The role of physical examinations in studies of musculoskeletal disorders of the elbow

Prevalence and factors associated with lateral epicondylitis among hospital healthcare workers

Background

Hospital healthcare workers have been reported to have a high prevalence of musculoskeletal disorders, but their association with lateral epicondylitis (LE) is unknown. This study aimed to clarify the prevalence of LE and its associated factors among hospital healthcare workers.

Methods

The present study included all staff members of a secondary emergency hospital who provided their consent to participate. Participants with a history of elbow joint trauma were excluded from this study. The diagnostic criteria for definite LE were: (1) pain in the elbow joint within 2 weeks of the study; (2) pain in the lateral epicondyle region on resisted extension of the wrist with the elbow extended; and (3) tenderness in the lateral epicondyle. The diagnosis of LE was defined by meeting all criteria. Age, height, weight, sex, dominant hand, occupation, years of employment, smoking history, drinking history, personal computer usage history, and smartphone usage history were investigated using a questionnaire. A physical examination, in addition to evaluation of pain in the lateral epicondyle, grip strength and wrist extension strength were measured. A statistical analysis was used to assess the prevalence of LE and its associated factors. All investigations, including the diagnosis of LE, were performed by a single orthopedic specialist.

Results

We evaluated 544 individuals, corresponding to approximately 80% of all staff members. The median age was 39 years (interquartile range, 30-48). The study population included 154 males and 390 females. The occupations of the participants were as follows: nurses (n = 265), doctors (n = 47), clerks (n = 93), therapists (n = 27), certified care workers (n = 23), medical technologists (n = 22), pharmacists (n = 19), and others (n = 48). LE was diagnosed in 30 limbs/30 individuals with a prevalence of approximately 5.5%. There was no difference in the prevalence of LE among occupations (P = .85). A logistic regression analysis revealed that age (odds ratio, 1.05; 95% confidence interval 1.01-1.1; P = .01) and smoking history (odds ratio, 2.94; 95% confidence interval 1.01-8.56; P = .04) were independently associated with LE.

Conclusion

This study was conducted to evaluate the prevalence of LE among hospital healthcare workers. The prevalence of LE was 5.5%, and LE was independently associated with age and smoking history.

Cardiovascular Disease Risk Factors Predict the Development and Numbers of Common Musculoskeletal Disorders in a Prospective Cohort

OBJECTIVE

The aim of the study is to assess risk of common musculoskeletal disorders (MSDs) based on cardiovascular disease (CVD) risk scores.

METHODS

Data from a 9-year prospective cohort of 1224 workers in three states were analyzed. Baseline data included questionnaires, structured interviews, physical examinations, anthropometric measurements, nerve conduction studies, and individualized measurement of job physical factors. Monthly follow-ups were conducted. Framingham risk scores were calculated. A priori case definitions were constructed for carpal tunnel syndrome, lateral epicondylopathy, medial epicondylopathy, and rotator cuff tendinopathy.

RESULTS

Adjusted RRs for one or more MSDs increased to 3.90 (95% confidence interval, 2.20-6.90) among those with 10-year cardiovascular disease risk scores greater than 15% and 17.4 (95% confidence interval, 3.85-78.62) among those with more than 4 disorders.

CONCLUSIONS

Cardiovascular disease factors are strongly associated with the subsequent development of common MSDs. Risks among those with multiple MSDs are considerably stronger.

Associations of screen work with neck and upper extremity symptoms: a systematic review with meta-analysis

Objectives

It has often been suggested that screen work (ie, work on desktop, laptop, notebook or tablet computers) is a risk factor for neck and upper extremity symptoms. However, an up-to-date overview and quantification of evidence are lacking. We aimed to systematically review the association of exposure to screen work with neck and upper extremity symptoms from prospective studies.

Methods

An electronic database search (PubMed, Embase, Cinahl and Scopus) for prospective studies on the association of exposure to screen work and musculoskeletal symptoms was conducted. Studies were synthesised regarding extracted data and risk of bias, and meta-analyses were conducted.

Results

After screening 3423 unique references, 19 articles from 12 studies (with 18 538 participants) were included for the current review, with the most recent exposure assessment reported in 2005. Studies described duration and input frequency of screen work (ie, computer, keyboard and mouse use, assessed using self-reports or software recordings) and musculoskeletal symptoms (ie, self-reported neck/shoulder and distal upper extremity symptoms and diagnosed carpal tunnel syndrome [CTS]). Although there was overall an increased occurrence of musculoskeletal symptoms with larger exposure to screen work (relative risk: 1.11 [1.03 1.19]), findings were rather inconsistent with weaker (and statistically non-significant) risks when screen work was assessed by software recording (1.05 [0.91 1.21]) compared to with self-report (1.14 [1.03 1.19]).

Conclusions

We found an increased risk of musculoskeletal symptoms with screen work. However, the evidence is heterogeneous, and it is striking that it lacks information from contemporary screen work using laptop, notebook or tablet computers.

The Role of Elbow Tender Point Examination in the Diagnosis of Lateral Epicondylitis

OBJECTIVE

To quantify sensitivity and specificity of the tender points and demonstrate how variability in case definition impacts prevalence of lateral epicondylitis (LE).

METHODS

Baseline data analyzed from 1216 workers from the WISTAH study, a multicenter prospective cohort study of upper extremity musculoskeletal disorders. All workers completed computerized questionnaires, structured interviews, and two independent physical examinations in accordance with an established protocol.

RESULTS

The prevalence of LE differed based on case definition ranging from 4.7% to 12.1%. Sensitivity was low for tender points 1 to 4 ranging from 6.8% to 34.6%. Specificity was high for tender points 1 to 4 ranging from 95.2% to 97.9%.

CONCLUSIONS

The prevalence of lateral epicondylitis differs markedly based on case definition used, ranging more than two-fold. Standardization of a case definition is essential to allow for comparisons across studies.

Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach

Chronic tendinopathies represent a major problem in the clinical practice of sports orthopaedic surgeons, sports doctors and other health professionals involved in the treatment of athletes and patients that perform repetitive actions. The lack of consensus relative to the diagnostic tools and treatment modalities represents a management dilemma for these professionals. With this review, the purpose of the ESSKA Basic Science Committee is to establish guidelines for understanding, diagnosing and treating this complex pathology.

Association between Epicondylitis and Cardiovascular Risk Factors in Pooled Occupational Cohorts

Background

The pathophysiology of lateral epicondylitis (LE) is unclear. Recent evidence suggests some common musculoskeletal disorders may have a basis in cardiovascular disease (CVD) risk factors. Thus, we examined CVD risks as potential LE risks.

Methods

Workers (n = 1824) were enrolled in two large prospective studies and underwent structured interviews and physical examinations at baseline. Analysis of pooled baseline data assessed the relationships separately between a modified Framingham Heart Study CVD risk score and three prevalence outcomes of: 1) lateral elbow pain, 2) positive resisted wrist or middle finger extension, and 3) a combination of both symptoms and at least one resisted maneuver. Quantified job exposures, personal and psychosocial confounders were statistically controlled. Odds ratios (ORs) and 95% Confidence Intervals (CIs) were calculated.

Results

There was a strong relationship between CVD risk score and lateral elbow symptoms, resisted wrist or middle finger extension and LE after adjustment for confounders. The adjusted ORs for symptoms were as high as 3.81 (95% CI 2.11, 6.85), for positive examination with adjusted odds ratios as high as 2.85 (95% CI 1.59, 5.12) and for combined symptoms and physical examination 6.20 (95% CI 2.04, 18.82). Relationships trended higher with higher CVD risk scores.

Conclusions

These data suggest a potentially modifiable disease mechanism for LE.

Critical review on the socio-economic impact of tendinopathy

There are currently no studies that determine the total burden that tendinopathy places on patients and society. A systematic search was conducted to understand the impact of tendinopathy. It demonstrated that the current prevalence is underestimated, particularly in active populations, such as athletes and workers. Search results demonstrate that due to the high prevalence, impact on patients' daily lives and the economic impact due to work-loss, treatments are significantly higher than currently observed. A well-accepted definition by medical professionals and the public will improve documentation and increase awareness, in order to better tackle the disease burden.

Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years

BACKGROUND

A previously published study found positive outcomes for a novel technique for ultrasound-guided percutaneous ultrasonic tenotomy, showing good tolerability, safety, and early efficacy within an office setting.

PURPOSE

In this follow-up study, all 20 members of the original cohort were contacted after 3 years to explore the sustainability of symptomatic relief, functional improvement, and sonographic soft tissue response for percutaneous ultrasonic tenotomy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All 20 subjects of the clinical trial that was performed from June to November 2011 were further assessed at 36 months after the procedure in terms of visual analog scale for pain, Disabilities of the Arm, Shoulder and Hand (DASH)-Compulsory/Work scores, need for adjunct procedures, and overall satisfaction. Importantly, all 20 were reassessed with ultrasound imaging at 36 months, and evidence of the common extensor tendon response was assessed in terms of tendon hypervascularity, tendon thickness, and the progress of the hypoechoic scar tissue.

RESULTS

A 100% clinical follow-up was achieved, inclusive of ultrasonographic assessment. None of the subjects required further treatment procedures, and 100% expressed satisfaction. Previous improvements in visual analog scale (current median ± SD, 0 ± 0.9; range, 0-3) and DASH-Work scores (current median, 0 ± 0) were sustained with conformity to a linear pattern on polynomial measures. There was further reduction in DASH-Compulsory scores to a median of 0 ± 0.644 (range, 0-2) with a significant decrease on repeated measures (P = .008). Tendon hypervascularity was resolved in 94% of patients, and 100% had reduction in tendon thickness. Overall reduction in the hypoechoic scar tissue was observed in all subjects, with a 90% response achieved by 6 months. Between 6 and 36 months, further reduction in the scar was observed in around 60% of patients, with 20% of patients having complete resolution of the hypoechoic scar.

CONCLUSION

Minimally invasive percutaneous ultrasonic tenotomy provided sustained pain relief and functional improvement for recalcitrant tennis elbow at 3-year follow-up. It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy.

Prevalence and risk factors of lateral epicondylitis in a mountain village in Japan

PURPOSE

To determine the prevalence and risk factors of lateral epicondylitis in a mountain village in Japan.

METHODS

176 men and 246 women aged 24 to 86 (mean, 61) years from a mountain village in Japan underwent regular medical examination and completed a self-administered questionnaire with items related to gender, weight, height, dominant hand, heaviness of labour (no job, light, intermediate, and heavy), presence of elbow pain 2 weeks before examination, and smoking and drinking experience. The diagnosis of lateral epicondylitis was based on self-reported symptoms and clinical signs.

RESULTS

The prevalence of lateral epicondylitis in a mountain village in Japan was 3.8% (95% confidence interval [CI], 2.2%-6.1%). Of the 422 subjects, 47 had elbow pain and 16 of them were diagnosed to have definite lateral epicondylitis. 15 of them were right-handed and had involvement of the left (n=8) and right (n=7) sides; the remaining one was left-handed and had involvement of the left side. The dominant hand was not associated with the affected side (p=1.00). Heaviness of labour was not associated with the elbow pain scores. The prevalence was highest in subjects aged 50 to 59 years (9% [95% CI, 3.8%-17.1%]) and those with no job (14% [95% CI, 1.1%-44.1%]).

CONCLUSION

Lateral epicondylitis was not associated with gender, age, body mass index, dominant hand, heaviness of labour, smoking, or drinking.

Impacts of differences in epidemiological case definitions on prevalence for upper-extremity musculoskeletal disorders

OBJECTIVE

The aim of this study was to systematically evaluate prevalence based on variations in case definitions used for epidemiological studies of musculoskeletal disorders (MSDs).

BACKGROUND

Prior studies of MSDs have mostly relied on a single case definition based on questionnaires.

METHOD

In a multicenter prospective cohort study, we systematically collected data to evaluate impacts of differences in case definitions of MSDs on prevalence of three common musculoskeletal disorders: (a) shoulder tendinosis, (b) lateral epicondylalgia, and (c) carpal tunnel syndrome. Production workers were from 21 employment settings in three diverse U.S. states and performed widely varying work. All workers completed laptop-administered structured interviews, two standardized physical examinations, and nerve conduction studies (NCS). Case definitions included symptoms only, and symptoms plus physical examinations and/or NCS.

RESULTS

A total of 1,227 subjects had complete health data at baseline. The prevalence for shoulder tendinosis is 23.0% if only glenohumeral pain is used for a case definition, compared with 8.0% if a combination of pain plus a positive supraspinatus test is used. The prevalence for lateral epicondylalgia varied on the basis of lateral elbow pain (12.0%), pain plus tenderness on palpation (9.9%), or pain plus tenderness on palpation plus resisted wrist or middle finger extension (3.5%). Carpal tunnel syndrome prevalence varied on the basis of tingling or numbness in a median nerve-served digit (29.9%) or tingling or numbness plus NCS abnormalities consistent with carpal tunnel syndrome (9.0%).

CONCLUSION

Variations in epidemiological case definitions have major impacts on prevalence of common MSDs. Wide-ranging differences in prevalence may have impacts on purported risk factors that need to be determined.

The reliability of a quality appraisal tool for studies of diagnostic reliability (QAREL)

Background

The aim of this project was to investigate the reliability of a new 11-item quality appraisal tool for studies of diagnostic reliability (QAREL). The tool was tested on studies reporting the reliability of any physical examination procedure. The reliability of physical examination is a challenging area to study given the complex testing procedures, the range of tests, and lack of procedural standardisation.

Methods

Three reviewers used QAREL to independently rate 29 articles, comprising 30 studies, published during 2007. The articles were identified from a search of relevant databases using the following string: “Reproducibility of results (MeSH) OR reliability (t.w.) AND Physical examination (MeSH) OR physical examination (t.w.).” A total of 415 articles were retrieved and screened for inclusion. The reviewers undertook an independent trial assessment prior to data collection, followed by a general discussion about how to score each item. At no time did the reviewers discuss individual papers. Reliability was assessed for each item using multi-rater kappa (κ).

Results

Multi-rater reliability estimates ranged from κ = 0.27 to 0.92 across all items. Six items were recorded with good reliability (κ > 0.60), three with moderate reliability (κ = 0.41 - 0.60), and two with fair reliability (κ = 0.21 - 0.40). Raters found it difficult to agree about the spectrum of patients included in a study (Item 1) and the correct application and interpretation of the test (Item 10).

Conclusions

In this study, we found that QAREL was a reliable assessment tool for studies of diagnostic reliability when raters agreed upon criteria for the interpretation of each item. Nine out of 11 items had good or moderate reliability, and two items achieved fair reliability. The heterogeneity in the tests included in this study may have resulted in an underestimation of the reliability of these two items. We discuss these and other factors that could affect our results and make recommendations for the use of QAREL.

Fasciotomy and surgical tenotomy for recalcitrant lateral elbow tendinopathy: early clinical experience with a novel device for minimally invasive percutaneous microresection

BACKGROUND

The optimal choice for intervention for recalcitrant lateral elbow tendinopathy remains unclear as various treatment modalities have documented comparable results in the literature.

PURPOSE

To explore the safety, tolerability, and early efficacy of a new minimally invasive mode of treatment that delivers focused, calibrated ultrasonic energy, effectively microresecting the pathological tendon and removing only pathological tissue.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Seven male and 13 female patients aged 33 to 65 years averaging 12.5 months (range, 4-48) of failed nonoperative therapy underwent the ultrasonic microresection procedure in an outpatient clinic setting. The procedure involved a sterile, ultrasound-guided percutaneous microresection with a proprietary device (TX1) performed through a stab incision under local anesthesia. The duration of the procedure and complications of the device or procedure were assessed. Outcome parameters included patient satisfaction; visual analog scale (VAS) pain scores; Disabilities of the Arm, Shoulder and Hand (DASH) scores at 1, 3, 6, and 12 months; and ultrasound assessment at 3 and 6 months.

RESULTS

The median duration for the sterile confirmatory ultrasound examination (phase 1) was 88.5 seconds (range, 39-211; SD, ±47.6), the median duration of the procedure proper (phase 2) was 10.1 minutes (range, 4.1-19.4; SD, ±3.7), and the median energy time (duration the TX1 device was activated) was 32.5 seconds (range, 18-58; SD, ±11.0). No complications were encountered. A significant improvement in VAS score (from 5.5 to 3.3; P < .001) occurred by 1 week, and significant improvements in both DASH-Compulsory (from 21.7 to 11.3; P = .001) and DASH-Work (from 25.0 to 6.3; P = .012) scores occurred by 1 month. The VAS scores further improved at 3, 6, and 12 months (from 2.0 to 1.0 to 0.50; P = .003 and .023). The DASH-Compulsory score improved significantly from 3 to 6 months (from 8.6 to 4.6; P = .003), and both the DASH-Compulsory and DASH-Work scores were sustained by 12 months. Sonographically reduced tendon thickness (19 patients), resolved or reduced hypervascularity (17 patients), and reduced hypoechoic area (18 patients) occurred by 6 months. Nineteen of the 20 patients (95%) expressed satisfaction with the procedure, with 9 patients being very satisfied with their overall experience at 6 months after the procedure, 10 patients somewhat satisfied, and 1 patient neutral.

CONCLUSION

Ultrasonic microresection of diseased tissue with the TX1 device provides a focally directed, safe, specific, minimally invasive, and well-tolerated treatment for recalcitrant lateral elbow tendinopathy in an office-based or ambulatory surgical setting with good evidence of some level of efficacy in 19 of 20 patients (95%) that is sustained for at least 1 year.

Inter-rater reliability of physical examinations in a prospective study of upper extremity musculoskeletal disorders

OBJECTIVE

To test the inter-rater reliability of physical examinations for upper extremity musculoskeletal disorders.

METHODS

A total of 111 subjects were examined by both an occupational medicine physician and a physical therapist, who were blinded to each others' tests results and subjects' current symptoms and health histories.

RESULTS

Inter-rater reliability was moderate to excellent (0.52 to 0.88) for shoulder tests but required the inclusion of symptoms for increased inter-rater reliability of fair to excellent (0.27 to 0.57) for the elbow and hand/wrist tests.

CONCLUSIONS

With the lack of "gold standard" tests, it is important that epidemiologic field studies conduct and report inter-rater reliability testing results between study examiners. It is important for researchers to report the results of inter-rater reliability, so that practitioners can weigh the results of study findings to improve both their diagnosis and treatment of these costly injuries.

Quantitative exposure-response relations between physical workload and prevalence of lateral epicondylitis in a working population

BACKGROUND

Lateral epicondylitis is a common work-related musculoskeletal disorder. The objective of this study was to identify risk factors associated with lateral epicondylitis among active workers.

METHODS

Seven-hundred thirty-three workers in 12 Washington worksites participated in structured interviews, physical examinations, and individual exposure assessments of biomechanical and psychosocial factors. Multivariable logistic modeling was used.

RESULTS

Thirty-eight subjects (5.2%) had lateral epicondylitis. Age (36-50 years-old), being female, and low social support at work were significant risk factors. Frequency of forceful exertion (> or =5 vs. < 1 times/min (OR 5.17, 95%CI 1.78-15.02), and > or =1 to <5 vs. <1 (OR 4.47, 95%CI 1.57-13.71)) and forearm supination at > or =45 degrees for > or =5% of the time with high lifting force (OR = 2.98, 95% CI 1.18-7.55) were significant physical load factors.

CONCLUSIONS

Frequency of forceful exertion or a combination of forearm supination and forceful lifting were significant physical factors and should be considered for prevention strategies.