The Role of Supinator in the Pathogenesis of Chronic Lateral Elbow Pain: A Biomechanical Study

Muscle-guided mapping of post-traumatic heterotopic ossification of the elbow: a novel computed tomography-based study

BACKGROUND

Heterotopic ossification (HO) involves abnormal bone formation in soft tissues near joints, commonly occurring after elbow trauma or surgery, leading to pain and functional limitations. Previous studies have primarily characterized HO distribution based on bony landmarks, lacking a detailed investigation into the characteristics of its distribution in periarticular soft tissue in post-traumatic elbows. This study aimed to (1) develop a muscle-guided classification system using computed tomography (CT) to map HO relative to elbow muscle-tendon units and (2) investigate correlations between HO location and severity.

METHODS

In a retrospective study, 56 patients with HO and elbow stiffness following trauma were analyzed. CT imaging was used to classify HO into 7 categories: Posterior - olecranon tip - triceps brachii; Posteromedial - medial gutter - flexor carpi ulnaris (PM-MG-FCU); Posterolateral - lateral gutter - anconeus; Medial - medial epicondylar - flexor muscles; Lateral - lateral epicondylar - extensor muscles; Anterior - humeroulnar joint - brachialis; and Anterior - humeroradial - supinator. HO severity was graded (1-3) based on CT morphology, and correlations between HO location and severity were assessed.

RESULTS

PM-MG-FCU was the most common HO location (67.9%). Significant correlations were found between HO severity and location, with higher rates of HO in grades 2 and 3, characterized by extensive mature bone formation and bone bridge development occurring in the posterolateral - lateral gutter - anconeus, posterior - olecranon tip - triceps brachii, and PM-MG-FCU.

CONCLUSION

The muscle-guided classification system effectively delineated HO distribution near elbow muscle-tendon units. HO locations surrounding the anconeus, triceps brachii, and flexor carpi ulnaris correlate with higher radiographic severity, providing valuable insights for treatment strategies.

Widespread Pressure Pain Hyperalgesia Is Not Associated With Morphological Changes of the Wrist Extensor Tendon in Unilateral Lateral Epicondylalgia: A Case-Control Study

OBJECTIVE

The aims of the current study were to investigate the presence of widespread pressure hyperalgesia, the presence of structural changes in the wrist extensor tendon and muscle, and their association in people with lateral epicondylalgia (LE).

METHODS

Thirty-seven patients with LE (43% women; mean age = 45.5 [SD = 9.5] years) and 37 controls matched for age and sex and free of pain participated in this study. Pressure pain thresholds (PPTs) were assessed bilaterally over the symptomatic area (elbow), 2 segment-related areas (C5-C6 joint, second intermetacarpal space), and 1 remote area (tibialis anterior) in a blinded design. Ultrasound measurements (eg, cross-sectional area, thickness, and width) of the common wrist extensor tendon and extensor carpi radialis brevis muscle as well as the thickness of the supinator muscle were assessed.

RESULTS

Patients with LE exhibited lower PPTs bilaterally at all points and lower PPTs at the lateral epicondyle and second intermetacarpal space on the symptomatic side as compared to the nonsymptomatic side (η2 from 0.123-0.369; large effects). Patients exhibited higher cross-sectional area and width of the common wrist extensor tendon (η2 from 0.268-0.311; large effects) than controls bilaterally, whereas tendon thickness was also higher (η2 = 0.039; small effects) on the painful side than on the nonpainful side.

CONCLUSIONS

This study reported bilateral widespread pressure pain hyperalgesia and morphological changes in the tendon, but not the muscle, in LE. Pressure pain sensitivity and morphological changes were not associated in individuals with LE.

IMPACT

Management of LE should consider altered nociceptive pain processing and structural tendon changes as 2 different phenomena in patients with LE.

Causes, symptoms, and treatments of nerve entrapments around the elbow: Current concepts

The elbow is a joint extremely susceptible to stiffness, even after a trivial trauma. As for other joints, several factors can generate stiffness such as immobilisation, joint incongruity, heterotopic ossification, adhesions, or pain. Prolonged joint immobilisation, pursued to assure bony and ligamentous healing, represents the most acknowledged risk factor for joint stiffness. The elbow is a common site of nerve entrapment syndromes. The reasons are multifactorial, but peculiar elbow anatomy and biomechanics play a role. Passing from the arm into the forearm, the ulnar, median, and radial nerves run at the elbow in close rapport with the joint, fibrous arches and through narrow fibro-osseous tunnel. The elbow joint, in fact, has a large range of flexion which exposes nerves lying posterior to the axis of rotation to traction and those anterior to compression.

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

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

A Combined Revision Surgical Technique for Failed Operative Lateral Epicondylitis With Concomitant Radial Tunnel Syndrome

Lateral epicondylitis afflicts a large percentage of the population with most recovering through conservative treatment. The 5% to 10% of patients who undergo operative intervention are met with mixed results. Those that fail to improve often demonstrate a complex presentation of inadequate debridement of the "angiofibroblastic tissue," missed concomitant radial tunnel syndrome, and iatrogenic residual devascularized tissue resulting from the index procedure. To address all 3 of these causes of failure, the authors have developed a revision procedure that includes repeat debridement of residual tendinosis, decompression of the posterior interosseous nerve, and a vascularized anconeus muscle flap to help cushion soft tissue defects and promote a healthier environment for healing. Performed initially in part in 20 patients, this combined procedure has developed into our recommended treatment for these challenging patients.

Is Dry Needling of the Supinator a Safe Procedure? A Potential Treatment for Lateral Epicondylalgia or Radial Tunnel Syndrome. A Cadaveric Study

The supinator muscle is involved in two pain conditions of the forearm and wrist: lateral epicondylalgia and radial tunnel syndrome. Its close anatomical relationship with the radial nerve at the arcade of Frohse encourages research on dry needling approaches. Our aim was to determine if a solid filiform needle safely penetrates the supinator muscle during the clinical application of dry needling. Needle insertion of the supinator muscle was conducted in ten cryopreserved forearm specimens with a 30 × 0.32 mm filiform needle. With the forearm pronated, the needle was inserted perpendicular into the skin at the dorsal aspect of the forearm at a point located 4cm distal to the lateral epicondyle. The needle was advanced to a depth judged to be in the supinator muscle. Safety was assessed by measuring the distance from the needle to the surrounding neurovascular bundles of the radial nerve. Accurate needle penetration of the supinator muscle was observed in 100% of the forearms (needle penetration:16.4 ± 2.7 mm 95% CI 14.5 mm to 18.3 mm). No neurovascular bundle of the radial nerve was pierced in any of the specimen’s forearms. The distances from the tip of the needle were 7.8 ± 2.9 mm (95% CI 5.7 mm to 9.8 mm) to the deep branch of the radial nerve and 8.6 ± 4.3 mm (95% CI 5.5 mm to 11.7 mm) to the superficial branch of the radial nerve. The results from this cadaveric study support the assumption that needling of the supinator muscle can be accurately and safely conducted by an experienced clinician.

The arcade of Frohse: a systematic review and meta-analysis

PURPOSE

The structure of the proximal margin of the superficial layer of the supinator muscle is of high interest to many researches. Its tendinous appearance, called the arcade of Frohse, may be clinically important because of its close relationship to the deep branch of the radial nerve passing beneath it and is considered to be the cause of several syndromes. Given the importance of this structure, we aimed to provide a comprehensive and evidence-based review with meta-analytic techniques.

MATERIALS AND METHODS

The meta-analysis was performed in adherence to the PRISMA guidelines. Three medical databases were searched in order to identify all potentially eligible articles. Included studies were assessed for quality and the extracted morphological and morphometric data from the relevant articles was analyzed with the use of random effects meta-analysis.

RESULTS

A total of 20 studies were included into this meta-analysis. The pooled prevalence of the arcade of Frohse was calculated to be 66% within the adult population and 0% in the fetuses. Other variations regarding the arcade of Frohse were identified as very rare. Analysis of the morphometric parameters revealed the average proportions to be 23.22 mm for the length, 11.05 mm for the width and the mean thickness is 0.67 mm.

CONCLUSIONS

The arcade of Frohse is a commonly found structure in adults and thoughtful knowledge of its texture and morphology is especially useful in neurology, neurosurgery, orthopedics, trauma surgery and hand surgery, because it is considered to be the most common source of compression for the deep branch of the radial nerve.

Effect of Radial Nerve Release on Lateral Epicondylitis Outcomes: A Prospective, Randomized, Double-Blinded Trial

PURPOSE

The purpose of our study was to examine the result of lateral epicondylitis surgery with and without posterior interosseous nerve release.

METHODS

We conducted a prospective, randomized, double-blind single-center clinical trial in 54 patients treated surgically for lateral epicondylitis, without any EMG or imaging sign of compression of the posterior interosseous nerve at the arcade of Frohse. The patients were equally divided into intervention (supplemental radial nerve release) and control groups (no radial nerve release). Clinical symptoms and disability related to the upper extremity were assessed by a blinded assessor prior to surgery, using both the Quick Disabilities of the Arm, Shoulder, and hand (QuickDASH) and Mayo Elbow Performance Score (MEPS) and again at 1-, 3-, and 6-month intervals after surgery.

RESULTS

Significant improvement was observed in both groups from the first month after surgery and for the whole evaluation period for both the MEPS and the QuickDASH scores.

CONCLUSIONS

Radial nerve release, in association with surgical treatment for lateral epicondylitis, was not associated with greater improvement.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Comprehensive Review of the Elbow Physical Examination

Physical examination of the elbow is a critical component in formulating an accurate diagnosis. Various special physical examinations have been described to improve the clinician's ability to establish an accurate diagnosis. A comprehensive approach to the physical examination of the elbow, including special tests, may facilitate improved diagnosis of elbow pathology.

A service evaluation and improvement project: a three year systematic audit cycle of the physiotherapy treatment for Lateral Epicondylalgia

OBJECTIVES

To improve outcomes of physiotherapy treatment for patients with Lateral Epicondylalgia.

DESIGN

A systematic audit and quality improvement project over three phases, each of one year duration.

SETTING

Salford Royal NHS Foundation Trust Teaching Hospital Musculoskeletal Physiotherapy out-patients department.

PARTICIPANTS

n=182.

INTERVENTIONS

Phase one - individual discretion; Phase two - strengthening as a core treatment however individual discretion regarding prescription and implementation; Phase three - standardised protocol using high load isometric exercise, progressing on to slow combined concentric & eccentric strengthening.

MAIN OUTCOME MEASURES

Global Rating of Change Scale, Pain-free grip strength, Patient Rated Tennis Elbow Evaluation, Tampa Scale of Kinesophobia-11.

RESULTS

Phase three demonstrated a reduction in the average number of treatments by 42% whilst improving the number of responders to treatment by 8% compared to phase one. Complete cessation of non-evidence based treatments was also observed by phase three.

CONCLUSIONS

Strengthening should be a core treatment for LE. Load setting needs to be sufficient. In phase three of the audit a standardised tendon loading programme using patient specific high load isometric exercises into discomfort/pain demonstrated a higher percentage of responders compared to previous phases.

The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review

Background

Ultrasound is considered a reliable, widely available, non-invasive and inexpensive imaging technique for assessing soft tissue involvement in Lateral epicondylalgia. Despite the number of diagnostic studies for Lateral Epicondylalgia, there is no consensus in the current literature on the best abnormal ultrasound findings that confirm lateral epicondylalgia.

Methods

Eligible studies identified by searching electronic databases, scanning reference lists of articles and chapters on ultrasound in reference books, and consultation of experts in sonography. Three reviewers (VCDIII, KP, KW) independently searched the databases using the agreed search strategy, and independently conducted all stages of article selection. Two reviewers (VCDIII, KP) then screened titles and abstracts to remove obvious irrelevance. Potentially relevant full text publications which met the inclusion criteria were reviewed by the primary investigator (VCDIII) and another reviewer (CGS).

Results

Among the 15 included diagnostic studies in this review, seven were Level II diagnostic accuracy studies for chronic lateral epicondylalgia based on the National Health and Medical Research Council Hierarchy of Evidence. Based from the pooled sensitivity of abnormal ultrasound findings with homogenous results (p > 0.05), the hypoechogenicity of the common extensor origin has the best combination of diagnostic sensitivity and specificity. It is moderately sensitive [Sensitivity: 0.64 (0.56-0.72)] and highly specific [Specificity: 0.82 (0.72-0.90)] in determining elbows with lateral epicondylalgia. Additionally, bone changes on the lateral epicondyle [Sensitivity: 0.56 (0.50-0.62)] were moderately sensitive to chronic LE. Conversely, neovascularity [Specificity: 1.00 (0.97-1.00)], calcifications [Specificity: 0.97 (0.94-0.99)] and cortical irregularities [Specificity: 0.96 (0.88-0.99)] have strong specificity for chronic lateral epicondylalgia. There is insufficient evidence supporting the use of Power Doppler Ultrasonogrophy, Real-time Sonoelastography and sonographic probe-induced tenderness in diagnosing LE.

Conclusions

The use of Gray-scale Ultrasonography is recommended in objectively diagnosing lateral epicondylalgia. The presence of hypoechogenicity and bone changes indicates presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia. In addition to diagnosis, detection of these abnormal ultrasound findings allows localization of pathologies to tendon or bone that would assist in designing an appropriate treatment suited to patient’s condition.

The supinator muscle: anatomical bases for deep branch of the radial nerve entrapment

PURPOSE

Our goals were to carry out an anatomical description of the internal architecture of the supinator muscle in order to describe potentially compressive structures for the deep branch of the radial nerve (DBRN) and to establish reference landmarks for the surgical treatment of radial tunnel syndrome.

METHODS

Thirty upper limbs were dissected. The pennation angle of proximal and distal arcades of the supinator to the radial shaft axis was measured. Possible compressive structures of both superficial and deep heads of supinator were recorded. Proximal and distal arcades of the superficial layer of the supinator were classified according to their fiber content as tendinous, musculo-tendinous, muscular or membranous. The distances of superficial layer of the supinator muscle to the humeroradial joint line and lateral epicondyle were measured.

RESULTS

Pennation angle was 33.6° (±4.2°) for the superficial layer and 50.2° (±6.6°) for the deep layer. The difference was statistically significant (p < 0.0001). The proximal arcade was purely tendinous in 20 cases (66.7 %). The distal arcade was mainly tendinous or musculo-tendinous (70 %). The average distance between the lateral epicondyle and the proximal arcade was 41.6 mm. We did not find any other potentially compressive structure within DBRN course between both layers.

CONCLUSION

Our anatomical results about pennation angle could be used as a basis for a thorough functional study about the supinator. Both proximal and distal arcades appeared as the two zones ables to compress the DBRN. Their localization should help the surgeon for the DBRN neurolysis.

The validity of upper-limb neurodynamic tests for detecting peripheral neuropathic pain

The validity of upper-limb neurodynamic tests (ULNTs) for detecting peripheral neuropathic pain (PNP) was assessed by reviewing the evidence on plausibility, the definition of a positive test, reliability, and concurrent validity. Evidence was identified by a structured search for peer-reviewed articles published in English before May 2011. The quality of concurrent validity studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool, where appropriate. Biomechanical and experimental pain data support the plausibility of ULNTs. Evidence suggests that a positive ULNT should at least partially reproduce the patient's symptoms and that structural differentiation should change these symptoms. Data indicate that this definition of a positive ULNT is reliable when used clinically. Limited evidence suggests that the median nerve test, but not the radial nerve test, helps determine whether a patient has cervical radiculopathy. The median nerve test does not help diagnose carpal tunnel syndrome. These findings should be interpreted cautiously, because diagnostic accuracy might have been distorted by the investigators' definitions of a positive ULNT. Furthermore, patients with PNP who presented with increased nerve mechanosensitivity rather than conduction loss might have been incorrectly classified by electrophysiological reference standards as not having PNP. The only evidence for concurrent validity of the ulnar nerve test was a case study on cubital tunnel syndrome. We recommend that researchers develop more comprehensive reference standards for PNP to accurately assess the concurrent validity of ULNTs and continue investigating the predictive validity of ULNTs for prognosis or treatment response.

Patient-reported outcome of surgical treatment of nerve entrapments in the proximal forearm

The outcome of decompression for long-standing symptoms of nerve entrapments in the proximal forearm was investigated in a retrospective study of 205 patients using a self-assessment questionnaire, 45 months after the operation. The questionnaire consisted of visual analogue scale recordings of pre- and postoperative pain during rest and activity, questions about remaining symptoms and appreciation of the result and the Disabilities of Arm, Shoulder and Hand form (DASH). Altogether, 59% of the patients were satisfied, 58% considered themselves improved, and 3% as being entirely relieved of all symptoms. Pain decreased significantly (P = 0.001). There was a significant correlation between preoperative duration and patient perceived post-operative pain. Preoperative pain was a chief complaint, and pain reduction appears to be the principal gain of the operation. Although the majority of the patients benefited from the operation, a substantial proportion was not satisfied. There is apparently room for improvement of the diagnostic and surgical methods applied in this study.

New Assessment of Forearm Strength: Reliability and Validity

OBJECTIVE. The objective was to determine the reliability of a portable forearm strength hydraulic dynamometer with a doorknob handle and assess its validity compared with a Cybex 6000 (Cybex International, Inc., Medway, MA) isometric torque assessment.

METHOD. Eighteen volunteers (with a total of 30 forearms) participated in this one-session methodological study to determine the intra- and interrater reliability and criterion validity of a forearm dynamometer.

RESULTS. Intrarater reliability for both assessors for pronation was (intraclass correlation coefficient [ICC]3,1 = .937–.961) and for supination was (ICC3,1 = .923–.968). Interrater reliability for pronation was ICC3,2 = .927 and for supination was ICC3,2 = .847. Criterion validity of the Baseline hydraulic dynamometer (Fabrication Enterprises Inc., White Plains, NY) compared with the Cybex 6000 was .574–.664 for pronation and .749–.750 for supination.

CONCLUSION. The Baseline hydraulic dynamometer with a more functional doorknob handle had good intra- and interrater reliability and demonstrated moderate validity compared with Cybex 6000 strength testing.

Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: a possible mechanism of palsy after two-incision repair for distal biceps rupture--clinical experience and a cadaveric investigation

Posterior interosseous nerve palsy is a recognized complication of 2-incision distal biceps tendon repair. We hypothesize that intraoperative forearm pronation can cause compression of the posterior interosseous nerve beneath the supinator and arcade of Frohse. Six human male cadaver upper extremities were dissected. Pressure on the posterior interosseous nerve beneath the arcade of Frohse and supinator was measured with a Swan-Ganz catheter connected to a pressure transducer. Pressure was significantly elevated in maximal pronation in all specimens with the elbow in both flexion and extension. Pressures at full pronation were significantly higher than pressures measured at 60 degrees of pronation (5 +/- 2 mm Hg in 60 degrees of pronation and 90 degrees of flexion, P < .0001; 7 +/- 3 mm Hg in 60 degrees of pronation and extension, P < 005). Maximal pronation can cause increased pressure on the posterior interosseous nerve. The safety of 2-incision distal biceps repair may be increased by avoiding prolonged, uninterrupted periods of hyperpronation.

Fractional lengthening of forearm extensors for resistant lateral epicondylitis

BACKGROUND

This study presents the surgical technique of fractional lengthening of extensor carpi radialis brevis, extensor digitorum communis and the superficial head of supinator, for chronic lateral epicondylitis. The anatomical basis for this surgical approach is reviewed. The results of surgical treatment in a consecutive series of patients with severe chronic lateral epicondylitis are reviewed.

METHODS

Twenty-one elbows in 17 subjects underwent surgery. All elbows had severe resistant symptoms, unresponsive to a minimum 6 months (mean 14 months) of a non-operative treatment protocol. All elbows showed either tendonopathy or a partial tear in the common extensor tendon origin at preoperative imaging.

RESULTS

All subjects were examined at a minimum of 1 year after surgery. The mean visual analogue pain (VAS) score reduced from 7.6 (maximum 10) preoperatively to 1.3 postoperatively (P<0.01). The mean preoperative ability to carry out normal work duties reduced from 4.3 (maximum 5) preoperatively to 1.5 postoperatively (P<0.01). Grip strength improved or remained equivalent following surgery. The mean VAS for patient satisfaction with surgery was 8.8 (maximum score 10). Using the Roles and Maudsley classification, 14 patients (82%) were rated good or excellent. Three subjects were rated fair or poor, were undergoing treatment for other pathology in the ipsilateral extremity and had ongoing compensation claims.

CONCLUSION

Fractional lengthening of forearm extensors is effective treatment for severe and chronic lateral epicondylitis. Outcomes following fractional lengthening surgery are less predictable when other pathology in the upper extremity requires concomitant treatment.

Validation of the Patient-rated Tennis Elbow Evaluation Questionnaire

The aim of this study was to determine the reliability, validity, and sensitivity of the Patient-rated Tennis Elbow Evaluation (PRTEE) Questionnaire in 78 tennis playing subjects who had chronic, unilateral, MRI-confirmed lateral elbow tendinopathy and who concomitantly participated in an outcome study. The PRTEE results were compared with results of the Visual Analog Scale (VAS); the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire; the Roles and Maudsley score; and the Upper Extremity Function Scale. Questionnaires were completed at baseline and 12 weeks. Reliability and internal consistency were excellent (PRTEE pain subscale, 0.94; PRTEE specific activities subscale, 0.93; PRTEE usual activities, 0.85). Correlations were good between the PRTEE subscales and total scale and the VAS and DASH. Standardized response means (SRM) were higher in the PRTEE (SRM=2.1) than in the other outcome measures (SRM, 1.5-1.7). The PRTEE was a reliable, reproducible, and sensitive instrument for assessment of chronic lateral elbow tendinopathy in a tennis playing cohort. It was at least as sensitive to change as the other outcome tools tested. The PRTEE may become the standard primary outcome measure in research of tennis elbow.

Management of radial tunnel syndrome: a therapist's clinical perspective

Current best evidence for the conservative management of radial tunnel syndrome (RTS) consists primarily of expert opinion and inferences taken from studies on other nerve compressions and related syndromes. There are limited data reported in the literature of this particular disorder. This article reviews literature on modalities, therapeutic exercise, ergonomic interventions, and cortical reorganization, and how they may be considered for intervention with RTS. The author's preferred method of treatment, as based on theoretical constructs, for RTS is presented. Definitive evidence in the literature to support the conservative interventions suggested is lacking. Suggestions for clinical management and study are included in this therapist's clinical perspective.

Radial tunnel syndrome: a surgeon's perspective

Radial tunnel syndrome is relatively uncommon but is an important cause of lateral forearm pain. Clinical examination is a crucial part of the diagnosis with weakness of finger extension and local tenderness at the ligament of Frohse being the two most important. Surgical release of the superficial head of the supinator muscle and the division of the ligament of Frohse is usually successful in relieving the symptoms. Radial tunnel syndrome (supinator syndrome) can coexist with tennis elbow and cervical brachial neuritis. The diagnosis must be considered when there is atypical tennis elbow or de Quervain's tenovaginitis stenosans resistant to normal treatment. The relationship between radial tunnel syndrome and work remains unclear but repeated supination of the forearm combined with extension of the elbow appears to aggravate the symptoms. There is no scientific evidence to suggest a direct causal relationship between work practices and radial tunnel syndrome.

A unified approach to radial tunnel syndrome and lateral tendinosis

Two of the most common diagnoses assigned to patients presenting with lateral elbow and proximal forearm pain are lateral tendinosis and radial tunnel syndrome. Traditionally, these 2 conditions have been treated as distinct and separate entities with most patients being diagnosed with either one or the other, but not both. The extensor carpi radialis brevis (ECRB) and, to a lesser the degree, a portion of the extensor digitorum communis that form the conjoined lateral extensor tendon are thought to be primarily responsible for the excessive traction that induces lateral tendinosis (a degenerative process of microtears in the tendon with impaired healing), but the supinator blends with these same fibers and shares a role in the pathology. The supinator, primarily the arcade of Frohse, has been thought to play the majority role in compressing the posterior interosseous nerve in radial tunnel syndrome, but the undersurface thick tendon of the ECRB may also cause substantial nerve compression. Reduction of the linear tension transmitted by the ECRB is the common element in the various surgical treatments for lateral tendinosis, performed anywhere from directly at the lateral epicondyle to the distal myotendinous junction. Nerve decompression by division of fascial bands is the goal in surgery for radial tunnel syndrome. These 2 surgical approaches need not be mutually exclusive. In fact, this separation of the 2 clinical entities may play a role in the unpredictable results reported in the literature. This article presents a unified approach to treating both pathologies simultaneously including short-term clinical results.

'Lateral elbow tendinopathy' is the most appropriate diagnostic term for the condition commonly referred-to as lateral epicondylitis

A plethora of terms that have been used to describe lateral epicondylitis including tennis elbow (TE), epicondylalgia, tendonitis, tendinosis and tendinopathy. These terms usually have the prefix extensor or lateral elbow. Lateral elbow tendinopathy seems to be the most appropriate term to use in clinical practice because other terms make reference to inappropriate aetiological, anatomical and pathophysiological terms. The correct diagnostic term is important for the right treatment.

Effectiveness of pulsed electromagnetic field therapy in lateral epicondylitis

We aimed to investigate the efficacy of pulsed electromagnetic field (PEMF) in lateral epicondylitis comparing the modality with sham PEMF and local steroid injection. Sixty patients with lateral epicondylitis were randomly and equally distributed into three groups as follows: Group I received PEMF, Group II sham PEMF, and Group III a corticosteroid + anesthetic agent injection. Pain levels during rest, activity, nighttime, resisted wrist dorsiflexion, and forearm supination were investigated with visual analog scale (VAS). Pain threshold on elbow was determined with algometer. All patients were evaluated before treatment at the third week and the third month. VAS values during activity and pain levels during resisted wrist dorsiflexion were significantly lower in Group III than Group I at the third week. Group I patients had lower pain during rest, activity and nighttime than Group III at third month. PEMF seems to reduce lateral epicondylitis pain better than sham PEMF. Corticosteroid and anesthetic agent injections can be used in patients for rapid return to activities.

[Shock wave treatment for tennis elbow]

Randomized controlled trials were evaluated to assess the effectiveness of extracorporeal shock wave treatment in the management of tennis elbow. Five trials had a mediocre methodology and four trials had a high-quality design. Well-designed randomized control trials have provided evidence of the effectiveness of shock wave intervention for tennis elbow.