Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy

Initial PROMIS Scores Correlate With Operative and Nonoperative Management of Lateral Epicondylitis

BACKGROUND

Lateral epicondylitis (LE) is a common source of elbow pain. Treatment options include physical therapy (PT), corticosteroid injection, or surgery, but the efficacy of each remains unclear. In this study, we compare Patient-Reported Outcomes Measurement Information System (PROMIS) scores between patients treated both operatively and nonoperatively for LE.

METHODS

Patients presenting to a tertiary academic medical center from February 2015 to December 2018 with a diagnosis of LE were identified. Those with initial and follow-up PROMIS physical function (PF), pain interference (PI), and Depression scores were included and stratified according to treatment. Single-factor analysis of variance testing was used to compare PROMIS scores between intervention types.

RESULTS

In all, 982 patients were initially identified with the diagnosis of LE and documented PROMIS scores. Initial treatment consisted of 266 patients receiving formal PT, 238 patients receiving injections, 20 patients undergoing surgery, and 296 patients receiving no formal treatment. At final follow-up, 235 (44.8%) patients had been treated with isolated PT, 237 (45.1%) with injections, and 52 (9.9%) with surgery. Patients who underwent formal PT had the highest initial PF scores when compared with all other interventions. Patients who underwent operative management had higher initial PI scores than those who pursued nonoperative management.

CONCLUSIONS

Patient-Reported Outcomes Measurement Information System PF and PI may be useful for determining which treatment course patients suffering from LE are likely to pursue. Pain as a limiting factor in daily living may be a better indication for operative management as opposed to physical metrics.

Modified arthroscopic tenotomy of the extensor carpi radialis brevis for refractory lateral epicondylitis: a cohort study

BACKGROUND

Different arthroscopic techniques exist for managing the extensor carpi radials brevis (ECRB) when treating refractory lateral epicondylitis. The purpose of this study is to compare the outcomes of a standard arthroscopic débridement with ECRB tendon release to an arthroscopic ECRB tenotomy distal to its insertion without débridement using a retrospective cohort study design.

METHODS

This study included patients underwent arthroscopic treatment of lateral epicondylitis during 2 different time periods: 2016-2019 (débridement) and 2019-2021 (modified tenotomy without débridement). Patients were assessed preoperatively and at the last follow-up with Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analog Scale of pain.

RESULTS

A total of 69 patients completed the follow-up (38 in the débridement group and 31 in the tenotomy group). Patients in both groups showed significant improvements were found in MEPS, DASH, and Visual Analog Scale after surgery. Patients in the tenotomy group had higher MEPSs and reported less pain with a minimum 2 year follow-up after surgery. DASH scores between groups were similar at all time periods.

CONCLUSION

Arthroscopic modified tenotomy of the ECRB without débridement improves function and pain significantly for patients with refractory lateral epicondylitis, which is not inferior to arthroscopic débridement technique.

A Review of Physiotherapy Techniques Used in the Treatment of Tennis Elbow

Tennis elbow, a common musculoskeletal disorder also known as lateral epicondylitis, causes pain and tenderness on the outside of the elbow. Although it is frequently linked to repetitive motions, such as those in racquet sports, it can affect people in a variety of occupations and activities. Tennis elbow can be treated conservatively with physiotherapy, which focuses on pain management, functional recovery, and recurrence prevention. The goal of this review is to give a thorough overview of the physiotherapy methods used to treat tennis elbow. In order to determine the most effective treatment options, it is crucial to comprehend the pathophysiology and etiology of tennis elbow from the outset of the study. The assessment and diagnosis of tennis elbow are next covered, emphasizing the importance of physiotherapists in correctly diagnosing the ailment and distinguishing it from other musculoskeletal problems that are comparable to it. This study primarily focuses on the numerous physiotherapy therapies for tennis elbow, which may include but are not limited to, and the section examines the use of manual treatments to treat pain and enhance joint function, including joint mobilizations, soft tissue massage, and myofascial release. Exercise rehabilitation covers the value of tailored workouts to bolster the weak muscles and enhance the elbow joint's biomechanics. Numerous workout regimens are covered, such as eccentric training and progressive resistance exercises, as well as modalities. Therapeutic agents frequently make use of modalities such as ultrasound, laser therapy, and cryotherapy. It may also make use of complementary therapeutic agents such as taping and bracing. In summary, this in-depth analysis highlights the crucial role that physical therapy plays in the treatment of tennis elbow. It seeks to give practitioners a useful tool for enhancing the care and results of patients with this common and crippling ailment by summarizing the most recent research and best practices in physiotherapy approaches.

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

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.

The Beneficial Effects of Eccentric Exercise in the Management of Lateral Elbow Tendinopathy: A Systematic Review and Meta-Analysis

As a first-line treatment for lateral elbow tendinopathy (LET), eccentric exercise has been suggested as a conservative treatment method. This study aimed to investigate the impact of eccentric exercise on LET with regard to pain reduction, and strength and functional improvement. The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched, and studies up to May 2021 were included if (1) randomization was used for patient allocation, (2) the study comprised patients with LET, (3) the intervention was eccentric exercise, and (4) the primary outcomes included improvement in pain intensity, muscle strength, or function. The meta-analysis comprised of six studies, totaling 429 participants. Additional eccentric exercise with underlying adjuvant therapy significantly improved the visual analog scale (VAS) scores (standardized mean difference [SMD], −0.63; 95% confidence interval [CI], −0.90–−0.36) and muscle strength (SMD, 1.05; 95% CI, 0.78–1.33) compared with adjuvant therapy alone. Compared with the concentric or isotonic exercise group, the eccentric exercise group showed significantly improved VAS scores (SMD, −0.30; 95% CI, −0.58–−0.02). However, no differences in muscle strength and function were observed between the two groups. Eccentric exercise can improve pain and muscle strength in patients with LET. The limited number of included studies and heterogeneous exercise parameters are important when interpreting these findings.

Arthroscopic lateral capsule resection is enough for the management of lateral epicondylitis

PURPOSE

Controversy exists with regards to the etiology and treatment of lateral epicondylitis and the role of the lateral capsule in this pathology. The aim of this study was to compare arthroscopic lateral capsule resection with or without extensor carpi radialis brevis (ECRB) tendon debridement for treatment of lateral epicondylitis.

METHODS

This is a retrospective study of 38 patients who underwent arthroscopic surgery for LE with two different techniques: Eighteen patients were treated with arthroscopic lateral capsular resection (LCR) + ECRB debridement and 20 patients were treated with arthroscopic LCR alone, without ECRB debridement. Both groups were assessed with Quick Disabilities of the Arm, Shoulder and Hand (QDASH) score for function and Visual Analog Scale (VAS) score for pain.

RESULTS

Quick DASH scores were 12 [Formula: see text] 5 and 13 [Formula: see text] 4 at Groups 1 and 2, respectively, without any statistically significant difference. VAS pain scores were 15 [Formula: see text] 2 for both groups. VAS function scores were 85 [Formula: see text] 22 and 86 [Formula: see text] 18 at Groups 1 and 2 respectively. Sick leave periods in terms of weeks were 7 [Formula: see text] 5 and 7 [Formula: see text] 4 at Groups 1 and 2, respectively. There was no statistically significant difference in outcome of the two groups compared in terms of VAS pain, function scores, failure (re-operation) rates and sick leave period at the end of final follow-up.

CONCLUSION

Both arthroscopic LCR alone and Arthroscopic LCR with ECRB debridement for the management of refractory LE provide significant improvement in pain and function. Isolated Arthroscopic LCR could be a sufficient surgical treatment for refractory LE. Thus, ECRB debridement or release may not be necessary in every case.

LEVEL OF EVIDENCE

IV.

Comparing the efficacy of continuous and pulsed ultrasound therapies in patients with lateral epicondylitis: A double-blind, randomized, placebo-controlled study

Objectives

The aim of this study was to investigate the efficacy of continuous and pulsed ultrasound therapies in lateral epicondylitis.

Patients and methods

A total of 51 patients (18 males, 33 females; mean age: 46.52±6.16 years; range, 27 to 64 years) who were diagnosed with lateral epicondylitis between February 2013 and October 2014 were included. The patients were randomized to either continuous ultrasound (n=17), pulsed ultrasound (n=17), or placebo (n=17) groups. First group received 10 sessions of continuous ultrasound therapy. The second group received 10 sessions of pulsed ultrasound therapy in a ratio of 1:4. The third group received 10 sessions of placebo treatment. The pain levels of the patients were evaluated using Visual Analog Scale (VAS). The muscle strength was evaluated using a dynamometer. For functional evaluation, Duruöz’s Hand Index (DHI) and Patient-Rated Tennis Elbow Evaluation (PRTEE) scales were used. Assessments were made at baseline, at the end of therapy, and one month after therapy. The thickness of the common extensor tendon was also measured using ultrasonic imaging at baseline and at the end of therapy.

Results

At the end of the study, there was a statistically significant improvement in the rest and activation VAS scores, and DHI and PRTEE scores in both continuous and pulsed ultrasound therapy groups, compared to placebo (p<0.05). However, no superiority was found between the continuous and pulsed ultrasound therapy groups (p>0.05). A statistically significant reduction in the common extensor tendon thickness was found only in the pulsed ultrasound therapy group (p<0.05).

Conclusion

Our study results show that both continuous and pulsed ultrasound applications are effective in the treatment of lateral epicondylitis.

Participant characteristics are poorly reported in exercise trials in tendinopathy: A systematic review

OBJECTIVE

To evaluate the reporting of eligibility criteria and baseline participant characteristics in randomised controlled trials investigating the effects of exercise interventions in tendinopathy.

METHODS

Randomised controlled trials investigating the effects of exercise therapy compared to a non-exercising intervention in upper and lower limb tendinopathy were included. Data extraction was categorised into the following domains: participant demographics, tendinopathy descriptors, general health, participant recruitment and eligibility criteria.

RESULTS

The review included the following tendinopathies: Achilles (n = 9), gluteal (n = 2), lateral elbow tendinopathy (n = 15), patellar (n = 3) plantar (n = 3), and rotator cuff (n = 13). Age, sex, duration of symptoms and symptom severity were commonly reported across the review, while prior history of tendinopathy was poorly reported (6/45). Variables such as physical activity level (17/45), sleep (0/45), psychological factors (2/45), medication at baseline (8/45), co morbid health complaints (10/45) and sociodemographic factors (11/45) were poorly reported across the included studies. Substantial variation existed between studies in the specific eligibility criteria used.

CONCLUSION

The findings of this systematic review demonstrate that participant characteristics are poorly reported in exercise trials in tendinopathy. To improve effectiveness of exercise interventions in tendinopathy, improved reporting of participant characteristics may allow better comparisons and targeted interventions for specific subgroups.

Medium-term results after treatment of percutaneous tennis elbow release under local anaesthesia

Background:

The purpose of this study was to evaluate the results of the technique of percutaneous release of common extensor procedure under local anesthesia for lateral epicondylitis and to emphasize its simplicity.

Methods:

Forty seven elbows (41 patients) were treated surgically for lateral epicondylitis in the outpatient minor procedure room under local anaesthesia. The indication for surgery was continuation of sypmtoms (such as pain, movement and power loss) despite conservative treatment lasting more than six months The treatment results were assessed using the visual analogue scale (VAS) and Mayo Elbow Performance Score (MEPS).

Results:

Twentysix right elbows and fifteen left elbows were treated surgically. Dominate elbow rate was 74%. The follow-up period was 36 to 72 months (mean 52 months). All patients had full range of motion. The average post operative pain score was 2.6(range 0 to 9). The average post operative MEPS score was 82 (range 40 to 100). ). Sixteen patients had excellent, twenty patients had good, two patients had fair and three patients had poor outcomes (repetitive problems).

Conclusion:

The percutaneous release of the common extensor origin is an important treatment option with minimal morbidity, safety, simplicity and good to excellent results in most patients. The procedure can be performed under local anaesthetic and leave a rarely visible scar. (www.actabiomedica.it)

Lateral epicondylalgia: A primary nervous system disorder

Lateral epicondylalgia (LE) is the most common chronic painful condition affecting the elbow in the general population. Although major advances have been accomplished in recent years in the understanding of LE, the underlying physiopathology is still a reason for debate. Differences in clinical presentation and evolution of the symptoms among patients, suggest the need for revisiting the current knowledge about subjacent mechanisms that attempt to explain pain and functional loss. Previous models have suggested that the condition is mainly a degenerative tendinopathy, associated with changes in pain pathways and the motor system. The hypothesis of this work is that LE is the clinical manifestation of a primary nervous system disorder, characterized by an abnormal increase in neuronal activity and a subsequent loss of homeostasis, which secondarily affects the musculoskeletal tissues of the elbow-forearm-hand complex. A new model for LE is presented, supported by an in-deep analysis of basic sciences, epidemiological and clinical studies.

Effectiveness of Low Level Laser Therapy (LLLT) in the treatment of Lateral elbow tendinopathy (LET): an umbrella review

PURPOSE

The aim of this umbrella review is to determine the effectiveness of LLLT in the treatment of LET and to provide recommendations based on this evidence.

METHODS

A comprehensive and systematic review was undertaken using Medline, EBSCO and EMBASE. Systematic reviews or meta-analysis were included if they compared Laser with at least one of the following: (i) placebo, (ii) no treatment, (iii) another treatment, conservative (physical therapy intervention or medical) or operative of LET. Principal outcomes included the assessment of short and long-term effect on functional status, pain, grip strength (pain-free or maximum) and a global measure (overall improvement).

RESULTS

Seven papers met the inclusion criteria for the umbrella review, Five papers were of moderate and two of low methodological quality. All reviews reported benefits associated with laser therapy Vs other intervention or placebo, however the significance of the identified benefits differed between studies and reviews. No review reported negative effects of laser therapy or harm to patients. All reviews noted significant variance between included studies with 2 reviews citing statistically significant heterogeneity. It is essential to consider this in the interpretation of these data.

CONCLUSION

This umbrella review found poor results for the effectiveness of LLLT in the management of LET. Therefore, further research with well-designed RCTs is required to provide meaningful evidence on the effectiveness (absolute and relative) of LLLT for the management of LET.

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

STUDY DESIGN

RCT.

INTRODUCTION

Lateral elbow tendinopathy is a common clinical condition. eccentric exercises. eccentric-concentric loading and, isometric exercises are indicated to reduce and manage tendon pain.

PURPOSE OF THE STUDY

To compare the effectiveness of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy.

METHODS

A randomized clinical trial was carried out in a rheumatology and rehabilitation center. A group of 34 patients with later elbow tendinopathy was randomly allocated to Group A (n = 11) who underwent eccentric training, Group B had eccentric-concentric and Group C who had eccentric-concentric and isometric training. All patients received 5 treatments per week for 4 weeks. Pain was evaluated using a visual analog scale and function using a visual analog scale and pain-free grip strength at the end of the 4-week course of treatment (week 4) and 1 month (week 8) after the end of treatment.

RESULTS

The eccentric-concentric training combined with isomentric contractions produced the largest effect in the reduction of pain and improvement of function at the end of the treatment (P < .05) and at any of the follow-up time points (P < .05).

CONCLUSION

The eccentric-concentric training combined with isomentric contractions was the most effective treatment. Future well-designed studies are needed to confirm the results of the present trial.

LEVEL OF EVIDENCE

III.

Effect of Metabolic Syndrome on the Functional Outcome of Corticosteroid Injection for Lateral Epicondylitis: Retrospective Matched Case-Control Study

Both obesity and diabetes mellitus are well-known risk factors for tendinopathies. We retrospectively compared the efficacy of single corticosteroid injections in treating lateral epicondylitis in patients with and without metabolic syndrome (MetS). Fifty-one patients with lateral epicondylitis and MetS were age- and sex-matched with 51 controls without MetS. Pain severity, Disability of the Arm, Shoulder, and Hand score, and grip strength were assessed at base line and at 6, 12 and 24 weeks post-injection. The pain scores in the MetS group were greater than those in the control group at 6 and 12 weeks. The disability scores and grip strength in the MetS group were significantly worse than those of the control group at 6 weeks. However, there were no significant differences at 24 weeks between the groups in terms of pain, disability scores and grip strengths. After 24 weeks, three patients (6%) in the control group and five patients (10%) in the MetS group had surgical decompression (p = 0.46). Patients with MetS are at risk for poor functional outcome after corticosteroid injection for lateral epicondylitis in the short term, but in the long term there was no difference in outcomes of steroid injection in patients with and without MetS.

Comparison of muscle activity of wrist extensors and kinematics of wrist joint during wrist extension in automobile assembly line workers with and without lateral epicondylitis

BACKGROUND

Overuse of the extensor carpi radialis (ECR) may play a role in the development of lateral epicondylitis (LE). However, no studies have investigated the muscle activity ratio between the ECR and extensor carpi ulnaris (ECU) associated with the kinematics during wrist extension in workers with LE.

OBJECTIVE

We compared the ratio (ECR/ECU) of muscle activity between the ECR and ECU and the kinematics of the wrist during wrist extension between workers with and without LE.

METHODS

Fifteen automobile assembly line workers with LE and 15 workers without LE participated in this study. The ratio of muscle activity was measured using surface electromyography, and wrist kinematics were measured by a three-dimensional motion analysis system while the workers extended their wrists actively to the maximum range to which they did not feel uncomfortable.

RESULTS

Significantly greater ratios of muscle activity, ranges of radial deviation, and combined motion of radial deviation and extension (CMDE) were shown in workers with LE compared to those without LE. Also, the range of wrist extension was significantly lower in workers with LE than in those without LE.

CONCLUSIONS

Quantifying the ratio of muscle activity with altered kinematics of wrist extension may help researchers to understand why overuse of ECR is occurring and explain LE development in automobile assembly line workers.

Lateral elbow tendinopathy: Evidence of physiotherapy management

Lateral elbow tendinopathy (LET) is a common musculoskeletal/sports injury. A plethora of physiotherapy techniques has been proposed in the management of LET. The exercise programme is the most common treatment in the management of LET. The optimal protocol of exercise programme is still unknown. The effectiveness of the exercise programme is low when it is applied as monotherapy. Therefore, exercise programme is combined with other physiotherapy modalities such as soft tissue techniques, external support, acupuncture, manual therapy and electrotherapy, in the treatment of LET. Future research is needed to determine which treatment strategy combined with exercise programme will provide the best results in LET rehabilitation.

Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis

Objective: To compare the effectiveness of Cyriax physiotherapy, a supervised exercise programme, and polarized polychromatic non-coherent light (Bioptron light) in the treatment of lateral epicondylitis.

Design: Controlled clinical trial.

Setting: Rheumatology and rehabilitation centre.

Subjects: This study was carried out with 75 patients who had lateral epicondylitis. They were allocated to three groups by sequential allocation.

Interventions: Group A ( n=25) was treated with Cyriax physiotherapy. A supervised exercise programme was given to group B ( n=25). Group C ( n=25) received polarized polychromatic non-coherent light (Bioptron light). All patients received three treatments per week for four weeks.

Outcomes: Pain was evaluated using a visual analogue scale and function using a visual analogue scale and pain-free grip strength at the end of the four-week course of treatment (week 4), one month (week 8), three months (week 16) and six months (week 28) after the end of treatment.

Results: The supervised exercise programme produced the largest effect in the reduction of pain and in the improvement of function at the end of the treatment ( P<0.05) and at any of the follow-up time points ( P<0.05).

Conclusion: The supervised exercise programme should be the first treatment option for therapists when they manage lateral epicondylitis patients. If this is not possible, Cyriax physiotherapy and polarized polychromatic non-coherent light (Bioptron light) may be suitable.

Greek adaptation and validation of the Patient-Rated Tennis Elbow Evaluation (PRTEE)

PURPOSE OF THE STUDY

To cross-culturally adapt and validate the Greek version of the Patient-Rated Tennis Elbow Evaluation (PRTEE-G) Questionnaire.

METHODS

Four bi-lingual translators were involved in the translation and cultural adaptation procedures. Eighty-two patients (61 women and 21 men) with Lateral Elbow Tendinopathy (LET) participated in the study. To establish test - retest reliability, the patients were asked to complete the PRTEE-G Questionnaire before and after the first physiotherapy treatment. Internal consistency of the translated instrument was measured using Cronbach 'alpha'. An intraclass correlation coefficient was used to assess the test - retest reliability of the PRTEE-G Questionnaire. Concurrent validity was measured by correlating the PRTEE-G Questionnaire scores with the Greek version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores using Pearson's correlation coefficient.

RESULTS

The Greek PRTEE questionnaire has acceptable internal consistency (Cronbach 'alpha' = 0.95), excellent test - retest reliability (ICC = 0.94) and demonstrates expected concurrent validity (r > 0.72).

CONCLUSION

The Greek version of PRTEE Questionnaire is a reliable and valid measure when administered to patients with LET.

Arthroscopic Treatment of Lateral Epicondylitis: Tenotomy Versus Debridement

PURPOSE

To compare the outcome of 2 arthroscopic techniques for treating recalcitrant lateral epicondylitis.

METHODS

The study included patients undergoing arthroscopic treatment of lateral epicondylitis during 2 different time periods: April 2005 to October 2007 (tenotomy) and May 2009 to June 2010 (debridement). By using a patient-administered form, baseline information including QuickDASH (disabilities of the arm, shoulder and hand) score (primary outcome), visual analog scale (VAS) of pain, and VAS of function was recorded prospectively. To have the same follow-up period of minimum 4 years in the 2 groups, the follow-up was conducted at 2 different points of time.

RESULTS

Of a total of 326 patients fulfilling the requirements for inclusion in the study, 283 patients (87%) were followed up (144 male and 139 female, median age 46 [21 to 65] years), 204 (87%) in the tenotomy group and 79 (88%) in the debridement group. In both groups, a significant improvement in the QuickDASH was found at the follow-up compared with baseline: from 60 to 12 in the debridement group (P < .001) and from 59 to 13 in the tenotomy group (P < .001). No statistically significant difference was found in baseline or follow-up QuickDASH, VAS of pain, VAS of function, or failure (reoperation) rate between the 2 groups. The mean length of sick leave was 2 weeks shorter in the debridement only group (P = .007).

CONCLUSIONS

Both arthroscopic methods lead to a significant improvement of pain and function, and no statistically significant difference was found in any outcome parameters between the 2 techniques at this minimum 4-year evaluation. The results indicate that tenotomy of the extensor carpi radialis brevis may be an unnecessary step in the arthroscopic treatment of lateral epicondylitis Debridement only is a potentially less costly procedure, and the current finding of a mean 2 weeks shorter sick leave in the debridement only group proposes a substantial cost saving in a societal perspective.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A systematic review of prognostic factors for distal upper limb pain

BACKGROUND

Musculoskeletal pain in the distal upper limb is relatively common, can be a cause of disability, presents a high cost to society and is clinically important. Previous reviews of prognostic factors have focused on pain in the proximal upper limb, whole upper extremity or isolated regions of the distal upper limb.

AIM

To identify factors that predict outcome of distal upper limb pain.

STUDY DESIGN

Systematic review.

METHOD

Eight bibliographic databases were searched from inception to March 2014. Eligible articles included adults with pain anywhere in the distal upper limb at baseline from randomised controlled trials with a waiting list, expectant policy or usual care group, or observational studies where no treatment or usual care was provided. Data describing the association between a putative prognostic factor and pain or functional outcome at follow-up were required. Quality was assessed using the Quality in Prognostic Studies tool.

RESULTS

Seven articles reporting on six studies were identified. Heterogeneity of study populations and outcome measures prevented a meta-analysis so a narrative synthesis of results was undertaken. Three factors (being female, a longer duration of the complaint at initial presentation and having musculoskeletal pain in multiple locations) were significantly associated with poor pain outcome in more than one study. Being female was the only factor significantly associated with poor functional outcome in more than one study.

CONCLUSIONS

A range of sociodemographic, pain-related, occupational and psychosocial prognostic factors for distal upper limb pain outcomes were investigated in studies included in the review. However, due to the lack of commonality of factors investigated and lack of consistency of results across studies, there is limited evidence for predictors of distal upper limb pain outcomes. Further research is required to identify prognostic factors of distal upper limb pain, particularly modifiable factors that may influence management.

Subjective criteria associated with return-to-play in sports physical therapy

AbstractIntroduction The Subjective Daily Assessment Scale (ESAD) is based on the visual analog scale (VAS) and assesses six parameters (pain, edema, heat, mobility, sensitivity, and confidence).Objective This study aimed to examine the association between the analyzed variables as assessed by the ESAD and physical therapy clinical discharge and return-to-play of injured athletes.Method Eighty-one patient records of athletes were analyzed; mean sample age was 23.9 ± 6.3 years. The athletes received treatment through the Sports Physical Therapy program of Santa Catarina State University, Brazil, between 2008 and 2011. Six parameters were ranked on a scale from 0 to 10, with 0 being the best possible condition and 10 the worst. Data analysis was conducted using stepwise Cox regression.Results At the time of the injury, the mean score for confidence was 5.82 ± 0.48, and at the time of return-to-play, it was 0.48 ± 1.1; the mean score for pain decreased from 3.7 ± 2.64 to 0.34 ± 0.83. However, due to the strong association between pain and confidence, only confidence remained in the final model. For each reduction in the value reported for confidence, the probability of return-to-play was 0.62 times greater.Conclusion The results showed that confidence was the best variable for predicting athlete return-to-play.

Astym treatment vs. eccentric exercise for lateral elbow tendinopathy: a randomized controlled clinical trial

Introduction. Patients with chronic lateral elbow (LE) tendinopathy, commonly known as tennis elbow, often experience prolonged symptoms and frequent relapses. Astym treatment, evidenced in animal studies to promote the healing and regeneration of soft tissues, is hypothesized to improve outcomes in LE tendinopathy patients. This study had two objectives: (1) to compare the efficacy of Astym treatment to an evidence-based eccentric exercise program (EE) for patients with chronic LE tendinopathy, and (2) to quantify outcomes of subjects non-responsive to EE who were subsequently treated with Astym treatment.

Study Design. Prospective, two group, parallel, randomized controlled trial completed at a large orthopedic center in Indiana. Inclusion criteria: age range of 18–65 years old, with clinical indications of LE tendinopathy greater than 12 weeks, with no recent corticosteriod injection or disease altering comorbidities.

Methods. Subjects with chronic LE tendinopathy (107 subjects with 113 affected elbows) were randomly assigned using computer-generated random number tables to 4 weeks of Astym treatment (57 elbows) or EE treatment (56 elbows). Data collected at baseline, 4, 8, 12 weeks, 6 and 12 months. Primary outcome measure: DASH; secondary outcome measures: pain with activity, maximum grip strength and function. The treating physicians and the rater were blinded; subjects and treating clinicians could not be blinded due to the nature of the treatments.

Results. Resolution response rates were 78.3% for the Astym group and 40.9% for the EE group. Astym subjects showed greater gains in DASH scores (p = 0.047) and in maximum grip strength (p = 0.008) than EE subjects. Astym therapy also resolved 20/21 (95.7%) of the EE non-responders, who showed improvements in DASH scores (p < 0.005), pain with activity (p = 0.002), and function (p = 0.004) following Astym treatment. Gains continued at 6 and 12 months. No adverse effects were reported.

Conclusion. This study suggests Astym therapy is an effective treatment option for patients with LE tendinopathy, as an initial treatment, and after an eccentric exercise program has failed.

Registration/Funding. Ball Memorial Hospital provided limited funding. Trial registration was not required by FDAAA 801.

Known about the Subject. Under the new paradigm of degenerative tendinopathy, eccentric exercise (EE) is emerging as a first line conservative treatment for LE tendinopathy. EE and Astym treatment are among the few treatment options aiming to improve the degenerative pathophysiology of the tendon. In this trial, Astym therapy, which has shown success in the treatment of tendinopathy, is compared to EE, which has also shown success in the treatment of tendinopathy.

Clinical Relevance. There is a need for more effective, conservative treatment options. Based on the current efficacy study, Astym therapy appears to be a promising, non-invasive treatment option.

Improving Field Observation of Spinal Posture in Sitting

Observing seated posture is important for ergonomic assessment; proper chair fit and chair adjustment should be considered for the entire context of work demands. Recommending only one seated posture presumes that all seated work has a similar location of visual targets, shoulder reach distances, and support surfaces. The nature of work tasks may influence posture more than does chair adjustment, and field observation of sitting should focus specifically on lumbar spine posture when work may cause forward movement of the torso. I suggest that the position and movement of the pelvis in relation to the torso is a reasonable and important indicator of spinal posture.

Autologous blood injection for treatment of tennis elbow

Background

Tennis elbow (TE) is a common myotendinosis. It was first described by Runge in 1873; different modes of treatment are used in management of TE.

Objectives

This study aimed to report the results of autologous blood injection (ABI) in the treatment of TE.

Materials and Methods

A prospective case study was performed to evaluate the results of ABI in the management of TE. The level of pain based on Nirschl phase scale (NPS) and a visual analogue scale (VAS) was calculated before and 1, 3 and 6 months after injection; then satisfaction was assessed.

Results

Twenty-nine patients with diagnosed TE were treated by ABI (24% males, 76 % female). The mean age of the patients was 44.1 ± 5.2 years. The level of pain on VAS decreased from 6.46 ± 2.08 to 0.54 ± 0.7 (P=0.001) and on NPS from 6.15 ± 1.48 to 0.54 ± 0.76 (P = 0.001) 6 months after treatment. At the end of the study, 84% of patients expressed a high level of satisfaction.

Conclusions

Given the acceptable outcomes, autologous blood injection can be considered a good treatment option for TE when traditional treatment has fails.

Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions

In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.

Joint manipulation in the management of lateral epicondylalgia: a clinical commentary

Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.

Extensor tendon release in tennis elbow: results and prognostic factors in 80 elbows

PURPOSE

The objectives of this study were to evaluate the results in the outpatient treatment of recalcitrant lateral epicondylitis with release of the common extensor origin according to Hohmann and to determine any prognostic factors.

METHODS

Eighty tennis elbows in 77 patients with a characteristic history of activity-related pain at the lateral epicondyle interfering with the activities of daily living refractory to conservative care for at least 6 months and a confirmatory physical examination were included. Clinical outcome was evaluated using the QuickDASH score system. Data were collected before the operation and at the medians of 18 months (range 6-36 months; short term) and 4 years (range 3-6 years; medium term) postoperatively.

RESULTS

The mean QuickDASH was improved both at the short- and the medium-term follow-ups and did not change significantly between the follow-ups. At the final follow-up, the QuickDASH was improved in 78 out of 80 elbows and 81% was rated as excellent or good (QuickDASH<40 points). We found a weak correlation between residual symptoms (a high QuickDASH score) at the final follow-up and high level of baseline symptoms (r=0.388), acute occurrence of symptoms (r=0.362), long duration of symptoms (r=0.276), female gender (r=0.269) and young age (r=0.203), whereas occurrence in dominant arm, a work-related cause or strenuous work did not correlate significantly with the outcome.

CONCLUSION

Open lateral extensor release performed as outpatient surgery results in improved clinical outcome at both short- and medium-term follow-ups with few complications. High baseline disability, sudden occurrence of symptoms, long duration of symptoms, female gender and young age were found to be weak predictors of poor outcome.

LEVEL OF EVIDENCE

Case series, Level IV.

Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial

BACKGROUND

Isokinetic eccentric training of the wrist extensors has recently been shown to be effective in treating chronic lateral epicondylosis. However, isokinetic dynamometry is not widely available or practical for daily exercise prescription. Therefore, the objective of this study was to assess the efficacy of a novel eccentric wrist extensor exercise added to standard treatment for chronic lateral epicondylosis.

MATERIALS AND METHODS

Twenty-one patients with chronic unilateral lateral epicondylosis were randomized into an eccentric training group (n = 11, 6 men, 5 women; age 47 +/- 2 yr) and a Standard Treatment Group (n = 10, 4 men, 6 women; age 51 +/- 4 yr). DASH questionnaire, VAS, tenderness measurement, and wrist and middle finger extension were recorded at baseline and after the treatment period.

RESULTS

Groups did not differ in terms of duration of symptoms (Eccentric 6 +/- 2 mo vs Standard 8 +/- 3 mos., P = .7), number of physical therapy visits (9 +/- 2 vs 10 +/- 2, P = .81) or duration of treatment (7.2 +/- 0.8 wk vs 7.0 +/- 0.6 wk, P = .69). Improvements in all dependent variables were greater for the Eccentric Group versus the Standard Treatment Group (percent improvement reported): DASH 76% vs 13%, P = .01; VAS 81% vs 22%, P = .002, tenderness 71% vs 5%, P = .003; strength (wrist and middle finger extension combined) 79% vs 15%, P = .011.

DISCUSSION

All outcome measures for chronic lateral epicondylosis were markedly improved with the addition of an eccentric wrist extensor exercise to standard physical therapy. This novel exercise, using an inexpensive rubber bar, provides a practical means of adding isolated eccentric training to the treatment of chronic lateral epicondylosis.

Hand therapist management of the lateral epicondylosis: a survey of expert opinion and practice patterns

Lateral epicondylosis (LE) is a common condition. Knowledge on practice patterns underlies identification of knowledge to practice gaps. The purpose was to determine the practice patterns and beliefs of hand therapists in managing LE. The study design used was a descriptive survey. A survey of Certified Hand Therapists and members of the American Society of Hand Therapists was conducted (n=693). Questions were framed around frequency and perceived effectiveness of interventions, examination techniques, outcome measures, and prognostic factors. More than 80% of therapists use education/activity modification, home exercise, LE orthoses, and stretching for both the acute and chronic LE. Therapists perceive education, orthoses and home exercise are the most effective for acute cases, whereas in chronic cases, orthoses dropped to ninth in ranked perceived effectiveness. Grip strength (80%) and numeric pain rating (71%) were the most commonly used outcome measures. Most (>70%) therapists perceived occupation and duration of symptoms are prognostic in terms of resolution of symptoms, whereas compliance with exercise (78%) and work factors are important for return to work. Therapists rely on impairment measures to evaluate hand therapy outcomes in patients with LE. Hand therapists are aligned with a number of recommendations from the available systematic reviews, although the use of outcome measures and optimal definition of education and exercise exhibit evidence to practice gaps.

LEVEL OF EVIDENCE

Level 5.

Understanding the role of sex differences in work injuries: Implications for primary care practice

PURPOSE

Primary care physicians care for work-injured women and men, yet there is little information on sex differences in outcomes and factors contributing to post-injury outcomes to guide their evaluation and recommendations.

METHODS

Two self-administered questionnaires were sent to a large sample of women and men with work injuries reported to the New Hampshire (USA) Department of Labour between November 2000 and March 2002. Factors associated with the work injury and outcomes were assessed.

RESULTS

A total of 3001 persons (1448 women and 1553 men) completed the first questionnaire and 67% completed the second questionnaire. Work-injured women were significantly younger, more educated, more likely to be single, had more pre-injury comorbidities, and worked in less physically demanding occupations as compared to work-injured men. Women's injuries were more often a result of routine job tasks and of gradual onset. Women had worse long-term outcomes including job stability and post-injury income. In multivariate analyses, being female was independently associated with a negative employer response and greater future work concerns.

CONCLUSIONS

Women and men differ in terms of work injury circumstances and factors contributing to post-injury outcomes. Primary care providers should consider sex when evaluating and treating work-injured adults.

Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial

Cyriax and Cyriax advocated the use of deep transverse friction massage in combination with Mill's manipulation in treating lateral epicondylalgia. Evidence comparing this approach with other physical therapies is lacking. The purpose of this randomized clinical trial was to compare the effectiveness of deep transverse friction massage with Mill's manipulation versus phonophoresis with supervised exercise in managing lateral epicondylalgia. Sixty patients age 30-60, presenting with the teno-periosteal variety of lateral epicondylalgia with symptom duration greater than one month, were randomized into two groups. The control group received phonophoresis with diclofenac gel over the area of the lateral epicondyle for 5 minutes combined with supervised exercise. The experimental group received 10 minutes of deep transverse friction massage followed by a single application of Mill's manipulation. Both groups received treatment 3 times per week for 4 weeks. Outcomes of interest included pain via visual analog scale (VAS), pain-free grip strength, and functional status measured with the Tennis Elbow Function Scale. Data were analyzed using a one-way ANOVA. Whereas both groups improved significantly from the initiation of treatment, a between-group comparison revealed significantly greater (p<0.05) improvements regarding pain, pain-free grip, and functional status for the experimental group compared to the control group. The results of this study demonstrate that Cyriax physiotherapy is a superior treatment approach compared to phonophoresis and exercise in managing lateral epicondylalgia.

Motor unit potential morphology differences in individuals with non-specific arm pain and lateral epicondylitis

Background

The pathophysiology of non-specific arm pain (NSAP) is unclear and the diagnosis is made by excluding other specific upper limb pathologies, such as lateral epicondylitis or cervical radiculopathy. The purpose of this study was to determine: (i) if the quantitative parameters related to motor unit potential morphology and/or motor unit firing patterns derived from electromyographic (EMG) signals detected from an affected muscle of patients with NSAP are different from those detected in the same muscle of individuals with lateral epicondylitis (LE) and/or control subjects and (ii) if the quantitative EMG parameters suggest that the underlying pathophysiology in NSAP is either myopathic or neuropathic in nature.

Methods

Sixteen subjects with NSAP, 11 subjects with LE, eight subjects deemed to be at-risk for developing a repetitive strain injury, and 37 control subjects participated. A quantitative electromyography evaluation was completed using decomposition-based quantitative electromyography (DQEMG). Needle- and surface-detected EMG signals were collected during low-level isometric contractions of the extensor carpi radialis brevis (ECRB) muscle. DQEMG was used to extract needle-detected motor unit potential trains (MUPTs), and needle-detected motor unit potential (MUP) and surface detected motor unit potential (SMUP) morphology and motor unit (MU) firing rates were compared among the four groups using one-way analysis of variance (ANOVA). Post hoc analyses were performed using Tukey's pairwise comparisons.

Results

Significant group differences were found for all MUP variables and for MU firing rate (p < 0.006). The post-hoc analyses revealed that patients with NSAP had smaller MUP amplitude and SMUP amplitude and area compared to the control and LE groups (p < 0.006). MUP duration and AAR values were significantly larger in the NSAP, LE and at-risk groups compared to the control group (p < 0.006); while MUP amplitude, duration and AAR values were smaller in the NSAP compared to the LE group. SMUP duration was significantly shorter in the NSAP group compared to the control group (p < 0.006). NSAP, LE and at-risk subjects had lower mean MU firing rates than the control subjects (p < 0.006).

Conclusion

The size-related parameters suggest that the NSAP group had significantly smaller MUPs and SMUPs than the control and LE subjects. Smaller MUPs and SMUPs may be indicative of muscle fiber atrophy and/or loss. A prospective study is needed to confirm any causal relationship between smaller MUPs and SMUPs and NSAP as found in this work.

Evaluating research studies that address prognosis for patients receiving physical therapy care: a clinical update

A prognosis is a broad statement that predicts a patient's likely status, or degree of change, at some time in the future. Clinicians are likely to improve the accuracy of their judgments of prognosis by incorporating relevant research findings. In recent years, there has been substantial growth in the number of primary studies and systematic reviews addressing prognosis for people likely to receive physical therapy care. The purpose of this clinical update is to provide a framework for identifying, appraising, and utilizing these research findings to help make prognostic judgments.

An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy

BACKGROUND

Lateral epicondylitis represents a frequent overuse injury. In spite of many conservative treatment procedures, prolonged symptoms and relapse are frequently observed.

OBJECTIVE

To compare the outcome of patients performing an isokinetic eccentric training with that of age-, gender-, activity-matched patients receiving a non-strengthening classical rehabilitation.

METHODS

Ninety-two patients with unilateral chronic lateral epicondylar tendinopathy (mean duration of symptoms 8+/-3 months) were assigned either to a control group (n = 46) or to an eccentrically trained group (n = 46). The control group underwent a passive standardised rehabilitation programme that excluded strengthening exercises. In addition to this programme, the trained group also performed eccentric exercises based on the repetitive lengthening of the active musculo-tendinous unit. The latter exercises started with submaximal contraction intensity and slow speed movement. Modalities were progressively intensified (increase in intensity contraction and speed movement) over a long period of treatment. Programme effectiveness was assessed through pain score evaluation, a disability questionnaire, muscle strength measurement and ultrasonographic examination.

RESULTS

Compared to the non-strengthening control group, the following observations were made in the eccentrically trained group: (1) a significantly more marked reduction of pain intensity, mainly after one month of treatment; (2) an absence of strength deficit on the involved side through bilateral comparison for the forearm supinator and wrist extensor muscles; (3) an improvement of the tendon image as demonstrated by decreasing thickness and a recovered homogenous tendon structure; and (4) a more marked improvement in disability status during occupational, spare time and sports activities.

CONCLUSION

These results highlight the relevance of implementing isokinetic adapted eccentric training in the management of chronic lateral epicondylar tendinopathy.

An exercise programme for the management of lateral elbow tendinopathy

BACKGROUND

Home exercise programmes and exercise programmes carried out in a clinical setting are commonly advocated for the treatment of lateral elbow tendinopathy (LET), a very common lesion of the arm with a well-defined clinical presentation. The aim of this study is to describe the use and effects of strengthening and stretching exercise programmes in the treatment of LET.

ECCENTRIC EXERCISES

Slow progressive eccentric exercises for LET should be performed with the elbow in extension, forearm in pronation, and wrist in extended position (as high as possible). However, it is unclear how the injured tendon, which is loaded eccentrically, returns to the starting position without experiencing concentric loading and how the "slowness" of eccentric exercises should be defined. Nor has the treatment regimen of the eccentric exercises of a supervised exercise programme been defined.

STRETCHING EXERCISES

Static stretching is defined as passively stretching a given muscle-tendon unit by slowly placing and maintaining it in a maximal position of stretch. We recommend the position should be held for 30-45 s, three times before and three times after eccentric exercises during each treatment session with a 30 s rest interval between each procedure. The treatment region of static stretching exercises when a supervised exercise programme is performed is unknown.

DISCUSSION

A well designed trial is needed to study the effectiveness of a supervised exercise programme for LET consisting of eccentric and static stretching exercises. The issues relating to the supervised exercise programme should be defined so that therapists can replicate the programme.

A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy

BACKGROUND

The use of ice as a supplement to an exercise programme has been recommended for the management of lateral elbow tendinopathy (LET). No studies have examined its effectiveness.

OBJECTIVES

To investigate whether an exercise programme supplemented with ice is more successful than the exercise programme alone in treating patients with LET.

METHODS

Patients with unilateral LET for at least four weeks were included in this pilot study. They were sequentially allocated to receive five times a week for four weeks either an exercise programme with ice or the exercise programme alone. The exercise programme consisted of slow progressive eccentric exercises of wrist extensors and static stretching of the extensor carpi radialis brevis tendon. In the exercise programme/ice group, the ice was applied after the exercise programme for 10 minutes in the form of an ice bag to the facet of the lateral epicondyle. Patients were evaluated at baseline, at the end of treatment, and three months after the end of treatment. Outcome measures used were the pain visual analogue scale and the dropout rate.

RESULTS

Forty patients met the inclusion criteria. At the end of treatment there was a decline in visual analogue scale of about 7 units in both groups compared with baseline (p<0.0005, paired t test). There were no significant differences in the magnitude of reduction between the groups at the end of treatment and at the three month follow up (p<0.0005, independent t test). There were no dropouts.

CONCLUSIONS

An exercise programme consisting of eccentric and static stretching exercises had reduced the pain in patients with LET at the end of the treatment and at the follow up whether or not ice was included. Further research to establish the relative, absolute, and cost effectiveness as well as the mechanism of action of the exercise programme is needed.

‘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 low-level laser therapy for lateral elbow tendinopathy

OBJECTIVE

Our aim was to determine the effectiveness of low-lever laser therapy (LLLT) in the management of lateral elbow tendinopathy (LET) and to provide recommendations based on this evidence.

BACKGROUND DATA

LET is a common clinical condition, and a wide array of physiotherapy treatments is used for treating LET.

METHODS

Randomized controlled trials (RCTs) identified by a search strategy in six databases were used in combination with reference checking. RCTs that included LLLT, patients with LET, and at least one of the clinically relevant outcome measure were selected. Aqualitative analysis of the selected studies was conducted using the Chalmers' technique.

RESULTS

Nine RCTs fulfilled the criteria and were included in the review. Although these studies had satisfactory methodology, shortcomings were not absent; poor results were revealed as to the effectiveness of LLLT for LET management.

CONCLUSIONS

LLLT need not be ruled out for LET as it is a dose-response modality, and the optimal treatment dose has obviously not yet have been discovered. Further research with well-designed RCTs is needed to establish the absolute and relative effectiveness of this intervention for LET.

Effectiveness of extracorporeal shock wave therapy for tennis elbow (lateral epicondylitis)

Randomised controlled trials were reviewed to evaluate the evidence of the effectiveness of extracorporeal shock wave therapy in the management of tennis elbow. Seven relevant trials were found, which had satisfactory methodology but conflicting results. Further research with well designed randomised control trials is needed to establish the absolute and relative effectiveness of this intervention for tennis elbow.

Computer use associated with poor long-term prognosis of conservatively managed lateral epicondylalgia

STUDY DESIGN

Multicenter prospective design with a cohort of patients with lateral epicondylalgia commencing physical therapy.

OBJECTIVE

To identify key factors associated with long-term prognosis of conservatively managed lateral epicondylalgia.

BACKGROUND

The response to conservative management of lateral epicondylalgia is inconsistent and the rate of recovery varies widely among individuals. The reasons for these discrepancies are not understood. The identification of factors associated with prognosis will aid in the prediction of patient outcomes.

METHODS AND MEASURES

Sixty patients with lateral epicondylalgia, recruited from 9 sports medicine clinics and 2 hospital outpatient physical therapy departments in Ontario, Canada, were followed for 6 months. A baseline clinical assessment was conducted on each participant using standard physical therapy techniques. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a 100-mm pain visual analog scale (VAS) were completed at baseline and 6 months later.

RESULTS

The key factor associated with both 6-month DASH and pain VAS scores was repetitive-work tasks (DASH, 9.8 [P < .011; pain VAS, 13.1 mm [P = .0105]). A subanalysis indicated that women were more likely than men to have cervical joint signs and, among women, positive cervical articular signs were also associated with higher final DASH and pain VAS scores.

CONCLUSIONS

Although many of the participants identified sports activities as the cause of their injury, these findings emphasize the importance that a patient's work tasks can have on recovery of lateral epicondylalgia. This would suggest that management should perhaps focus on work stations, postures, and behaviors.