were used to tighten the brace around a forearm). Their
findings were that bracing at any tension produced no
significant difference in strength, proprioception, or
stretch reflex latency of forearm extensor muscles but
did increase the passive stretch pain threshold in all the
brace applications. Repeating the study on volunteers
with lateral epicondylosis, they found that forearm
bracing improved wrist joint proprioception and in-
creased the pain threshold to passive stretching of the
wrist extensors, but there was no significant effect on
wrist extensor strength or stretch reflex latency.
8
In similar studies, Meyer and colleagues
9,10
evalu-
ated the effects of bracing on the force transmitted to the
ECRB origin. In the clinical arm of the study, 2
modified Aircast braces were applied at rest, and the
pressure increase at the proximal forearm during a
maximal grip test was measured using a pediatric blood
pressure cuff inserted into the Aircast brace ‘‘air
pocket.^A pressure within the brace at rest of 40 to
50 mm Hg resulted in the greatest increase of pressure
during a maximal grip from the at-rest value. At low
ECRB loads (5 lb distally), a brace applied at 50 mm Hg
reduced the force transmitted to the ECRB origin by
13% (Fig. 2). During a maximal grip test, this pressure
increased by up to 100 mm Hg, resulting in a reduction
of transmitted forces to the ECRB by 32%. The study
further compared 2 brace designs, a flat band versus one
with an air ‘‘pocket^directly over the ECRB belly. The
air pocket design consistently produced a pressure
increase of at least 33% more over the belly of ECRB
FIGURE 1. An example of a flat-design forearm brace.
FIGURE 2. Proximal force reduction related to brace
pressure and distal force in cadavers. A forearm brace
was applied at 4 different pressures and 3 different
weights attached to the ECRB tendon distally. The
percentage of force reduction at the origin of ECRB was
measured for each scenario. Adapted from J Hand Ther.
2002;15:179Y184. Original graph, adapted from Table 1,
page 181.
FIGURE 3. Brace pressure change related to brace type.
A flat or a pillow-type brace was applied to the proximal
forearm at increasing resting pressures, and the final
pressures measured during maximal grip. Adapted from
J Hand Surg [Am]. 2003;28:279Y287. Original graph,
adapted from Table 2, page 284.
Techniques in Shoulder and Elbow Surgery76
Kroslak and Murrell
Copyr ight © Lippincott Williams & Wilkins. Unauthoriz ed reproduction of this article is prohibited.
than the equivalent flat band, during the maximal grip
test (Fig. 3).
The relative value of braces with an extra pad over
the proximal forearm was evaluated in a study by
Walther et al,
11
who measured the vibration and
acceleration amplitudes of the forearm and elbow with
3 different braces: clasp type, pad over the epicondyle,
and pad over the forearm. The braces were applied
according to the manufacturers’ instructions, and 10
skilled healthy tennis players had the acceleration at the
racquet, wrist, and elbow measured while performing
‘ideal^backhand strokes (Fig. 4). The vibration and
acceleration results were plotted on a graph as a wave,
with stronger vibration producing larger peak-to-peak
deflections. All the braces reduced the peak-to-peak
acceleration and, therefore, the stress forces at the
elbow, with the most significant reduction of 46% with
the pad over forearm brace.
Counterforce braces may have a negative effect on
peak grip and wrist extension isometric forces during
prolonged activity. A study by Knebel et al
12
on 50
healthy army volunteers evaluated the effect of bracing
on grip and wrist extension force before and after
fatiguing exercise. They found that although the grip
and wrist extension forces after fatiguing exercise
decreased regardless of the intervention, wearing the
brace significantly reduced both the wrist extension
(26% reduction vs 15% reduction) and grip strength
(28% reduction vs 18% reduction) compared with
the nonbrace group after a bout of fatigue-inducing
exercise.
In summary, the biomechanical studies suggest that
bracing over the proximal forearm does reduce the
stresses at the ECRB origin,
9,10
especially with braces
that have some form of padding directly over the
ECRB,
11
but it comes at a cost in terms of wrist and
grip strength after fatiguing exercise.
12
Application of
the braces at 40 to 50 mm Hg is below diastolic blood
pressure and thus should not cause any swelling or
vascular compromise, but with maximal grip, the brace
pressure can go up to 150 mm Hg, which would
certainly result in obstruction of blood flow during
prolonged or strenuous exercise.
Single Application Studies
Testing the various brace designs in clinical practice,
Wuori et al
13
conducted a study on 50 patients with
tennis elbow, comparing 2 brace designs, a placebo
brace and no brace. In a one-off test, every patient
performed a pain-free maximum grip test and a visual
scale pain score with each brace situation sequentially,
with the sequence randomly allocated. There was no
significant difference between any of the situations on
either grip strength or pain; however, the pain was
greater during testing than before testing. This study has
obvious limitations in the lack of longer follow-up and
doing the tests sequentially (Fig. 5).
Clinical Trials
A retrospective cohort study of injured workers con-
ducted by Derebery et al
14
evaluated the outcomes of
more than 4500 patients with medial and lateral epi-
condylitis during the course of 18 months. The study did
not differentiate between the different types of splints
and braces, but in their outcome measures of limited
work, doctor and physiotherapy visits, and treatment
FIGURE 4. An example of a clasp-style brace, with a
small pad over the proximal belly of ECRB.
FIGURE 5. Maximal pain-free grip related to brace type.
The different braces were applied according to manufac-
turers’ instructions, and 3 averaged maximal pain-free
grips were performed and measured. The bracing and
measurements were performed on the patients’ affected
and unaffected arms for comparison. Adapted from
Arch Phys Med Rehabil. 1998;79:832Y837. Original
graph, adapted from Table 2, page 834.
Volume 8, Issue 2 77
Tennis Elbow Counterforce Bracing
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duration, patients treated with splints had statistically
significantly worse outcomes in all categories compared
with those without any splint or brace. Patients with
splints had up to 20% higher rate of limited duties at work
and had more medical visits, and the duration of their
treatment was on average 12 days longer.
In a prospective study using 185 patients, Solveborn
15
compared tennis elbow treated with stretching exer-
cises or with bracing in 2 separate consecutive groups.
From the first follow-up at 1 month onward, there was
a significant improvement in pain perception and
clinical examination findings in both groups, but with
a statistically much more favorable results in the
stretching group. Comparing the 2 groups for a follow-
up at 1 and 3 months shows a moderate effect, with
Cohen dof 0.57 and a 44% change between the groups
(Table 1).
In a smaller study, Clements and Chow
16
evaluated
the effect of adding counterforce bracing to the standard
therapy (ultrasound, ice, stretching, and strengthening
exercises) in 16 patients for 4 weeks. Using a handheld
dynamometer and visual analogue scales for pain and
function, they found statistically significantly greater
improvements in both pain (P= 0.05) and grip strength
(P= 0.025) in the group with the brace compared with
therapy alone. Function also improved in the brace
group but did not reach statistical significance.
Struijs et al
17
also compared braces to physical
therapy conducted in a blinded randomized trial on 180
patients with tennis elbow. The study compared 3
regimes: brace only, physiotherapy only, and combina-
tion of both. Physiotherapy consisted of 9 sessions for 6
weeks and included pulsed ultrasound and friction
massage, as well as an exercise and stretching program
to be done at home twice a day. At 6 weeks, the brace-
only group had better results for activities of daily
living, whereas the physiotherapy group did better at
pain, disability, and satisfaction. At 6 months and 1
year, there was no significant difference among the 3
groups in any of the outcomes.
|SYSTEMATIC REVIEWS
A Cochrane Database systematic review in 2002 found
that no definitive conclusions can be drawn in regard to
the usefulness of orthotic devices in tennis elbow.
18
This opinion was later supported by Borkholder et al
19
in their 2004 systematic review, who concluded that
current studies provide an early positive, but not
conclusive, evidence that bracing works in lateral
epicondylosis.
19
|SUMMARY
Biomechanical studies indicate that counterforce brac-
ing reduces the forces at the origin of ECRB, with this
effect being maximal using braces that include a pad
directly over the ECRB belly and in mild to moderate
exercise. However, prolonged fatiguing exercise with
the brace on leads to a reduction in wrist extension and
grip strength more so than without.
In clinical trials, the results are mixed. Some large
number studies comparing bracing to physiotherapy and
exercise found that although both groups improved
significantly from baseline, the long-term difference
between the groups was either nonsignificant or in favor
of the physical therapy. Smaller studies that evaluated
the additive effect of bracing on standard therapy found
an increase in functional improvement in the bracing
group. Systemic reviews of bracing in tennis elbow
concluded that further studies are required.
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TABLE 1. Pain response to stretching and forearm bracing
Stretching Brace Significance
0 months 49 T22 49 T22 NS
1 month 27 T21 39 T21 0.0003
3 months 20 T21 32 T21 0.0017
9 months 13 T18 19 T18 NS
Using a pain visual analogue scale from 0 to 100 mm, patients rated their pain at 0, 1, 3, and 9 months for groups treated with stretching and bracing.
Significance quoted is for difference between groups. Adapted from Scand J Med Sci Sports. 1997;7:229Y237. Original table, adapted from Fig. 3,
page 233.
Techniques in Shoulder and Elbow Surgery78
Kroslak and Murrell
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J Hand Ther. 2004;17:181Y199.
Volume 8, Issue 2 79
Tennis Elbow Counterforce Bracing
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... The lateral epicondylitis (LE) of the elbow pathology caused by injury of musculotendinous in the extensor carpi radialis brevis muscles, and can also affect the extensor digitorum communis (Garg et al. 2010;Nirschl and Ashman 2003;Kroslav and Murrel 2007) and in some cases affects the extensor carpi radialis longus (Freitas 2005), all in the level of their common origin at the lateral epicondyle. It is characterized by pain at the lateral epicondyle exacerbated with wrist extension, supination and grip strength (Garg et al. 2010;Struijs et al. 2005) and sensitivity in muscle mass proximal (Trudel et al. 2004). ...
... Despite of lateral epicondylitis is also referred to as "tennis elbow", is present in less than 5-10 % of players (Garg et al. 2010) and can appear in various tasks of excessive and repetitive effort involving movements gripping or pronation-supination (Garg et al. 2010;Kroslav and Murrel 2007;Anderson and Rutt 1992) as carpenters, surgeons, musicians, housewives (Anderson and Rutt 1992), occupations in construction, installation, manufacturing and feeding process (Trudel et al. 2004). There is a probability of 40-50 % of tennis players occur describe an annual incidence of 1-3 % in general population (Garg et al. 2010;Bauer and Murray 1999;Meyer et al. 2002). ...
... Thus, the principle behind many treatments is to reduce the force acting at the origin of the extensor muscles of the wrist allowing time for recovery to occur (Kroslav and Murrel 2007). Nirschl (2003) (2) promote the healing of tissue specific; (3) promote general fitness; (4) control of workload forces; (5) removal of the pathological tissue by surgery. ...
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Purpose The objective of this study was to evaluate the effectiveness of mobilization with movement and kinesiotherapy in the treatment of patients with lateral epicondylosis. Methods This cases series included eight volunteers who had chronic lateral epicondylosis. The patients were treated with stretching, massage deep transverse at the lateral epicondyle and mobilization with movement associated with eccentric exercise. The mobilization with movement that consisted of a force of lateral glide of the proximal forearm. We performed twelve sessions, twice a week for 45 min/session. All patients underwent an evaluation with a visual analog scale and functional assessment through questionnaires patient-rated tennis elbow evaluation (PRTEE) and disabilities of the arm, shoulder and hand (DASH), before and after the treatment. Data were analyzed by student’s t test (p < 0.05). Results The results showed statistical differences in pain symptoms before and after treatment, in the analysis and functional assessment through both questionnaires comparing the pre and post treatment. Conclusion The data obtained in this study demonstrates improvement of the function and pain status of the sample investigated.
... Wadsworth., et al. [34] suggested that use of the forearm support band caused decrease of the patients pain and subsequently decreased reflex inhibition of the wrist extensors that pain causes and allowed the patient to contract more forcefully. Biomechanical studies have shown that a forearm orthosis can decrease the forces acting at the ECRB origin if the pressure pad is placed over the belly of the ECRB, but tends to be more effective if the pressure pad is positioned distal to the lateral epicondyle [31,35]. ...
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Abstract Objective this study was done to assess the therapeutic efficacy of forearm support band and wrist splint in minimizing severity of pain and improving hand grip strength with lateral epicondylitis cases, and determine which one of these two common splints is more effective to reduce pain intensity and improve grip strength. Method: Thirty male and female patients with tennis elbow were selected from orthopedic Department at National instate of neurolocomotor system. All patients were randomly assigned into two groups. The group (A) (n = 15, mean age: 44.8 ± 6.87 years) received forearm support band for four weeks, while the group (B) (n = 15, mean age: 42.86 ± 6.34 years) received wrist splint. All patients received exercises (12 sessions, 3 sessions per week) over a four weeks period. They were evaluated using visual analog scale to determine the pain intensity, and handheld dynamometer to determine hand grip strength in both groups. Results: The results of the current study revealed that forearm support band or wrist splint combination with exercises for four weeks in patients with tennis elbow resulted in significant increase in hand grip strength in the post-treatment, associated with a significant decrease in pain intensity in the post-treatment in both groups. In addition, it revealed that there was significant difference between forearm support and wrist splint as regard to pain reduction which wrist splint allows a greater degree of pain relief than the forearm support band for patients with lateral epicondylitis, while there was no difference as regard to grip strength improvement between both groups. Conclusion: It was concluded that forearm support band or wrist splint (cock-up splint) combined with exercises were effective in improving pain intensity and increasing hand grip strength in patient with tennis elbow, and wrist splint allows a greater degree of pain relief than the forearm support band. Keywords: Lateral Epicondylitis; Exercises; Forearm Support Band; Wrist Splint
... Wadsworth., et al. [34] suggested that use of the forearm support band caused decrease of the patients pain and subsequently decreased reflex inhibition of the wrist extensors that pain causes and allowed the patient to contract more forcefully. Biomechanical studies have shown that a forearm orthosis can decrease the forces acting at the ECRB origin if the pressure pad is placed over the belly of the ECRB, but tends to be more effective if the pressure pad is positioned distal to the lateral epicondyle [31,35]. ...
Thesis
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Objective this study was done to assess the therapeutic efficacy of forearm support band and wrist splint in minimizing severity of pain and improving hand grip strength with lateral epicondylitis cases, and determine which one of these two common splints is more effective to reduce pain intensity and improve grip strength. Method: Thirty male and female patients with tennis elbow were selected from orthopedic Department at National instate of neu-rolocomotor system. All patients were randomly assigned into two groups. The group (A) (n = 15, mean age: 44.8 ± 6.87 years) received forearm support band for four weeks, while the group (B) (n = 15, mean age: 42.86 ± 6.34 years) received wrist splint. All patients received exercises (12 sessions, 3 sessions per week) over a four weeks period. They were evaluated using visual analog scale to determine the pain intensity, and handheld dynamometer to determine hand grip strength in both groups. Results: The results of the current study revealed that forearm support band or wrist splint combination with exercises for four weeks in patients with tennis elbow resulted in significant increase in hand grip strength in the post-treatment, associated with a significant decrease in pain intensity in the post-treatment in both groups. In addition, it revealed that there was significant difference between forearm support and wrist splint as regard to pain reduction which wrist splint allows a greater degree of pain relief than the forearm support band for patients with lateral epicondylitis, while there was no difference as regard to grip strength improvement between both groups. Conclusion: It was concluded that forearm support band or wrist splint (cock-up splint) combined with exercises were effective in improving pain intensity and increasing hand grip strength in patient with tennis elbow, and wrist splint allows a greater degree of pain relief than the forearm support band.
... At rest, we found an increase on the recruitment pattern with exception to ECU and EDC, the 2.5 cm orthoses. These findings agree with Snyder-Mackler [33] that reported reduced ECR and EDC electromyography activity with the Aircast TM brace. The data presented at this study corroborates with Ng and Chan study [17], showing increased activation of the muscles studied on maximum and sub maximum tasks, with exception to ECR with the narrowest non-articular proximal forearm orthoses (2.5 cm) during maximum grip. ...
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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.
... Biomechanical studies have shown that a forearm orthosis can decrease the forces acting on the ECRB origin if the pressure pad is placed over the belly of the ECRB. However, it tends to be more effective if the pressure pad is positioned distal to the lateral epicondyle (19,20). ...
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Background: Lateral epicondylitis is a common cause of pain and upper limb dysfunction. The use of counterforce straps for treatment of lateral epicondylitis is widespread. This kind of orthosis can be modified to have a greater effect on relieving pain by reducing tension on the origin of the extensor pronator muscles. Objectives: To determine the immediate effects of a newly designed orthosis on pain and grip strength in patients with lateral epicondylitis. Materials and methods: Twelve participants (six men and six women) were recruited (mean age = 41 ± 6.7 years) and evaluated for pain and grip strength in three sessions. A 48-hour break was taken between each session. The first session was without any orthosis, the second session was with the new modified tennis elbow orthosis, and the third session was with a conventional tennis elbow strap. Results: Both counterforce straps were effective. However, significantly more improvement was observed in pain and grip strength after using the newly modified orthosis (P < 0.05). Conclusions: The newly designed strap reduces pain more effectively and improves grip strength by causing greater localized pressure on two regions with different force applications (two component vectors versus one).
... Theoretically, because this limits the expansion of the extensor musculature in the proximal third of the forearm, it may diminish the force on vulnerable or sensitive areas. The brace generally has a width of five centimeters (cm) and is placed 4 to 5 (15) . ...
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Lateral epicondylitis, also known as tennis elbow, is a common condition that is estimated to affect 1% to 3% of the population. The word epicondylitis suggests inflammation, although histological analysis on the tissue fails to show any inflammatory process. The structure most commonly affected is the origin of the tendon of the extensor carpi radialis brevis and the mechanism of injury is associated with overloading. Nonsurgical treatment is the preferred method, and this includes rest, physiotherapy, cortisone infiltration, platelet-rich plasma injections and use of specific immobilization. Surgical treatment is recommended when functional disability and pain persist. Both the open and the arthroscopic surgical technique with resection of the degenerated tendon tissue present good results in the literature.
... 11 Decreasing forces on the origin of the ECRB is perceived to be a general principle of treatment of lateral epicondylitis. 12 As far back as 1882, Morris 13 suggested that symptoms of tennis elbow would soon disappear if supination and pronation of forearm was restricted for a few weeks. Other treatment options for tennis elbow include rest, injection therapy, physical therapy, non-steroidal anti-inflammatory drugs, shock wave therapy, orthotic treatment, ultrasound, and surgery. ...
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While the effectiveness of orthoses prescribed for tennis elbow has been reported in several studies, the effect of how they may limit movements which aggravate this condition has not yet been explored. The purpose of this study was to evaluate the effect of a new spiral hand-forearm splint that restricts the movement of the wrist and forearm, on grip strength, pain, and function in patients with tennis elbow. Quasi-experimental design. A total of 15 patients with tennis elbow (mean age 43 years) took part in this study. The amount of pain, grip force, and function were compared using a visual analog scale, Jamar dynamometer, and the Disability of the Arm, Shoulder, and Hand questionnaire, respectively. This was performed at baseline and repeated after 4 weeks of splint use. Active motion of the forearm was measured by a goniometer. The spiral splint significantly relieved pain and improved function and grip force in patients after 4 weeks of application (P < 0.05). The new splint design had a positive effect on the treatment of tennis elbow symptoms which included pain, grip strength, and function. Restriction of rotational movement (e.g. reduction of the supination and pronation of forearm) may have played the main role in this. This new splint design may be considered as a new approach in the conservative treatment and rehabilitation of patients with tennis elbow. © The International Society for Prosthetics and Orthotics 2015.
... The brace generally has a width of five centimeters (cm) and is placed 4 to 5 cm distally to the epicondyle. Although there is some evidence that it is effective from a biomechanical point of view, there is not such evidence from a clinical point of view, as demonstrated by Kroslak and Murrell (15) . ...
Article
Full-text available
Lateral epicondylitis, also known as tennis elbow, is a common condition that is estimated to affect 1% to 3% of the population. The word epicondylitis suggests inflammation, although histological analysis on the tissue fails to show any inflammatory process. The structure most commonly affected is the origin of the tendon of the extensor carpi radialis brevis and the mechanism of injury is associated with overloading. Nonsurgical treatment is the preferred method, and this includes rest, physiotherapy, cortisone infiltration, platelet-rich plasma injections and use of specific immobilization. Surgical treatment is recommended when functional disability and pain persist. Both the open and the arthroscopic surgical technique with resection of the degenerated tendon tissue present good results in the literature.
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Background Lateral elbow tendinopathy, also known as “tennis elbow” or “lateral epicondylitis,” is a common disease leading to pain in the lateral side of the elbow and disability during hand gripping. A counterforce brace is one of the most conventional treatments. However, its effects on outcomes remain inconclusive. Objectives To investigate the effects of counterforce braces on pain in subjects with lateral elbow tendinopathy. Grip strength was reviewed as a secondary outcome. Study design Systematic review and meta-analysis of randomized controlled trials. Methods PubMed, Embase, Scopus, Web of Science, CENTRAL, PEDro, ProQuest, RECAL, and RehabData were searched from January 1, 1995, through June 15, 2019. Results Seventeen studies were included with a total of 1145 participants. A small improvement in pain over the short term (standardized mean difference −0.02; 95% confidence interval: −0.85 to 0.80) and a moderate-to-large improvement in pain in subjects 45 years or younger (standardized mean difference −0.86; 95% confidence interval: −2.45 to 0.72) in favor of the brace versus physiotherapy interventions were found. In contrast, over the long-term physiotherapy interventions (standardized mean difference 1.17; 95% confidence interval: −0.00 to 2.34), wrist splint (standardized mean difference 0.35; 95% confidence interval: −0.07 to 0.76), and laser therapy (standardized mean difference 0.58; 95% confidence interval: −0.44 to 1.59) had better effects on pain improvement versus the brace. Conclusion The results indicated that physiotherapy interventions compared to counterforce braces have better effects, especially over the long-term. However, counterforce braces may have better effects on pain in younger people (<45 years old) over the short term (<6 weeks). Clinical relevance The results suggest that counterforce bracing is a reasonable strategy to alleviate pain over the short term. However, the subgroup analysis suggests that factors such as age may have a role in their effectiveness.
Article
Background Counterforce orthoses are used to manage lateral elbow tendinopathy, and their effectiveness in improving motor function has been documented. Little is known about the impact of bracing on sensory function. The objective of this study was to investigate the immediate effectiveness of 2 counterforce orthoses in improving the sensorimotor abilities of the hand in patients with lateral elbow tendinopathy. Methods In this crossover, randomized controlled trial, elbow proprioception, pain severity, pain-free grip strength, and finger dexterity were measured in 50 participants with a diagnosis of lateral elbow tendinopathy. Outcomes were measured in 3 randomized conditions (no brace, forearm band, or elbow sleeve). Data were analyzed using 1-way repeated-measures analysis of variance for each outcome measure. Results Better scores were observed with the forearm band, as compared with no orthosis, for multiple outcomes including joint position reproduction score at 70° of elbow flexion (P = .006), pain (P < .001), grip strength (P = .01), and dexterity (P < .001). The elbow sleeve yielded better scores than no orthosis for the following outcomes: joint position reproduction score at 110° (P < .001), pain (P < .001), and grip strength (P = .012). No statistically significant difference was found between the orthoses' effects on pain reduction and grip strength (P > .05). The forearm band showed better scores on joint position reproduction at 70° compared with the elbow sleeve (P = .006), whereas the elbow sleeve showed better scores at 110° (P < .001). Conclusion Our results support the mechanisms occurring with the use of either of the described orthotic interventions. Future randomized trials with longer-term outcomes that include sensorimotor mechanisms might enhance our understanding of the comparative effectiveness.
Article
Background The authors evaluated the effectiveness of brace-only treatment, physical therapy, and the combination of these for patients with tennis elbow. Methods Patients were randomized over 3 groups: brace-only treatment, physical therapy, and the combination of these. Main outcome measures were success rate, severity of complaints, pain, disability, and satisfaction. Data were analyzed using both intention-to-treat and per-protocol analyses. Follow-up was 1 year. Results A total of 180 patients were randomized. Physical therapy was superior to brace only at 6 weeks for pain, disability, and satisfaction. Contrarily, brace-only treatment was superior on ability of daily activities. Combination treatment was superior to brace on severity of complaints, disability, and satisfaction. At 26 weeks and 52 weeks, no significant differences were identified. Conclusion Conflicting results were found. Brace treatment might be useful as initial therapy. Combination therapy has no additional advantage compared to physical therapy but is superior to brace only for the short term.
Article
The purpose of the study was to determine the effectiveness of a custom-made below elbow lateral counterforce splint along with standard physiotherapy compared with physiotherapy alone, for the treatment of lateral epicondylitis. It was hypothesized that the recovery from lateral epicondylitis is greater following four weeks of standard physiotherapy and the use of the splint, than following four weeks of standard physiotherapy alone. The experimental group (with the splint and physiotherapy) demonstrated a significant improvement in pain (p = 0.05) and maximum grip strength (p = 0.025) of the affected arm compared to the control group. The experimental group showed a greater improvement in function approaching but not reaching significance. The results indicate that this custom-made splint is of value in facilitating the recovery from lateral epicondylitis.
Article
Tennis elbow (lateral epicondylitis) is the pattern of pain most commonly seen at the origin of the wrist extensors from the lateral epicondyle of the humerus and less commonly seen at the origin of the flexor-pronator from the medial epicondyle. This article discusses methods of diagnosis and both conservative and operative treatment techniques.
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Tennis elbow occurs as a result of repetitive microtrauma to the musculotendinous unit causing inflammatory and degenerative tissue damage. A good understanding of the aetiology and pathoanatomy will aid the clinician in preventing and recognising this condition. Early recognition with a quality rehabilitative programme, and the judicious use of surgical intervention usually results in full recovery and excellent functional outcomes.
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Stretching or upper forearm bands were used in the treatment of radial epicondylalgia ('tennis elbow') in a prospective study of 185 patients. The two consecutive series did not differ with respect to, for example, age (median 43 years), gender (57% men), symptom duration (mean 12 months) and symptomatic elbow (68% right), and were examined before and after 1 month of treatment, then at 3 and 9 months, and at a long-term follow-up (44/33 months). The 94 stretching-treated patients were instructed to perform home exercises twice daily, but were also treated at six physiotherapist sessions the first month. The other 91 patients were told to use a prescribed proximal forearm band in daily activities as much as possible. Both treatments were successful with a continuous symptom reduction, but the outcome was statistically significant in favour of stretching at all follow-ups, as assessed by subjective evaluation on a visual analogue pain scale, tabulated pain and condition alternatives on questionnaires, and objective findings such as palpation tenderness at the radial epicondyle, the (Mills') 'tennis elbow pain test', and range-of-motion. Practically all measured range-of-motions were restricted in both groups before treatment and did increase with stretching during the follow-up period, while the various changes in the forearm band group were statistically non-significant.
Article
To determine the effect of bracing on measures of pain-free grip strength and pain scores in individuals with unilateral lateral epicondylitis through a comparison of two elbow braces, a placebo brace, and a no-brace situation. Repeated-measures design in which the subjects acted as their own controls. A clinical research laboratory at a hand and upper limb clinic. Fifty individuals diagnosed by a physician with unilateral lateral epicondylitis, having symptoms for at least 3 weeks, were recruited from the community. The braces studied were the Count'R-Force Tennis Elbow Brace, the Body Glove Airprene Elbow Support, and a placebo brace that consisted of a modified DePuy Levy Clinic Patella Strap. Pain-free grip strength measured using an NK Biotechnical Corporation Hand Assessment System DIGIT-grip Device and pain scores measured on a visual numeric rating scale. No significant differences in pain-free grip strength or pain were observed between any of the test situations (p > .05). Pain during the test, however, was greater than pain before or after the test (p < .05). When tests were completed on one occasion with the brace on, no advantages of elbow bracing were detected. Whether bracing is effective when used as a treatment technique for an extended period of time should be addressed in future research.
Article
Tendon injuries can be divided into several categories on the basis of the nature of their onset and the tissues involved. Acute tendon injuries, such as laceration of the flexor tendons of the fingers, are traumatic in nature. Chronic overuse injuries are the result of multiple microtraumatic events that cause disruption of the internal structure of the tendon and degeneration of the cells and matrix, which fail to mature into normal tendon; at times, such injuries result in tendinosis35. The healing of acute tendon injuries has been studied from the perspective of the body's response to lacerations of flexor tendons as well as after operative intervention35,67. Tendinosis is incompletely understood. Although the term tendinitis is used frequently and often indiscriminately, histopathological studies have shown that specimens of tendon obtained from areas of chronic overuse do not contain large numbers of macrophages, lymphocytes, or neutrophils26,35,59. Rather, tendinosis appears to be a degenerative process that is characterized by the presence of dense populations of fibroblasts, vascular hyperplasia, and disorganized collagen. This constellation of findings has been termed angiofibroblastic hyperplasia48. It is not clear why tendinosis is painful, given the absence of acute inflammatory cells, nor is it known why the collagen fails to mature. If it can be assumed that tendinosis has essentially the same pathogenesis regardless of where it occurs in the body, then the examination of specimens from patients who have tennis elbow can serve as a model for the investigation of pain in other regions in which tendinosis has been reported, such as the rotator cuff, the Achilles tendon, the patellar ligament, the adductors of the hip, the triceps, the flexors and extensors of the elbow, and the plantar fascia7,26,27 …
Article
A crossover experimental design with repeated measures. To determine whether the forearm support band alters wrist extensor muscle fatigue. Fatigue of the wrist extensor muscles is thought to be a contributing factor in the development of lateral epicondylitis. The forearm support band is purported to reduce or prevent symptoms of lateral epicondylitis but the mechanism of action is unknown. Fifty unimpaired subjects (36 men, 14 women; mean age = 29 +/- 6 years) were tested with and without a forearm support band before and after a fatiguing bout of exercise. Peak wrist extension isometric force, peak isometric grip force, and median power spectral frequency for wrist extensor electromyographic activity were measured before and after exercise and with and without the forearm support band. A 2 x 2 repeated measures multivariate analysis of variance was used to analyze the data, followed by univariate analysis of variance and Tukey's multiple comparison tests. Peak wrist extension isometric force, peak grip isometric force, and median power spectral frequency were all reduced after exercise. However, there was a significant reduction in peak grip isometric force and peak wrist extension isometric force values for the with-forearm support band condition (grip force 28%, wrist extension force 26%) compared to the without-forearm support band condition (grip force 18%, wrist extension force 15%). Wearing the forearm support band increased the rate of fatigue in unimpaired individuals. Our findings do not support the premise that wearing the forearm support band reduces muscle fatigue in the wrist extensors.
Article
Lateral epicondylitis (tennis elbow) is a frequently reported condition. A wide variety of treatment strategies has been described. As of yet, no optimal strategy has been identified. To assess the effectiveness of orthotic devices for the treatment of tennis elbow. We searched Medline, Embase, CINAHL, the Cochrane Controlled Trial Register, Current Contents up to May 1999 and reference lists from all retrieved articles. Experts on the subjects were approached for additional trials. All randomised clinical trials (RCT) describing individuals with diagnosed lateral epicondylitis and comparing the use of an orthotic device as a treatment strategy were evaluated for inclusion. Two reviewers independently assessed the validity of the included trials and extracted data on relevant outcome measures. Dichotomous outcomes were expressed as Relative Risks (RRs) and continuous outcomes as Standardised Mean Differences (SMD), both with corresponding 95% confidence intervals (95% CI). Statistical pooling and subgroup analyses were intended Five RCTs (N per group 7-49) were included. Validity score ranged from 3-9 positive items out of 11. Subgroup analyses were not performed due to the small number of trials. The limited number of included trials present few outcome measures and limited long-term results. Pooling was not possible due to large heterogeneity amongst trials. No definitive conclusions can be drawn concerning effectiveness of orthotic devices for lateral epicondylitis. More well-designed and well-conducted RCTs of sufficient power are warranted.
Article
The purpose of the study was to investigate the biomechanical effects of different types of braces that are used in the treatment of patients with epicondylitis radialis. Vibration and acceleration of the forearm and the elbow were measured with sensors taped to defined anatomic points on the skin surface. The impact-induced vibration of the racket-arm system was analyzed while the subjects were playing tennis. Different designed brace systems were investigated with respect to acceleration amplitudes and acceleration integrals. Clasp-based brace systems showed a slight reduction of acceleration amplitudes (-6%) and acceleration integrals (-8%). Braces with pads at the lateral epicondyle reduced acceleration amplitudes by 20% and acceleration integrals by 22%. Braces with pads placed at the forearm showed the highest reduction of acceleration amplitudes (-46%) and acceleration integrals (-42%). Overload of the wrist extensors, which is considered to be a major pathogenic factor in lateral epicondylitis, can be reduced by braces. There is a significant difference in the effects among different biomechanical principles of braces.