Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) - A systematic review

The Physical Examination of the Throwing Elbow

This section is dedicated to the comprehensive evaluation of the overhead throwing athlete's elbow. The elbow provides a unique diagnostic dilemma that requires extensive knowledge and appreciation of elbow anatomy and kinematics, given the extreme forces seen across the elbow during the overhead throwing motion, the superficial nature of the majority of anatomic structures, and the complex interplay among bony, ligamentous, musculotendinous, and neurologic structures. The physical examination of the ulnar collateral ligament, valgus extension overload syndrome, medial and lateral epicondylitis, posterolateral rotatory instability, tendon ruptures, and compressive neuropathies will be covered.

Impact of Heavy Slow Resistance vs. Convectional Exercise in Lateral Epicondylitis-A Pilot Study

Background

The extensor carpi radial muscle may become imbalanced compared to other muscles in the upper arm and can disrupt the overall muscle balance in the upper limb. This muscular imbalance may then cause inflammation or irritation in the tendon. Regular physical activity is rarely used as the only treatment for lowering limb edema. Heavy slow resistance (HSR) training is effective compared to regular exercises. HSR affects functional abilities and physical refinement differently from conventional workouts. This study evaluated the effects of HSR and conventional exercise (CE) on subjects aged 45-65 years with unilateral elbow pain on, in Chennai city.

Methods

Patient received conservative care in the Physiotherapy Department from January 2022 to April 2022. This study compares the pre- and posttypes. Tennis Elbow Evaluation (Patient-Rated Tennis Elbow Evaluation, PRTEE) questionnaires, a patient-specific functional scale, and grip strength tests were used in the study. Results from the study's treatment HSR group and treatment CE group are contrasted.

Results

After 12 weeks of therapy, investigators reassessed grip strength, PRTEE scores, and functional scale responses. In the posttest results of the Patient-Rated Tennis Elbow Evaluation survey, there is a statistically significant difference between Group HSR and Group CE (p < 0.001). The posttest outcomes from the patient-specific activity scoring scheme questionnaire revealed a statistically significant disparity between Groups HSR and CE (p < 0.001). The mean values for both groups exhibited a noteworthy change, with Team HSR demonstrating higher values in contrast to the control treatment.

Conclusion

HSR exercise demonstrates superior effectiveness over CEs for lateral epicondylitis (LE) management, emphasizing its significance in treatment.

Comparative Efficacy of Platelet-Rich Plasma, Corticosteroid, Hyaluronic Acid, and Placebo (Saline) Injections in Patients with Lateral Elbow Tendinopathy: A Randomized Controlled Trial

Background: Lateral elbow tendinopathy is a common condition that significantly alters the function of the upper extremities. In case of first-line treatment failure, different local injections are usually used. Due to the lack of sufficient evidence to support it, we conducted the study to compare the outcomes of different single injections, including Platelet-Rich Plasma (PRP), Corticosteroids (CS), Hyaluronic Acid (HA), and placebo (saline). Methods: Sixty patients with confirmed lateral elbow tendinopathy were enrolled in the study and divided into four groups. Pain intensity (average for the current day, at rest, during provocative tests) measured by Visual Analogue Scale (VAS), pressure pain threshold (PPT), Patient-Rated Tennis Elbow Evaluation (PRTEE), Disability of Arm, Shoulder and Hand (DASH), Subjected Elbow Value (SEV), and strength of selected muscle groups were measured before and during follow-up visits (1, 4, 12, 24, and 52 weeks after treatment). The treatment was considered successful when minimal clinically important difference (MCID) was achieved in primary outcomes (VAS, PRTEE). Results: A significant improvement was achieved in most measurements in all groups. At the final follow-up, MCID for the mean pain reduction measured with VAS and improvement in the PRTEE score were achieved in 52 and 54 patients, respectively. The complete absence of pain was achieved after 1, 4, 12, 24, and 52 weeks in 2, 5, 10, 22, and 40 patients, respectively. The comparison between the groups found a significant difference in pain intensity between CS and other groups one week after injection, between the CS and PRP group in the fourth week, and between PRP and HA in the fourth week (p < 0.05). No other significant differences were found between each group at each follow-up time point. Conclusions: We conclude that each injection treatment provides good long-term clinical outcomes, but not better than placebo. A CS injection might be regarded as a more effective treatment only within the first month post-injection.

Evaluation and Surveillance of Lateral Elbow Tendinopathy in Manual Workers: Identifying Elbows at Risk

Background

Manual workers are at risk of developing lateral elbow tendinopathy (LET). We aimed to validate the hypothesis that asymptomatic elbows of manual workers with LET are more likely to have positive physical examination results and morpho-mechanical changes on elbow ultrasonography compared to healthy individuals.

Methods

This cross-sectional case-control study included 30 manual workers with unilateral LET (LET group) and 30 age- and sex-matched healthy volunteers (control group). Demographic data collection and functional evaluation were performed using the Disabilities of the Arm, Shoulder, and Hand; Patient-Rated Tennis Elbow Evaluation; and European Quality of Life Five-Dimensions questionnaires. Physical examination of the elbows and evaluation of the common extensor tendon (CET) with B-mode morphology ultrasonography and Young's modulus elastography were performed. The LET-unaffected and LET-affected elbows in the LET group were compared with the elbows in the control group.

Results

The LET-unaffected elbows in the LET group had a higher prevalence of positive chair test results and focal hypoechoic change and microcalcification on ultrasonography than those in the control group (P < 0.05, 0.005, and 0.05, respectively). In addition, LET-affected elbows showed higher focal hypoechoic change, microcalcification, erosive cortex, and neovascularity than elbows in the control group (P < 0.001, 0.001, 0.005, and 0.001, respectively). The unaffected and affected elbows showed greater CET thickness than those in the control group (P < 0.05 and 0.005).

Conclusion

The unaffected elbows of manual workers with unilateral LET should be considered at risk of LET. We proposed a risk assessment and surveillance protocol based on chair test results and abnormal ultrasonographic findings.

Heavy slow resistance training, radial extracorporeal shock wave therapy or advice for patients with tennis elbow in the Norwegian secondary care: a randomised controlled feasibility trial

OBJECTIVES

To evaluate the feasibility of recruitment, appointment adherence, intervention compliance, acceptance and comprehensibility, in addition to retention rate and data completeness. An ancillary aim was to describe within-group changes in the secondary outcome measures (patient-reported and performance-based).

DESIGN

A single-centre, three-armed, randomised controlled feasibility trial with a parallel design, with follow-up after 3 and 6 months.

SETTING

Participants were recruited from the outpatient clinic at Oslo University Hospital.

PARTICIPANTS

Patients with lateral epicondylalgia, commonly known as tennis elbow.

INTERVENTIONS

Participants were randomised in a 1:1:1 ratio to heavy slow resistance training, radial extracorporeal shock wave therapy or information and advice.

MAIN OUTCOME MEASURES

Feasibility was assessed according to a priori criteria for success.

RESULTS

In total, 89 patients were screened for eligibility, and 69 (78%) patients were eligible for randomisation. 60 (92%) participants were randomised which gave a recruitment rate of 3.4 per month (against an a priori success cut-off of 3.75). The participants rated all the interventions as acceptable and comprehensive. Only 6 of 19 (32%) did comply with heavy slow resistance training. Retention rate and completeness of data were successful at 3 months. At 6 months, the retention rate was below the criteria for success. Patient-reported and performance-based outcomes improved in all groups.

CONCLUSION

The current study shows that the process of recruitment and the retention rate at follow-up can be feasible with minor amendments. Participants had low compliance with heavy slow resistance training mainly due to pain aggravation, which suggests that this intervention was not suitable for patients with tennis elbow. Shock wave therapy and information and advice should be investigated further in a full-scale randomised controlled trial including sham shock wave therapy.

TRIAL REGISTRATION NUMBER

NCT04803825.

Physiotherapy practices in the clinical assessment of lateral elbow tendinopathy: An international survey

BACKGROUND AND PURPOSE

Understanding physiotherapy practices is important to identify variations from empirical evidence and highlight requirements for training. This survey explored international physiotherapy practices for assessment of lateral elbow tendinopathy (LET).

METHODS

Two hundred ninety-nine surveyed physiotherapists from eight member countries of the International Federation of Manual and Orthopaedic Physical Therapists completed the survey. Respondents rated their frequency of use (never, rarely, sometimes, often, and always) for items related to: patient history; diagnostic tests; grip and upper limb strength; cervical and neurological assessment; and medical imaging. To establish practices, the five response categories were dichotomised into routine practice (often, always) and not-routine practice (sometimes, rarely, never). A response rate of ≥70% for each dichotomy was used to determine whether an assessment item was deemed routine practice or not, with items not meeting either criterion considered neither routine nor not-routine practice.

RESULTS

Most respondents were from United States (63%). The 'chair pick up test', 'cervical special tests', and 'plain radiograph' met our criteria for not routine practice (i.e., 70%, 72%, and 71%, respectively). All other assessment items did not meet the criteria to be considered routine or not-routine practice.

CONCLUSION

The chair pick-up test, cervical spine special tests (e.g., Spurling's test), and plain radiography appear to not be routinely used in the assessment of LET. The finding that no assessment technique met the criteria for routine use may imply that physiotherapists adopt a nuanced approach to selecting clinical assessment items as opposed to routinely applying tests.

High Versus Low-Energy Extracorporeal Shockwave Therapy for Chronic Lateral Epicondylitis: A Retrospective Study

Background: Chronic lateral epicondylitis (LE), also known as tennis elbow, affects 1-3% of the population, primarily those over 40 years old. Most cases resolve with conservative treatments, but some require more advanced interventions. Extracorporeal shockwave therapy (ESWT) has emerged as a non-surgical treatment option, utilizing either low- or high-energy levels to alleviate pain and improve function. Objective: This study aimed to compare the efficacy of low-energy versus high-energy ESWT in the treatment of chronic LE, focusing on pain relief and functional improvement. Methods: A retrospective observational study was conducted including patients treated for chronic LE between 2021 and 2024. Participants were divided into two groups: low-energy ESWT (0.10 mJ/mm2) and high-energy ESWT (0.20 mJ/mm2). Both groups received 2400 pulses at a frequency of 6 Hz once a week for three weeks. Pain and functional outcomes were measured using a visual analog scale (VAS) and the Patient-Rated Tennis Elbow Evaluation Questionnaire (PRTEE) at the baseline, three months (T1), and six months (T2) post-treatment. Results: Forty-six patients participated, with 24 in the low-energy group and 22 in the high-energy group. Baseline demographics and clinical characteristics were similar across groups. At T1 and T2, the low-energy group showed significantly greater reductions in the VAS scores (T1: 4.45 ± 0.8 vs. 3.6 ± 1.7, p = 0.04; T2: 3.2 ± 1.2 vs. 2.1 ± 1.1, p = 0.004) and PRTEE scores (T1: 34.3 ± 6.9 vs. 26.8 ± 11.9, p = 0.03; T2: 25.3 ± 6 vs. 17.6 ± 9, p = 0.005). Significant treatment-time interactions were observed for both the VAS and PRTEE scores, indicating sustained improvements in the low-energy group. Conclusions: Low-energy ESWT was more effective than high-energy ESWT in treating chronic LE, providing greater and longer-lasting pain relief and functional improvement. These findings suggest that low-energy ESWT should be preferred in clinical practice for managing this condition. Future research should focus on larger sample sizes and randomized controlled trials to confirm these results and explore the underlying mechanisms of differential efficacy between energy levels.

Lateral and Medial Elbow Tendinopathy and Previous Injuries to Adjacent Joints: A Multicenter Observational Study

BACKGROUND

Lateral and medial elbow tendinopathies are common soft tissue disorders affecting 1-3% of the general population, causing significant pain and functional impairment in the elbow and upper limb. While often associated with overuse and repetitive strain, their exact etiology, including potential associations with prior injuries in adjacent joints, remains unclear. This preliminary study aims to explore the distribution of lateral and medial elbow tendinopathies and investigate the occurrence of previous lesions in adjacent joints among diagnosed individuals, providing foundational insights for future research.

METHODS

A multicenter cross-sectional observational study was conducted involving 90 subjects diagnosed with lateral and/or medial elbow tendinopathy. The data collection occurred during the initial consultations, including demographic information, clinical assessments, and history of prior injuries in adjacent joints.

RESULTS

Among the sample, 44.4% reported prior injuries to adjacent joints in the affected upper limb, with 45.6% of these injuries identified as musculotendinous in nature. The analysis also showed that the type of elbow tendinopathy was significantly associated with sex (p = 0.01) and occupational origin (p = 0.022).

CONCLUSIONS

While a notable percentage of the subjects reported prior musculoskeletal injuries in the same limb, the study's geographic limitations and reliance on self-reported data introduce potential recall bias. These preliminary findings suggest a possible relationship between prior adjacent joint injuries and elbow tendinopathy. Further research with larger sample sizes and more rigorous study design is needed to confirm these observations and explore the underlying mechanisms.

Regeneration of full thickness common extensor tendon tear after percutaneous microfragmented adipose graft

Tennis elbow, also commonly known as lateral epicondylitis or common extensor tendinosis, is a common musculoskeletal injury in the adult population. Currently, the standard treatment regimen prescribed for this injury involves a combination of rest, physical therapy, bracing and anti-inflammatory medications. If refractory to these conservative measures, platelet-rich plasma has been shown effective. However, in the case of full thickness tears, surgery has remained the only treatment option until now. We present a case report of a 56-year-old man with a diagnosis of a left large full thickness tear and rupture with retraction of his common extensor tendon (CET) following a corticosteroid injection. The patient was treated with microfragmented adipose transfer. He was re-evaluated around 7 weeks and again at 15 weeks post-treatment and demonstrated ultrasound evidence of complete bridging and remodeling of his prior full thickness CET tear and resolution of retraction. This case presents a promising option for patients with full thickness CET tears who would like to refrain from or are unable to have surgery. Further research and possible randomized controlled trials are needed to further assess the full efficacy of microfragmented adipose transfer in the treatment of full thickness CET tears.

Effects of extracorporeal shockwave therapy versus ultrasonic therapy and deep friction massage in the management of lateral epicondylitis: a randomized clinical trial

The study's goal was to compare and evaluate the benefits of deep friction massage and ultrasonic therapy (US) vs extracorporeal shockwave therapy (ESWT) for people with lateral epicondylitis. This double-blind, parallel-arm randomized clinical trial was conducted after ethical approval on a sample of 80 subjects with lateral epicondylitis. Participants were enrolled based on predefined eligibility criteria. They were randomly allocated to groups A and B. Group A received ESWT, while Group B received the US combined with deep friction massage. Data was collected using the Numeric Pain Rating Score (NPRS) and Patient-rated tennis elbow evaluation questionnaire (PRTEE) at baseline, at 3rd, and at 7th week of treatment. On the basis of the normality of the data, a non-parametric test was applied to evaluate between-group and within-group differences. P value ≤ 0.05 was considered significant. There was a significant difference between groups (p < 0.001). Comparisons of PRTEE scores at 3rd week and 7th week of intervention were found significant for both groups (p < 0.001). While considering between-group comparisons based on percentile scores of PRTEE at baseline, 3rd and 7th week of intervention, in group A Median (IQR) at the baseline was 24.00 (5.00), at 3rd week, 10.00 (5.00) and 7th week was 1.50 (2.50) and in group B Median (IQR) at the baseline was 25.00 (4.00), at 3rd week 19.50 (4.50) and at 7th week was 11.50 (2.50). The results were significant in both groups (p = 0.000), but between-group analysis revealed that ESWT is more effective in patients with lateral epicondylitis.

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow

BACKGROUND

Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes.

METHODS

Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs).

RESULTS

Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes.

CONCLUSIONS

The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.

Clinical and Ultrasonographic Effectiveness of Two Different Splints Used for the Treatment of Lateral Epicondylitis: A Prospective Randomized Controlled Study

OBJECTIVE

This study compares the clinical and ultrasonographic efficacy of 2 splint types, the lateral epicondylitis band (LEB) and the wrist extensor splint (WES), for treatment of lateral epicondylitis (LE).

DESIGN

Randomized controlled single-blind trial.

SETTING

Outpatient clinic.

PARTICIPANTS

159 participants diagnosed with unilateral LE based on clinical and ultrasonographic findings, and 2-12 weeks from symptom onset, were included (N=159).

INTERVENTIONS

One group received joint-protection education-only (wait-and-see), while the other 2 groups were fit with splints: one the LEB and the other the WES. Both splint groups received joint-protection education.

MAIN OUTCOME MEASURES

The primary outcome measure was the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire. Secondary outcome measures were the Visual Analog Scale (VAS) for pain, hand grip strength by dynamometry, algometric measurements, patient satisfaction, and selected ultrasonographic parameters (maximum tendon thickness measurements (MTTM) in the capitellar-radiocapitellar region and total ultrasonography scale score [TUSS]). All outcomes were assessed at baseline, 3-weeks, and 6-weeks post intervention initiation.

RESULTS

Participants' mean age was 46.85±8.63 years. Of the participants, 40.88% (n=65) were male and 59.12% (n=94) were female. The baseline median (1Q-3Q) values of PRTEE-total scores were 58.5 (51-68) for the LEB, 63.5 (56.25-70.25) for the WES and 57 (48-68) for the education-only groups. At 6-weeks, the PRTEE-total scores had decreased by 44 points for those randomized to the LEB, 46 points to the WES and 7 points in the education-only groups(P<.001). While the LEB and WES approaches were superior to the wait-and-see approach in algometric measurements, VAS, and PRTEE scores (P<.05), no significant changes were found in MTTM and TUSS values. The LEB group was superior to the WES group in hand grip strength and patient satisfaction (P<.05).

CONCLUSION

Using either splint for 6 weeks can be considered effective for the relief of pain and increased functionality in persons with subacute LE, although the LEB had a more positive effect on grip strength and patient satisfaction than the WES.

Effects of a Conventional Treatment Plus Scapular Exercises Program in Patients With Chronic Lateral Elbow Tendinopathy: A Pre-Post Single-Group Study

BACKGROUND

Weakness of the shoulder girdle muscles has been reported in patients with chronic lateral elbow tendinopathy. The aim of this study was to assess the short- and long-term effects of a conventional treatment plus scapular exercises program in patients with chronic lateral elbow tendinopathy.

METHODS

A single-group prestudy and poststudy were conducted. The primary outcome was the Patient-Rated Tennis Elbow Evaluation questionnaire score. Secondary outcomes were grip strength; Disabilities of the Arm, Shoulder, and Hand questionnaire score; Visual Analogue Scale score at rest and at grip, and presence of scapular dyskinesis.

RESULTS

A total of 65 patients (72.3% females), with a mean age of 41.8 years, were analyzed. At the end of 6 weeks, the results showed clinically and statistically significant differences (P < .05). At 1-year follow-up, the differences were: Patient-Rated Tennis Elbow Evaluation -31 points (P < .001); grip strength +33.6% (P < .001); Disabilities of the Arm, Shoulder, and Hand -34.2 points (P < .001); Visual Analogue Scale at rest -2.5 cm (P < .001); and Visual Analogue Scale at grip -2.3 cm (P < .001).

CONCLUSION

At the end of 6 weeks and at 1-year follow-up, conventional treatment plus scapular exercises program showed statistically and clinically significant differences in all functional outcomes assessed in patients with lateral elbow tendinopathy.

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

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

Wrist Extensor Training With Blood Flow Restriction for the Management of Lateral Elbow Tendinopathy: A Case Report

Lateral elbow tendinopathy (LET) is a common overuse injury with complex underlying pathophysiological mechanisms. Although several modes of exercise with or without passive interventions have been recommended as the first-line treatment option of the condition, their effectiveness remains inconclusive. The aim of this case report is to evaluate the effect of wrist extensor exercises with blood flow restriction (BFR) as an add-on intervention to a multi-modal physiotherapy programme to improve outcomes in a patient with LET. A 51-year-old male patient presented with a history of right LET for six months. Interventions included wrist extension exercise with BFR, a two-stage progressive loading training programme of the upper limb, soft-tissue massage, education and a home exercise programme for six weeks (12 visits). A substantial improvement in pain intensity, pain-free grip strength, Patient Rated Tennis Elbow Evaluation score and self-perceived recovery was reported at three-, six-, and 12-week follow-up measurements. A 21% reduction in pressure pain thresholds at the lateral epicondyle was found immediately after wrist extensor exercise with BFR. Based on our findings, adding wrist extensor exercises with BFR to a multimodal physiotherapy programme seems a promising approach to improve the treatment outcome in LET. Nonetheless, further research is needed to confirm the present results.

Lateral Epicondylitis: Critical Analysis Review of Current Nonoperative Treatments

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Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm.

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The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time.

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Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments.

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In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

Differences in Clinical Tests for Assessing Lateral Epicondylitis Elbow in Adults Concerning Their Physical Activity Level: Test Reliability, Accuracy of Ultrasound Imaging, and Relationship with Energy Expenditure

BACKGROUND

Physical activity (PA) can generate physical stress on the musculoskeletal system. Thus, the aim of the current study was to assess the influence of the level of physical activity on clinical tests used in the diagnosis of lateral epicondylitis in adults, intertest reliability and accuracy based on ultrasound imaging, and relationship with energy expenditure.

METHODS

102 adults with lateral epicondylitis were assessed via an International Physical Activity Questionnaire and divided according to PA level: low (n = 19) moderate (n = 42) or high (n = 41). Pain (visual analog scale), Cozen's and Mill's clinical tests and ultrasound exams were performed.

RESULTS

The Cozen's and Mill's tests differed among PA levels. Excellent reliability was found for Mill's test for PA levels and the ultrasound exam (low ICC = 1.0, moderate ICC = 0.82 and high ICC = 0.99). Good reliability was found for Cozen's test (low ICC = 0.80, moderate ICC = 0.74 and high ICC = 0.73), but with significant differences between the ultrasound exams. The Cozen's and Mill's clinical tests had no relationship to the level of energy expenditure for PA levels.

CONCLUSION

Mill's test was reliable and accurate for the PA levels. Intertest reliability was poor for the PA levels. Mill's test proved to be accurate based on the ultrasound exam. The pain caused by the tests was not related to the level of energy expenditure.

A New Test for the Advanced Diagnosis of Lateral Elbow Tendinopathy with Concomitant Intrasubstance Tear: Failure to Resist Extension Effort (the Free Test)

Background

Lateral elbow tendinopathy (LET) is one of the most common causes of musculoskeletal pain. The diagnosis is based on the clinical history and different physical maneuvers. Ultrasound (US) is a complementary diagnostic method to detect degenerative tendon changes and intrasubstance tears (IST). To date, there is no available physical maneuver to identify an IST in patients with LET.

Aim

To evaluate the diagnostic accuracy of an index test to detect an IST confirmed by ultrasound in patients with LET.

Methods

A diagnostic retrospective study was performed. Patients who presented medical records with LET were recruited. Two orthopaedic surgeons developed the physical maneuver. The index test was considered positive when the position failed to resist the wrist extension maximum effort. Clinical findings were associated with confirmation of IST by US. Data were calculated using diagnostic accuracy, sensitivity, and specificity with 95% confidence intervals.

Results

Thirty-nine patients (39 elbows) were analyzed, 25 (64%) women and 14 (36%) men, with an average age of 47.7 years. The index test's sensitivity was 0.86 (95% CI, 0.67-0.96). Accuracy was 0.79 (95% CI, 0.64-0.91), and the specificity was 0.64 (95% CI, 0.31-0.89).

Conclusion

The index test presented very good sensitivity and good accuracy in patients with LET with US diagnostic confirmation of IST.

Level of Evidence

Diagnostic study, Level III.

Low-Load Resistance Training With Blood Flow Restriction Is Effective for Managing Lateral Elbow Tendinopathy: A Randomized, Sham-Controlled Trial

OBJECTIVE: To evaluate the effect of low-load resistance training with blood flow restriction (LLRT-BFR) when compared to LLRT with sham-BFR in patients with lateral elbow tendinopathy (LET). DESIGN: Randomized controlled trial. METHODS: Forty-six patients with LET were randomly assigned to a LLRT-BFR or a LLRT with sham-BFR treatment group. All patients received soft tissue massage, supervised exercises with BFR or sham intervention (twice a week for 6 weeks), advice, and a home exercise program. The primary outcome measures were pain intensity, patient-rated tennis elbow evaluation (PRTEE) score, pain-free grip strength, and global rating of change, measured at baseline, 6 weeks, and 12 weeks. Between-group differences were evaluated using mixed-effects models with participant-specific random effects for continuous data. Global rating of change was analyzed using logistic regression. RESULTS: Statistically significant between-group differences were found in favor of LLRT-BFR compared to LLRT with sham-BFR in pain intensity at 12-week follow-up (-1.54, 95% CI: -2.89 to -0.18; P = .026), pain-free grip strength ratio at 6-week follow-up (0.20, 95% CI: 0.06 to 0.34; P = .005), and PRTEE at 6- and 12-week follow-up (-11.92, 95% CI: -20.26 to -3.59; P = .006, and -15.23, 95% CI: -23.57 to -6.9; P<.001, respectively). At 6- and 12-weeks, patients in the LLRT-BFR group had greater odds of reporting complete recovery or significant improvement (OR = 6.0, OR = 4.09, respectively). CONCLUSION: Low-load resistance training with blood flow restriction produced significantly better results compared to the LLRT with sham-BFR for all primary outcomes. Considering the clinically significant between-group improvement in function (>11 points in PRTEE) and the better success rates in the LLRT-BFR group, this intervention may improve recovery in LET. J Orthop Sports Phys Ther 2022;52(12):803-825. Epub: 14 September 2022. doi:10.2519/jospt.2022.11211.

Effectiveness of High-Intensity Laser Therapy Plus Ultrasound-Guided Peritendinous Hyaluronic Acid Compared to Therapeutic Exercise for Patients with Lateral Elbow Tendinopathy

Lateral elbow tendinopathy (LET) is a common painful musculoskeletal disorder. Several treatments have been proposed to provide pain reduction and functional recovery, including laser therapy, hyaluronic acid peritendinous injection (Hy-A), and therapeutic exercise (TE). Our study aims to assess the effectiveness of a combined approach with high-intensity laser therapy (HILT) and Hy-A injections compared to TE on pain, muscle strength, and disability in patients with painful LET. A retrospective longitudinal study was carried out by consulting the medical records of patients with a diagnosis of painful LET formulated by clinical and instrumental findings that received functional evaluations, including the Patient-Rated Tennis Elbow Evaluation (PRTEE) and muscle strength measurement at least four times: T0 (“baseline”), 1-month (T1), 3-month (T2), and 6-month follow-ups (T3). Medical records of 80 patients were analyzed. In the HILT + HyA group, the Peak-strength (p < 0.001) and mean strength (p < 0.001) significantly increased compared to the TE group between study times. For the PRTEE-total-score as for the subscales, the HILT + HyA group reported statistically significant reductions only for the comparisons of baseline versus T1 and baseline versus T2. No serious adverse events occurred. Our findings suggest that Hy-A associated with HILT might be more effective than TE for people with LET in the short−medium term.

Comparison of Hyaluronate & Steroid Injection in the Treatment of Chronic Lateral Epicondylitis and Evaluation of Treatment Efficacy With MRI: A Single-Blind, Prospective, Randomized Controlled Clinical Study

Introduction: Injection therapy in refractory cases of lateral epicondylitis might relieve symptoms, although no consensus exists on which material to use. Corticosteroids are widely used but recent literature indicated possible tenotoxic effects and inefficacy in mid- and long-term follow-up (FU). Hyaluronate/hyaluronic acid (HA) might be of better clinical efficacy. Magnetic resonance imaging (MRI) might reflect the clinical changes in the short-term FU.

Methods: A single-blind, prospective, randomized controlled study was designed. A total of 80 patients were included. A total of 40 patients received a single triamcinolone injection and 40 received a hyaluronic acid (HA) injection. Follow-up was repeated at six and 12 weeks. The shortened disabilities of the arm, shoulder, and hand questionnaire (Q-DASH) score; visual analog scale (VAS) for pain at rest, and hand grip strength were collected. Dynamometer measurements were done at baseline and FU examinations. The MRI images at baseline and 12 weeks FU were evaluated.

Results: There were significant differences between the groups favoring the triamcinolone group at six weeks. At 12 weeks, no differences existed between the groups in any of the parameters. The MRI grades were nonsignificantly different between baseline and at 12 weeks.

Conclusion: Both triamcinolone and HA were shown to relieve pain and increase functional outcomes. However, the effects were short-lived. The MRI did not show significant differences at 12 weeks, although clinical improvements were substantial.

Treatment, Diagnostic Criteria and Variability of Terminology for Lateral Elbow Pain: Findings from an Overview of Systematic Reviews

Background: Lateral elbow pain (LEP) represents a musculoskeletal disorder affecting the epicondyloid region of the elbow. The terminological framework of this problem in literature, to date, is confusing. This systematic review (SR) aims to analyse the panorama of the scientific literature concerning the pathogenetic framework, treatment, and clinical diagnosis of LEP. Methods: We conducted an SR according to the guidelines of the PRISMA statement. We performed research using the electronic Medline, Epistemonikos, and Cochrane Library databases. The research started on 12 January 2022 and finished on 30 April 2022. We included all systematic reviews and meta-analyses published, in English, between 1989 and 2022. The articles’ selection was based on critical appraisal using Amstar 2. In the selected reviews we obtained the etiopathogenic terminology used to describe the symptoms, treatment, and diagnostic criteria of LEP. Results: Twenty-five SRs met the eligibility criteria and were included in the study. From these SRs, 227 RCT articles were analysed and different treatments proposals were extracted, such as exercise, manipulation corticosteroid injection, and surgery. In the selected articles, 10 different terms emerged to describe LEP and 12 different clinical tests. The most common treatments detected in this SR were a conservative multimodal approach (e.g., eccentric exercises, manual therapy, acupuncture, ultrasound), then surgery or other invasive treatments (e.g., corticosteroid injection, tenotomy). The most common term detected in this SR was “lateral epicondylitis” (n = 95, 51.6%), followed by “tennis elbow” (n = 51, 28.1%) and “lateral epicondylalgia” (n = 18, 9.4%). Among the diagnostic tests were painful palpation (n = 101, 46.8%), the Cozen test (n = 91, 42.1%), the pain-free grip-strength test (n = 41, 19.0%), and the Maudsley test (n = 48, 22.2%). A total of 43.1% of RCTs (n = 96) included subjects with LEP > 3 months, 40.2% (n = 85) included patients with LEP < 3 months, and 16.7% of the items (n = 35) were not specified by the inclusion criteria on the onset of symptoms. Conclusions: In this SR, a considerable terminological heterogeneity emerged in the description of LEP, associated with the lack of clear and recognised diagnostic criteria in evaluating and treating patients with lateral elbow pain.

Greek physiotherapists' contemporary knowledge and practice for lateral elbow tendinopathy: An online survey

OBJECTIVES

To investigate physiotherapists' current knowledge and practice in the management of patients with lateral elbow tendinopathy, to explore associations between the participants' education and management preferences and to identify potential evidence-to-practice gaps by making comparisons with recent research recommendations.

DESIGN

An on-line cross-sectional survey.

SUBJECTS

Registered physiotherapists working in Greece with previous experience in the management of lateral elbow tendinopathy.

RESULTS

Three hundred and seventy eight responses met the inclusion criteria. Most responders (70.4%-91.5%) use pain provocation tests for the diagnosis of the condition, while a limited proportion uses patient rated outcome measures (6.9%-13%). Supervised exercise is the mainstay of rehabilitation (92.6%), followed by adjunctive research recommended treatment techniques such as manual therapy (72%) and advice (59.5%). Up to 83.6% of participants use adjunctive treatment techniques that are not recommended or without research recommendation (such as electrophysical agents, ice etc.). Physiotherapists with post-graduate education in musculoskeletal physiotherapy are almost three times more likely to choose only research recommended treatment approaches. There is a lack of consensus in an optimal exercise programme (type, volume, duration etc.) in patients with lateral elbow tendinopathy.

CONCLUSION

Despite research recommendations a limited use of patient rated outcome measures in lateral elbow tendinopathy is recorded. Supervised exercise is the first line treatment option for most physiotherapists, although the optimal application is still unclear. A large proportion of physiotherapists apply adjunctive treatment techniques that are either ineffective or poorly researched suggesting a substantial evidence-to-practice gap. Better access to knowledge, organisational and peer-support can potentially help to bridge this gap.

Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of extracorporeal shockwave therapy compared with other interventions on pain, grip strength and disability in patients with lateral elbow tendinopathy.

DATA SOURCES

MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, Cochrane Library and clinical trial registries.

REVIEW METHODS

We included randomized controlled trials assessing the effectiveness of extracorporeal shockwave therapy alone or as an additive intervention compared with sham or other interventions. Pain intensity, grip strength and elbow disability were used as primary outcome measures. We assessed methodological quality with the PEDro score and quality of evidence with the GRADE approach.

RESULTS

Twenty-seven studies with 1871 patients were finally included. Extracorporeal shockwave therapy reduced pain intensity at mid-term follow-up (standardized mean difference: -1.21, 95% confidence interval:-1.53, -0.89, P < 0.001) and improved grip strength at very short- (mean difference:3.92, 95% confidence interval: 0.91, 6.94, P = 0.01) and short-term follow-up (mean difference:4.87, 95% confidence interval:2.24, 7.50, P < 0.001) compared with sham treatment. However, no clinically significant results were found between comparators in all outcomes and follow-up times. Extracorporeal shockwave therapy presented clinically better compared to Laser in grip strength at short-term (mean difference:3.50, 95% confidence interval:2.40, 4.60, P < 0.001) and ultrasound in pain intensity at very-short-term follow-up (standardized mean difference: -1.54, 95% confidence interval: -2.60, -0.48, P = 0.005).

CONCLUSION

Low to moderate certainty of evidence suggests that there are no clinical benefits of extracorporeal shockwave therapy compared to sham interventions or corticosteroid injections. Based on very-low and moderate certainty of evidence, extracorporeal shockwave therapy outperforms against Laser and ultrasound, respectively.Level of Evidence: Therapy, level 1a.