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Tennis Elbow (Lateral Epicondylitis)

Authors:
Benjamin K Buchanan
Benjamin K Buchanan
Matthew Varacallo at Penn Highlands Healthcare System
Matthew Varacallo
  • Penn Highlands Healthcare System
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Abstract

Lateral epicondylitis, also commonly referred to as tennis elbow, describes an overuse injury secondary to eccentric overload of the common extensor tendon at the origin of the extensor carpi radialis brevis (ECRB) tendon.[1][2]
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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.
Tennis Elbow (Lateral Epicondylitis)
Authors
Benjamin K. Buchanan ; Matthew Varacallo .
Affiliations
William Beaumont Army Medical Center
Department of Orthopaedic Surgery, University of Kentucky School of Medicine
Last Update: January 20, 2019.
Introduction
Lateral epicondylitis, also commonly referred to as tennis elbow, describes an overuse injury secondary to eccentric
overload of the common extensor tendon at the origin of the extensor carpi radialis brevis (ECRB) tendon.[1][2]
Etiology
Tennis elbow is often an overuse injury primarily due to repetitive strain from tasks and activities that involve loaded
and repeated gripping and/or wrist extension. It historically occurs in tennis players but can result from any sports that
require repetitive wrist extension, radial deviation, and/or forearm supination. It is also seen in athletes who play
squash and badminton and other sports or activities that require similar movements. As it relates to athletes, this
condition is often precipitated by poor mechanics and technique or improper equipment.[3]
Epidemiology
Tennis elbow is the most common cause of elbow symptoms in patients presenting with elbow pain in general. The
condition tends to affect men and women equally. The annual incidence is one to three percent in the United States.
Despite the condition being commonly referred to as tennis elbow, tennis players make up only 10% of the patient
population. Half of tennis players develop pain around the elbow, of which 75% represent true tennis elbow. It is more
common in individuals older than 40 years of age. Smoking, obesity, a repetitive movement for at least two hours
daily, and vigorous activity (managing physical loads over 20 kg) are risk factors in the general population for the
development of this condition. The natural course of the condition is favorable with spontaneous recovery within one
to two years in 80% to 90% percent of the patients.[4][5][4]
Pathophysiology
This condition is primarily a degenerative overuse process of the extensor carpi radialis brevis and common extensor
tendon. Aside from degenerative changes, the histological findings include granulation tissue, micro-rupture, an
abundance of fibroblasts, vascular hyperplasia, unstructured collagen, and notably a lack of traditional inflammatory
cells (macrophages, lymphocytes, neutrophils) within the tissue. The term has been previously described as
angiofibroblastic dysplasia based on multiple histologic studies describing its microscopic appearance and
characteristics [6][7]. Ultrasound evaluation often reveals calcifications, intrasubstance tears, marked irregularity of
the lateral epicondyle, and thickening and heterogeneity of the common extensor tendon.[8]
Histopathology
Multiple studies reporting the histologic appearance of pathologic ECRB specimens characterize any combination of
1 2
1
2
the following characteristics: [7]
hypertrophic or abundant fibroblasts
collagen disorganization
vascular hyperplasia
lack of inflammatory cells
History and Physical
Patients will typically report pain with an insidious onset but upon further questioning will often relate an overuse
history without a specific inciting traumatic event. The pain commonly occurs one to three days after unaccustomed
activity that involves repeated wrist extension.
In an athlete, the history may reveal new equipment use or an atypical workout circumstance such as an abnormally
intense or prolonged workout. This condition can also be precipitated by an acute injury or strain such as lifting a
heavy object or performing a hard backhand swing in tennis. This acute injury can lead to a more chronic process (i.e.
acute-on-chronic overuse injury). The pain is usually over the lateral elbow that worsens with activity and improves
with rest. The pain can vary from being mild, for example, with aggravating activities like tennis or the repeated use
of a hand tool, or it can be such severe pain that simple activities like picking up and holding a coffee cup or a coffee
cup sign will act as a trigger for the pain.
On examination, the point of maximal tenderness is usually over the lateral epicondyle, occasionally in a focal, distal
location about 1 cm to 2 cm from the lateral epicondyle itself. Palpation of the entire tendon may have some degree
and discomfort, and the connecting muscle may exhibit significant tightness. The patient’s pain will increase or be
reproduced with resisted wrist extension, especially when the elbow is extended and the forearm is pronated. Resisted
extension of the middle finger, while the elbow is extended, is particularly painful secondary to increased stress
placed on the tendon, further supporting the diagnosis. Notably, there should be an absence of radicular symptoms or
numbness/tingling. These symptoms suggest an alternative process such as a radial nerve entrapment although these
conditions can coexist[9].
Evaluation
Lateral epicondylitis is a clinical diagnosis and imaging is often not necessary. A provider may consider obtaining
elbow radiographic series (anteroposterior and lateral) if other injuries or conditions are suspected by history and/or
physical exam. Other conditions warranting potential imaging workup include evaluating for concomitant
degenerative joint changes, fractures, tumors, or bursitis. If the patient is not responding to nonoperative
management modalities, then the provider may consider ordering an MRI or ultrasound to evaluate for tears, stress
fractures, or osteochondral defects.[10]
Treatment / Management
Nonoperative management
First line management for the management of lateral epicondylitis includes rest from offending activity as guided by
the level of pain. Ice after activity and oral/topic NSAIDs can be used to help with pain control. Forearm
counterforce straps ("Cho-Pat" straps) are prescribed to relieve tension at the lateral epicondyle. These should be worn
during activity. The role of cho-pat straps is relatively controversial as some patients may report pain over the area of
maximal tenderness secondary to direct mechanical compression on the area itself. Brace use in the form of a cock-
up wrist splint should be prescribed to take stress off of the wrist extensors [9].
Occupational therapy with a focus on forearm stretching and strengthening and progression to eccentric muscle
strengthening of the common extensor tendon has also shown to be helpful. If pain does not respond to conservative
measures, then consider more advanced or invasive techniques such as topical nitrates, botulinum toxin, autologous
platelet-rich plasma, and dextrose prolotherapy.
Surgical management
Surgery should be considered as a last resort in the management of lateral epicondylitis. Prolonged
nonoperative management (i.e. 6- to 12-months) should be attempted prior to considering surgical management.
Specific surgical techniques utilized vary throughout the literature. Most surgeons prefer varying degrees of ECRB
debridement and/or release of the tendinous origin at the lateral epicondyle. In the setting of the surgeon electing
to forego an actual ECRB detachment, a generous debridement should be performed at the ECRB origin
with confirmation of debridement of the pathologic tissue and stimulation of a healthy, bleeding, bony bed of tissue at
the lateral epicondyle to help stimulate healing potential.[11][12]
Differential Diagnosis
The differential diagnosis for lateral epicondylitis includes, but is not limited to, any of the following conditions: [13]
Elbow bursitis
Cervical radiculopathy
Posterolateral elbow plica
Posterolateral rotatory instability (PLRI)
Radial nerve entrapment
Radial tunnel syndrome
palpation 3-4 cm distal and anterior to the lateral epicondyle
pain with resisted third-finger extension
pain with resisted forearm supination
Occult fracture(s)
Capitellar osteochondritis dissecans
Triceps tendinitis
Radiocapitellar osteoarthritis
Shingles
Complications
Failing to address concomitant pathology
patients report inferior outcomes and lack of improvement if the primary cause of symptoms is not
addressed; patients should be educated regarding the risks and benefits of surgery -- the former include
but are not limited to infection, blood loss, neurovascular injury, continued pain, stiffness, or continued or
1.
worsening overall dysfunction
radial nerve entrapment can be missed or not addressed clinically in up to 5% of patients being managed
for lateral epicondylitis
Iatrogenic LUCL injury
occurs iatrogenically with increased risk if the surgical dissection extends beyond the radial head equator
postoperative iatrogenic posterolateral rotatory instability (PLRI) can develop if the extension or LUCL
compromise is significant
Iatrogenic neurovascular injury
radial nerve injury
Heterotopic ossification
decrease risk with via copious saline irrigation following decortication and debridement
Infection
Pearls and Other Issues
After diagnosis, patient education, and a prescription for conservative treatment, patients can typically follow-up, as
needed. Sometimes more chronic cases will need additional follow-up to consider more advanced therapies. Posterior
interosseous nerve entrapment (radial tunnel syndrome) may coexist in up to 15% of cases. Keep this diagnosis in
mind as a coexisting condition or alternative diagnosis if radicular symptoms are present. Corticosteroid injections
have been shown to be beneficial in the short-term (less than six weeks) but ineffective in the long term. Topical
nitrates are thought to increase blood flow to the area and as a result, promote healing to the tendon. There has been
some suggestion that extracorporeal shockwave therapy can be used to treat this condition chronically. Although,
there have been no significant improvements using this therapy thus far. Although evidence has been mixed, platelet-
rich plasma and dextrose prolotherapy are pro-inflammatory agents that are designed to cause inflammation or
irritation to the tendon and trigger a healing response. Platelet rich plasma seems to have better evidence to date as
compared to dextrose prolotherapy. Most notably patients with chronic pain due to this condition report decreased
levels of pain and increased levels of functionality compared to corticosteroid injections.[14][15]
Enhancing Healthcare Team Outcomes
Tennis elbow is very common in society and can occur from many types of racquet sports including golf. Most
patients present to the primary care provider with pain around the elbow and the key is patient education. One has to
adopt good habits like stretching before taking part in the intense physical activity. In addition, when the pain comes
on, it is important to rest the hand. Nurses and physicians in a sports clinic should emphasize the importance of
improving muscle strength and conditioning. In addition, one has to use proper equipment.
With rest, the majority of patients with tennis elbow improve within 3-18 months. Surgery is rarely required. [16]
Questions
To access free multiple choice questions on this topic, click here.
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Copyright © 2018, StatPearls Publishing LLC.
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Bookshelf ID: NBK431092 PMID: 28613744
... It is described as an overuse injury mainly because of repeated strain from jobs and activities involving loaded and repeated gripping and/or wrist extension. (Buchanan & Varacallo, 2024) Inflammation is present during very early stages of LE. After inflammation, there is an appearance of the vascular hyperplasia and active fibroblasts. ...
... (Brummel et al., 2014) It is important to remember that lateral elbow pain can be caused by many other conditions such as elbow bursitis, radial nerve entrapment, triceps tendinitis, occult fracture, synovial plica, osteochondritis dissecans of the capitellum, radiocapitellar arthrosis, radial tunnel syndrome, cervical radiculopathy, and posterolateral rotatory instability. (Brummel et al., 2014;Buchanan & Varacallo, 2024) ...
... We intend to provide a better uptake of managing this condition. Treatment options will be presented sequentially to more advanced methods, all summarized in the Tabl. 1. Tabl. 1 Comparison of Treatment Methods (Altay et al., 2002;Assendelft et al., 1996;Baker & Baker, 2008;Baker & Shalvoy, 1991;Baumgard & Schwartz, 1982;Brummel et al., 2014;Buchanan & Varacallo, 2024;Buchbinder et al., 2008;Buchbinder et al., 2005;Burn et al., 2018;Coonrad & Hooper, 1973;Creaney et al., 2011;Cutts et al., 2020;Cyriax, 1936;Dunn et al., 2008;Garg et al., 2010;Gosens et al., 2011;Haake et al., 2002;Halpern et al., 2012;Hayton et al., 2005;Jafarian et al., 2009;Kalichman et al., 2011;Kazemi et al., 2010;Lo & Safran, 2007;McCallum et al., 2011;Mills, 1928;Murrell, 2007;Nazar et al., 2012;Nirschl & Pettrone, 1979;Paoloni et al., 2003;Peerbooms et al., 2010;Szabo et al., 2006;Wolf et al., 2011;Wong et al., 2005;Zhou & Wang, 2020) ...
Approaches to Treating Tennis Elbow: Surgical vs. Conservative Treatment
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Full-text available
  • Nov 2024
Introduction Tennis Elbow, known also as Lateral Epicondylitis (LE) is a very common overuse injury affecting not only tennis players. Mainly, it causes pain, weakness in grip strength and difficulties with daily activities. Most patients are successfully treated with non-surgical methods but some of them eventually require surgical intervention. Aim of study The objective of this study is to evaluate both surgical and non-surgical treatment methods for Tennis Elbow and seeks to introduce doctors and patients to the assets and downsides associated with them. State of Knowledge Tennis Elbow occurs in 1-3% of adults, most likely when frequently performing repeated movements of flexion and extension of the elbow. At the early stages inflammation is present, after that the vascular hyperplasia and active fibroblasts occur. Most common risk factors are manual labour, ipsilateral rotator cuff tear, ipsilateral Carpal Tunnel Syndrome (CTS), female sex, dominant-side involvement, and hypertriglyceridemia. Summary (Conclusion) There is a wide range of available conservative treatment methods for Lateral Epicondylitis including physical therapy, various injections, and medication. They should be considered as the first line treatment showing high success rate for mild and moderate cases. Surgical methods have high success rates as well though they are considered more invasive and performed only on chronic patients. Best approach ought to be carefully selected for each patient based on severity of symptoms and patient needs.
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... Sports injuries can be of two types: acute and chronic, i.e., due to repeated microtraumas. Acute injuries are generally due to high-energy trauma, such as anterior cruciate ligament injuries that occur in football, whereas microtrauma injuries are typical of all the sporting activities characterized by a repeated gesture over time, such as tendinopathy of the swimmer's rotator cuff [58] or the epicondylitis of the tennis elbow [59] or the golfer's epitrochleitis [60]. The main causes of acute and chronic traumatic events are attributable to three types of dynamics, such as the following: conflict between athletes in sports with predominant physical contact (football 53%, wrestling 42%, and rugby 40%); accidental falls that can occur in sports that involve the use of mechanical and non-mechanical equipment (motorcycling 73% and cycling 59%); and twisting and strain of the limbs in individual sports where the aid of external agents is not required (volleyball 46% and gymnastics 37%) [61]. ...
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The hemostatic system is characterized by a delicate balance between pro- and anticoagulant forces, and the smallest alteration can cause serious events such as hemorrhages or thrombosis. Although exercise has been shown to play a protective role in athletes, several factors may increase the risk of developing venous thromboembolism (VTE), including hemoconcentration induced by exertion, immobilization following sports injuries, frequent long-distance flights, dehydration, and the use of oral contraceptives in female athletes. Biomarkers such as D-dimer, Factor VIII, thrombin generation, inflammatory cytokines, and leukocyte count are involved in the diagnosis of deep vein thrombosis (DVT), although their interpretation is complex and may indicate the presence of other conditions such as infections, inflammation, and heart disease. Therefore, the identification of biomarkers with high sensitivity and specificity is needed for the screening and early diagnosis of thromboembolism. Recent evidence about the correlation between the intensity of physical activity and VTE is divergent, whereas the repeated gestures in sports such as baseball, hockey, volleyball, swimming, wrestling, or, on the other hand, soccer players, runners, and martial art training represent a risk factor predisposing to the onset of upper and lower DVT. Anticoagulant therapy is the gold standard, reducing the risk of serious complications such as pulmonary embolism. The aim of this review is to provide a general overview about the interplay between physical exercise and the risk of thromboembolism in athletes, focusing on the main causes of thrombosis in professional athletes and underlying the need to identify new markers and therapies that can represent a valid tool for safeguarding the athlete’s health.
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... The structure most often damaged is the extensor carpi radialis brevis (ECRB) tendon. A chronic aseptic inflammatory status of this tendon is caused by repeated microtrauma and is the most common cause of musculoskeletal pain in the elbow [2]. ...
The Clinical Results of Percutaneous Drilling in the Treatment of Chronic Lateral Epicondylitis
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Full-text available
  • Jul 2024
Aim: Lateral epicondylitis is one of the leading orthopedic problems encountered in daily practice. Treatments are more symptomatic than curative. Percutaneous drilling is a minimally invasive method that provides satisfactory results. The aim of this study was to evaluate patients who had undergone percutaneous drilling for chronic lateral epicondylitis. Material and method: The study included 31 patients who underwent surgical percutaneous drilling because of chronic lateral epicondylitis between 2018 and 2021. The patients were evaluated with respect to demographic characteristics, including age, gender, body mass index (BMI), occupation, education level, hobbies, dominant side, and smoking status. The VAS (Visual Analog Scale) pain scores, PRTEE score (Patient-Rated Tennis Elbow Evaluation - a lateral epicondylitis function scale), and Roles-Maudsly score were examined preoperatively and at one and 12 months postoperatively together with grip strength measured with a Jamar hand dynamometer. Results: Statistically significant improvements were determined in the VAS score during activity from 8.9 preoperatively to 2.06 at 12 months postoperatively (p<0.01), and in the PRTEE score, from 64.12 preoperatively to 20.61 at 12 months postoperatively (p<0.01). The Roles-Maudsly score at 12 months postoperatively was determined to be excellent in 13 (41.9%) patients, and good in 14 (45.2%). Mean grip strength increased from 69.55 before treatment to 90.97 at the end of 12 months postoperatively. Conclusion: Autobiological treatments are at the forefront of current treatments for tendinopathies. Percutaneous drilling is a closed method and can be considered an ideal method in the treatment of tendinosis caused by inflammation and mesenchymal stem cells (MSCs) contained in hematoma. It is also an advantageous treatment method for patients with aesthetic concerns as it does not leave any scar tissue and has a low risk of complications.
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... Musculoskeletal ultrasound examination reveals increased calcification, increase in heterogeneity, and thickening observed in common extensor tendons and marked irregularity of lateral epicondyle. [7,8] Subjects with LE are unable to perform normal functional tasks such as holding and gripping activities. LE patient presents with pain and local tenderness along and distal to the lateral epicondyle of the elbow joint and limited functional activities. ...
Comparison of active release and post-isometric relaxation techniques on functional performance in patients with chronic lateral epicondylitis
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Full-text available
  • Jun 2024
Lateral epicondylitis (LE) occurs as a result of repetitive strain near the place of origin of the extensor carpi radialis brevis tendon. This is due to eccentric overload and repetition, causing chronic degeneration of the forearm’s common extensor tendons, which are attached to the lateral epicondyle of the humerus. This study aimed to assess the comparative effects of post-isometric relaxation (PIR) and active release techniques (ARTs) on pain inhibition, grip strength, and functional ability among individuals suffering from chronic LE. A randomized clinical trial was conducted on 30 individuals suffering from chronic LE. All of the subjects were randomly assigned to one of two treatment groups: PIR method or active release approach. Both groups received 12 sessions over four weeks. The numerical pain rating scale (NPRS), handheld dynamometer, and patient-rated tennis elbow evaluation (PRTEE) were used to assess the impacts of therapy before and after treatment sessions. The results showed that the NPRS pain score, strength of the grip, and functional performance all showed substantial differences between the two groups (P < 0.05) as well as within-group differences (P < 0.05). The study concluded that PIR techniques were more effective as compared to ARTs for pain reduction, improved strength of gripping, enhanced functionality, and showed better outcomes in terms of mean difference of NPRS, dynamometer, and PRTEE scoring across the groups.
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... LE can be found in 1% to 3% of the general population and increases in older people, smokers, people who are obese, and those with heavy repetitive activities. 8 Most LE cases can resolve spontaneously or with conservative treatment. However, up to 10% of patients do not respond to conservative treatment. ...
Comparison of Clinical Outcomes After Different Surgical Approaches for Lateral Epicondylitis: A Systematic Review and Meta-analysis
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Background Lateral epicondylitis (LE) is one of the most common causes of lateral elbow pain. When nonoperative treatment fails, 1 of the 3 surgical approaches—open, percutaneous, or arthroscopic—is used. However, determining which approach has the superior clinical outcome remains controversial. Purpose To review the outcomes of different operative modalities for LE qualitatively and quantitatively. Study Design Systematic review; Level of evidence, 4. Methods This review was performed and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies published in PubMed, Medline (via EBSCO), and ScienceDirect databases that treated LE with open, percutaneous, or arthroscopic approaches with at least 12 months of follow-up were included. Study quality was assessed using the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies score. The primary outcome was the success rate of each operative treatment approach—open, percutaneous, and arthroscopic. Results From an initial search result of 603 studies, 43 studies (n = 1941 elbows) were ultimately included. The arthroscopic approach had the highest success rate (91.9% [95% CI, 89.2%-94.7%]) compared with the percutaneous (91% [95% CI, 87.3%-94.6%]) and open (82.7% [95% CI, 75.6%-89.8%]) approaches for LE surgery with changes in the mean visual analog scale pain score of 5.54, 4.90, and 3.63, respectively. According to the Disabilities of the Arm, Shoulder and Hand score, the functional outcome improved in the arthroscopic group (from 54.11 to 15.47), the percutaneous group (from 44.90 to 10.47), and the open group (from 53.55 to 16.13). The overall improvement was also found in the Mayo Elbow Performance Score, the arthroscopic group (from 55.12 to 90.97), the percutaneous group (from 56.31 to 87.65), and the open group (from 64 to 93.37). Conclusion Arthroscopic surgery had the highest rate of success and the best improvement in functional outcomes among the 3 approaches of LE surgery.
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... Half of tennis players have elbow pain, with 75% of those suffering from real tennis elbow. (5) It occurs more frequently in those over the age of 40. In the general population, smoking, obesity, daily repetitive movement for at least two hours, and intense activity (handling physical loads exceeding 20 kg) are factors in the development of this condition.(2) ...
Short term effect of local steroid injection in lateral epicondylitis
Article
Full-text available
  • Mar 2021
Introduction: Lateral epicondylitis is a common cause of pain in the lateral side of elbow. It affects 1% to 3% of adults in general population per year.' it is common in dominant arm, tennis players and in workers who are involved in repetitive gripping and heavy lifting tasks because of repeated micro trauma to extensor tendons origin from lateral epicondyle. Objective: To compare the outcome of local steroid injection and local anesthetic injection after 2 weeks in management of lateral epicondylitis. Setting: Department of orthopedics, Hayatabad Medical Complex, Peshawar. Study design: Randomized clinical trial. Study Duration: 21st September 2020 to 21st March 2021. Methodology: A total of 60 patients were included in study (30 in each group). All patients were observed to compare the outcome of local steroid injection and local anesthetic injection after 2 weeks in management of lateral epicondylitis. Results: Distribution of Age among groups of 60 (30 in each group) were analyzed. Most of the patients between the age category (31-40 years) group A (steroid injection) was 9(42.9%) and group B 12(57.1%). Mean age was 41.56 ±3.357. There were 16(50.0%) male & 14(50%) female in group A. In group B, there were 16 (50.0%) male &14(50% female.
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... 1 It is an overuse injury characterized by chronic symptomatic degeneration of the Extensor Carpi Radialis Brevis (ECRB) tendon at the attachment area of the humeral epicondyle. 2 Although the name suggests a connection to tennis, this condition can occur in individuals who engage in repetitive wrist extension, radial deviation, and forearm supination, regardless of their involvement in tennis or any specific sport. Lateral epicondylitis is not limited to athletes but can also affect people in various professions such as carpenters, drivers, students, and computer workers, who perform repetitive activities involving the wrist extensor tendons. ...
Effects of Eccentric Tyler Twist Extensor-Strengthening Exercises in Lateral Epicondylitis
Article
  • Mar 2024
Background: Lateral epicondylitis, commonly known as tennis elbow, is characterized by pain and functional limitations at the elbow due to overuse. This study focuses on evaluating the effects of Tyler twist wrist extensor-strengthening exercises, aiming to provide insights into an effective intervention for this condition. Objective: This study aimed to determine the effects of Tyler twist wrist extensor strengthening exercises on pain, disability, and grip strength in patients with lateral epicondylitis. Methodology: A randomized controlled trial was conducted at Cina Medical Center Rawalpindi from February 2022 to January 2023. Fifty-two participants meeting the inclusion criteria were assigned to either Group A or Group B. Group A received eccentric Tyler twist exercises in addition to conventional physiotherapy, while Group B received conventional physiotherapy alone. Pain, functional disability, and grip strength were assessed at baseline, the second week, and the fourth week. Data was analyzed with SPSS version 25. Demographics and descriptive data is presented in form of percentages, frequencies and mean + SD. Normality of the data is determined via Shapiro Wilk Test. We applied mixed-way ANOVA to find the interaction between two groups. R e s u l t s : Within-group analysis demonstrated a significant improvement in pain, functional disability, and grip strength for both groups (p-value < 0.01). Between-group analysis revealed a significant difference in pain, functional disability, and grip strength. Conclusion: The addition of eccentric Tyler twist exercises to conventional therapy showed a statistically significant difference in terms of pain, functional disability, and grip strength in patients with lateral epicondylitis.
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Avaliação da eficácia das ondas de choque no tratamento da Epicondilite Lateral
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Full-text available
  • Nov 2024
A epicondilite lateral é um processo inflamatório comum em indivíduos ativos que não está apenas associada a atividades de lazer, mas também às ocupacionais, esta condição leva ao afastamento laboral, e a incapacidade de realizar atividades diárias impactando significativamente o cenário socioeconômico. Atualmente, a terapia por ondas de choque extracorpórea ganha destaque na pesquisa por seus efeitos benéficos na reabilitação musculoesquelética, promovendo neovascularização e reduzindo inflamação e rigidez tecidual. O tratamento conservador padrão para epicondilite lateral inclui exercícios supervisionados por fisioterapeutas, com um protocolo que pode abranger exercícios isométricos e isotônicos, alongamentos e técnicas para melhorar a propriocepção. Se não houver melhora após seis meses, pode-se considerar intervenção cirúrgica. A aplicação correta das ondas de choque é avaliada e ainda está sendo investigado sua eficácia isoladamente e integrada a outras terapias.
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Serum Protein Electrophoresis: An Important Tool for Diagnosis and Monitoring of Plasma Cell Neoplasms
Chapter
  • Oct 2024
Serum Protein Electrophoresis (SPEP) is a widely used test besides bone marrow aspiration and biopsy for diagnosing and monitoring plasma cell neoplasms. Immunofixation electrophoresis (IFE) is done to complement SPEP. Both of them have a distinct role in the management of plasma cell neoplasms as per international guidelines. Understanding the SPEP patterns associated with various plasma cell neoplasms and recognizing the significance of its quantitative evaluation is crucial for accurate diagnosis and therapy monitoring. SPEP and IFE are done utilizing different methodologies, e.g., Agarose gel electrophoresis and capillary zone electrophoresis. In this chapter, different patterns of SPEP as found in agarose gel electrophoresis system, Sebia Hydrasis 2 Scan Focusing System® was elaborated. The complementary role of SPEP and IFE in the diagnosis and monitoring of plasma cell neoplasms was also discussed.
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Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles
Article
Full-text available
  • Dec 2018
The wrist extensor muscles make up a significant component of the posterior forearm musculature. In general, these muscles originate on or near the lateral epicondyle and insert on the distal forearm or in the hand. Clinical pathology affecting one or multiple muscles in this group is not uncommon. For example, lateral epicondylitis affects 1­5% of the general population.
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Tendon neuroplastic training for lateral elbow tendinopathy: 2 case reports
Article
Full-text available
  • Sep 2018
  • J Can Chiropract Assoc
Objective: To report 2 cases of lateral elbow tendinopathy treated with a novel adaptation of tendon neuroplastic training (TNT). Clinical features: Patient 1: A 61-year-old male machine operator presented with one year of bilateral lateral elbow pain related to his occupation of using torque wrenches.Patient 2: A 37-year-old male electrician presented with two months of recurrent left lateral elbow pain related to repetitive motions of gripping and pulling at work. Intervention and outcome: Both patients underwent 8 weeks of a novel rehabilitation program, including TNT, which involved pacing their resistance exercises to a metronome. Both patients experienced clinically meaningful improvements in pain and functional outcome scores that were sustained at the 3-month follow-up. Summary: Recent evidence suggests that the central nervous system may play a role in chronic tendinopathies. It is possible that TNT may address the central nervous system component of chronic/recurrent tendinopathy that is not addressed by traditional passive therapies. However, further research is needed.
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Platelet-Rich Plasma for Elbow Pathologies: a Descriptive Review of Current Literature
Article
Full-text available
  • Dec 2018
Purpose of Review Platelet-rich plasma is used in many orthopedic pathologies such as tendinopathies and ligament injuries. The clinical results reported in the scientific literature are, however, confusing. The aim of this manuscript is to provide a narrative literature review regarding the role of PRP in the most common elbow soft tissue pathologies. Recent Findings The response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis. PRP injection does not seem to have the potential complications associated with a steroid injection such as skin atrophy, discoloration, and secondary tendon tears. Only a few manuscripts comparing the results of PRP treatment with either extracorporeal shockwave (ESW), dry needling, or even surgical treatments in lateral epicondylitis exist. The use of PRP in other elbow pathologies such as golfer’s elbow, ulnar collateral ligament injury, and distal biceps and triceps pathology is examined in few studies, with unclear recommendations. Summary Regarding elbow pathologies, PRP injections in tennis elbow seems to be the best-studied intervention. A major limitation in these studies is the significant heterogeneity in the methods used for preparing PRP, for example employing leukocyte-rich, leukocyte-poor preparations, PRP with or without activation, which makes the results of the studies difficult to compare. Results of this review show that more studies on larger cohorts, with comparable formulations, and with longer follow-up are required to give optimal suggestions concerning the use of PRP in elbow pathologies.
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Prospective randomized controlled trial in the treatment of lateral epicondylitis with a new dynamic wrist orthosis
Article
Full-text available
  • Sep 2018
Background: In the treatment of lateral epicondylitis (LE), the role of a new dynamic wrist orthosis is unclear. Patients and methods: Patients suffering from a LE longer than 3 months were multicentrically and prospectively randomized into a physiotherapeutic group (PT group) and in a physiotherapy group plus wrist orthosis (PT + O group). Physiotherapy consisted of daily eccentric strengthening exercises under initial professional supervision. Inclusion criteria were a Placzek score greater than 4. Exclusion criteria were previous surgery, rheumatic arthritis, elbow instability, radicular symptoms, higher-grade extensor tendon rupture, or cervical osteoarthritis. The clinical evaluation was performed after 12 weeks and 12 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale, Placzek Score, the pain rating (VAS), range of motion and the Subjective Elbow Score were evaluated. Results: Of the initially 61 patients, 31 were followed up after 12 weeks and 22 after 12 months. Twenty-nine patients (43%) were male, the mean age was 46, and 44 patients (66%) had the right elbow involved. At 12 weeks, there was a pain reduction on the VAS in both groups (PT + O: 6.5-3.7 [p = .001]; PT: 4.7-4.1 [p = .468]), albeit it was only significant for the PT + O group. At 12 months, reduction was significant in both groups (PT + O: 1.1 [p = .000]; PT: 1.3 [p = .000]). The painless maximum hand strength in kg improved in both groups significant after 3 and 12 months. The Placzek score was reduced from 8.25 to 3.5 [p = .001] after 12 weeks for the PT + O group and from 8.1 to 3.8 [p = .000] in the PT group, as well as after 12 months in the PT + O group to 0 [p = .000] and in the PT group to 2.0 [p = .000]. The PRTEE improved in both groups after 12 weeks (PT + O: 52.8--31.3 [p = .002]; PT: 48.6-37.6 [p = .185]) and 12 months (PT + O: 16.15 [p = .000]; PT: 16.6 [p = .000]), although the reduction at 12 weeks was not significant for the PT group. Conclusion: The elbow orthosis appears to accelerate the healing process with respect to the PRTEE and pain on the VAS (12 weeks follow-up), although there is an adjustment after 12 months in both groups and a significant improvement of symptoms is achieved in all endpoints.
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Elbow Posterolateral Rotatory Instability due to Cubitus Varus and Overuse
Article
Full-text available
  • Aug 2018
A malunion as a complication of distal humerus fractures has been frequently linked with aesthetic problems but less frequently with posterolateral rotatory instability. We report 2 cases of childhood posttraumatic cubitus varus with subsequent posterolateral rotatory instability and their treatment with a minimum of 2 years of follow-up. The etiology of the so-called posterolateral rotatory instability of the elbow is mostly traumatic, but iatrogenic causes have also been described such as the treatment of tennis elbow and less frequently and chronically due to overuse and overload because of distal humerus malunion.
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Management of Lateral Elbow Tendinopathy-One Size Does Not Fit All
Article
Full-text available
  • Sep 2015
  • J ORTHOP SPORT PHYS
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
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Favorable Responsiveness of the Hand10 Questionnaire to Assess Treatment Outcomes for Lateral Epicondylitis
Article
  • Jun 2018
Background: The aim of our study was to compare the responsiveness of the Hand10 questionnaire and the Pain visual analogue scale (VAS) for the assessment of lateral epicondylitis. Methods: The standardized response mean and effect size were used as indicators of responsiveness, measured at baseline and after 6 months of treatment. Among the 54 patients enrolled, 28 were treated using a forearm band, compress and stretching, with the other 26 patients treated using compress and stretching. Results: The standardized response mean and the effect size were 1.18 and 1.38, respectively, of the Hand10 and 1.39 and 1.75, respectively, for the Pain VAS. Conclusions: The responsiveness of both tests was considered to be large, based on Cohen's classification of effect size, supporting the use of the Hand10 questionnaire to assess treatment outcomes for lateral epicondylitis.
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Lateral epicondylitis: Associations of MR imaging and clinical assessments with treatment options in patients receiving conservative and arthroscopic managements
Article
  • Oct 2017
Objectives: We assessed the implications of MR imaging with clinical history in lateral epicondylitis management by evaluating imaging and clinical features in patients with lateral epicondylitis treated conservatively or operatively. Methods: Sixty patients with lateral epicondylitis treated conservatively (n = 38) or operatively (n = 22) from 2011-2015 were included. MR imaging findings of common extensor tendon (CET), lateral collateral ligament (LCL) complex, muscle oedema, ulnar nerve and elbow joint were reviewed. Clinical data recorded were frequency, duration and intensity of pain, history of trauma and injection therapy, range of motion. Results: MRI-assessed CET and LCL complex abnormalities, muscle oedema, radiocapitellar joint widening, joint effusion/synovitis, pain frequency and intensity differed significantly between the two groups (p < .05) with increased severity in operative group. Persistent pain (OR 12.2, p < .01), CET abnormality on longitudinal plane (OR 7.5, p = .03 for grade 2; OR 22.4, p < .01 for grade 3) and muscle oedema (OR 6.7, p = .03) were major factors associated with operative treatment. Area under the ROC curve of predicted probabilities for combination of these factors was 0.83. Conclusion: MR imaging, combined with clinical assessment, could facilitate appropriate management planning for patients with lateral epicondylitis. Key points: • MRI can reflect different disease severity between patients treated conservatively/operatively. • CET abnormality, muscle oedema were major MRI findings with operative treatment. • Patients in operative group were more likely to experience persistent pain. • MRI plus clinical symptoms could facilitate appropriate management for lateral epicondylitis.
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Epidemiology and Disease Burden of Lateral Epicondylitis in the USA: Analysis of 85,318 Patients
Article
  • Jun 2017
Background: National rates of lateral epicondylitis and surgical treatment are poorly defined. Disease burden of lateral epicondylitis (LE) continues to increase annually. Further study is necessary to optimize treatment algorithms to reduce associated health-care expenditures. Questions/purposes: The purpose of this study is to review the annual incidence of LE, surgical rates, and associated health-care costs in a population setting. Methods: A national database was queried for LE from 2007 to 2014. Surgical cases were identified and annual rates were recorded. Demographic and epidemiologic data were reported with descriptive statistics, while trends over time were analyzed using linear regression. Results: Eighty-five thousand three hundred eighteen cases of LE were identified. The annual incidence per 10,000 patients remained constant (p = 0.304). The proportion of diagnoses in patients <65 years decreased (p ≤ 0.002) and ≥65 years increased (p < 0.001) over the study period. One thousand six hundred ninety-four patients (2%) required operative treatment. The annual rate of surgical intervention remained constant (p = 0.623). The proportion of patients <40 years requiring surgery decreased (p < 0.001) as the proportion of patients ≥65 years needing surgery increased (p = 0.003). Total reimbursement for LE procedures during the study period was 7,220,912.Averageper−patientreimbursementwas7,220,912. Average per-patient reimbursement was 4263. Both annual total reimbursement (p = 0.006) and per-patient reimbursement rates (p = 0.002) significantly increased. Conclusion: The annual incidence of LE and rate of surgical intervention have remained constant from 2007 to 2014. The proportion of patients over >65 years diagnosed with, and receiving surgical treatment for, LE has significantly increased in recent years. Total reimbursement and average per-patient reimbursement have steadily risen, demonstrating the increasing burden of cost on the health-care system.
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Local corticosteroid versus autologous blood injections in lateral epicondylitis: Meta-analysis of randomized controlled trials
Article
  • Sep 2016
  • Eur J Phys Rehabil Med
Background: Lateral epicondylitis is a common painful elbow disorder. Several approaches to treatment have been proposed, with a local injection of corticosteroids being the most frequently used. Recent insights into the pathophysiology encouraged the introduction of autologous blood injections as an alternative treatment method. Aim: The aim of this meta-analysis is to summarize quantitatively the evidence regarding the efficacy of corticosteroids and autologous blood injections for treatment of pain in lateral epicondylitis. Design: Meta-analysis. Setting: Outpatient treatment. Population: Studies were considered eligible based on the following inclusion criteria: adult human, diagnosis of lateral epicondylitis, randomized controlled trials comparing corticosteroids versus autologous blood injections, pain assessment. Exclusion criteria were previous surgery for lateral epicondylitis or for other elbow disorders, concurrent treatment with drugs or physiotherapy, diagnosis of musculoskeletal systemic disorder. Methods: A systematic search of literature was performed according to PRISMA statement. Effect size of each included study was calculated and analyzed in a random-effects model. Results: Four studies, enrolling total of 218 patients (139 females and 79 males), were included in quantitative analysis. At 2 weeks there was a trend towards a reduction of VAS score in the corticosteroid group (WMD = 2.12 [95% CI: 4.38 to 0.14], P=0.07). No significant differences were recorded in the medium-term (4-12 weeks; WMD = 0.85 [95% CI: -0.44 to 2.15], P= 0.19) and long-term (24 weeks; WMD = 0.63 [95% CI: -2.40 to 3.66], P= 0.68) follow-up. Conclusions: Few high-quality trials compare the efficacy of corticosteroid and autologous blood injections in the control of pain related to lateral epicondylitis. Available data indicate that corticosteroids tend to reduce VAS score in short-term follow-up, although these data are not statistically significant. No differences were recorded in the medium and long term. Clinical rehabilitation impact: Contrary to popular opinion among medical professionals, and despite pathophysiological cues, the currently available data offer no support for the effectiveness of autologous blood injections in medium- and long- term follow-up. Further studies are necessary to establish which treatment has more impact on pain in lateral epicondylitis. These data could be then used as a basis for practical guidelines and new protocols of treatment.
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