Clinical Value of Ultrasonographic Assessment in Lateral Epicondylitis Versus Asymptomatic Healthy Controls

Development and validation of a severity-focused score for the assessment of lateral epicondylitis using enhanced magnetic resonance imaging

BACKGROUND

Magnetic resonance imaging (MRI) does not sufficiently reflect the severity of lateral epicondylitis. Although some authors have reported meaningful findings on conventional MRI, it is not widely accepted that MRI is useful for evaluating lateral epicondylitis. The aim of this study is to evaluate the relationship between the lateral epicondylitis severity score (LESS) using contrast-enhanced T1-weighted MRI and patients' perceptive pain and clinical courses.

METHODS

This retrospective study included 80 patients diagnosed with lateral epicondylitis and who also went contrast-enhanced 3.0-T MRI. The study cohort was split into a development (n = 50) and a validation cohort (n = 30). The patient's pain was assessed using a visual analog scale (VAS), and the involvement of the common extension tendon (CET) origin, radial collateral ligament, lateral ulnar collateral ligament, and plica were evaluated using T2-weighted images. The enhancement of CET and subcutaneous tissue was scored using a novel classification in the contrast-enhanced T1-weighted MRI. LESS was calculated from MRI findings to determine the severity of lateral epicondylitis. Pearson's correlation analysis was performed to evaluate the relationship between patients' VAS scores and MRI findings. Receiver operating characteristic curve was constructed to determine cut-off value of LESS for the surgical treatment of lateral epicondylitis.

RESULTS

The average age of the development cohort (n = 50) and the validation cohort (n = 30) were 49.8 (31-66) years and 52.3 (37-67) years, and the average VAS score were 7.3 (4-9) and 7.2 (5-10) respectively. In T2-weighted image evaluation, the correlation of VAS and grade of CET, radial collateral ligament, lateral ulnar collateral ligament, and plica were -0.03 (P = .87), -0.03 (P = .87), -0.14 (P = .39), and 0.36 (P = .02). Discordant contrast enhancement in T1-weighted images compared to nonspecific T2-weighted images was observed in 46 of 50 cases (92%). A statistically significant correlation was observed between the patients' VAS and LESS scores (r = 0.67, P < .01). Area under curve was 0.76 (P < .01) and the optimal cut-off value of LESS for the surgical treatment of lateral epicondylitis was 5.5 (sensitivity 72.7%, specificity 70.6%). When the cut-off value was used to predict surgical treatment in the validation cohort, the sensitivity was 100% and the specificity was 75%.

CONCLUSION

Contrast-enhanced T1-weighted images provided more detail than conventional T2-weighted images in evaluation of structural or unobserved abnormalities to assess the severity of the lateral epicondylitis, and had excellent inter- and intraobserver reliability. LESS showed significant positive correlation with pain severity. If the LESS is 5.5 or more, surgical treatment of lateral epicondylitis may need to be considered.

Multimodal ultrasound assessment of the injection therapy in lateral epicondylitis: a retrospective observational study

BACKGROUND

At present, there is a dearth of objective methodologies for assessing the effectiveness of treatments for Lateral Epicondylitis (LE). This study examined 73 patients suffering from tennis elbow using a multimodal ultrasound approach and investigated the correlation between pertinent indicators and clinical scores.

METHODS

73 patients diagnosed with unilateral tennis elbow by interventional ultrasound at Zhejiang Rongjun Hospital were included in the study. Ultrasound data of the extensor tendon, as well as VAS (Visual Analog Scale) and MEPS (Mayo Elbow Performance Score) for the affected elbow, were collected before and after a two-week treatment period. The study aimed to compare the alterations in gray-scale ultrasound features, hemodynamic parameters, and elastography scores pre- and post-treatment, and to analyze the correlation between the changes in ultrasound parameters and pain scores.

RESULTS

Following treatment, the effective group exhibited a reduction in both the blood flow grade and elastic score of the extensor tendon. Additionally, the extensor tendon thickness in the effective group diminished to a greater extent than in the ineffective group. The effective group also experienced a higher rate of decrease in blood flow grade and a more pronounced increase in Resistive Index (RI) compared to the ineffective group. The reduction in tendon thickness, the increase in RI, and the improvement in elastic score were all positively correlated with the reduction in VAS scores. Notably, the increase in RI demonstrated the strongest correlation with the decrease in VAS scores.

CONCLUSIONS

Multimodal ultrasound plays a significant role in the clinical assessment of treatment outcomes for Lateral Epicondylitis.

Demonstrating the relationship of ultrasonographic parameters with disease activity and pain in lateral epicondylitis

To evaluate the relationship of ultrasonographic evaluation parameters with pain, muscle strength and disease severity in lateral epicondylitis (LE). 64 people were included in present retrospective, cross-sectional study. Activity and rest pain was questioned with Visual Analog Scale (VAS). Also, Patient Rated Tennis Elbow Evaluation (PRTEE) and the maximum grip strength were evaluated. Hypoechoic region, neovascularity, cortical irregularity, enthesopathy and peritendinous fluid or bursitis were evaluated by ultrasonography. 48 of the patients were female and 16 were male. Mean age was 48.53 ± 6.12, body mass index was 27.70 ± 4.75. 55 (85.9%) hypoechoic region, 31 (48.4%) neovascularity, 21 (32.8%) cortical irregularity, 19 (29,7%) enthesopathy, and 18 (28.1%) peritendinous fluid or bursitis were detected by ultrasonography. When the ultrasonographic findings and clinical findings of the patients were compared, no significant difference was found between the hypoechoic region, cortical irregularity, enthesopathy and clinical findings (P > .05), while the extension grip strength was found to be significantly lower in patients with neovascularity (P = .045). In addition, patients with peritendinous fluid or bursitis, were found to be significantly lower in both flexion (P = .033) and extension (P = .023) grip strength, while PRTEE function (P = .021) subgroup and total (P = .038) scores were significantly higher. Hypoechoic region, cortical irregularities and enthesopathy were not evaluated to be associated with disease severity, pain and muscle strength. Neovascularity was found to be associated only with extension grip strength. Peritendinous fluid or bursitis was found to be associated with both flexion and extension grip strength and disease activity, but not associated with pain.

Assessment of common extensor tendon vascularization using superb microvascular imaging: a potential tool in the evaluation of extracorporeal shock wave therapy and therapeutic ultrasound effectiveness in lateral epicondylitis

BACKGROUND

Lateral epicondylitis, also known as tennis elbow, is the most common elbow pain in the adult age group.

PURPOSE

To evaluate common extensor tendon (CET) vascularity with superb microvascular imaging (SMI) before and after extracorporeal shock wave therapy (ESWT) and ultrasound (US) treatment in patients with lateral epycondylitis and to compare the effects of two different treatments on tendon vascularity.

MATERIAL AND METHODS

Patients with lateral epycondylitis were divided into two groups; 30 patients were treated with ESWT (group 1) and 30 patients were treated with therapeutic US (group 2). We performed a high-frequency (14-MHz) linear array transducer to evaluate tendon anatomy and vascularity before and after treatment in both groups.

RESULTS

The decrease in Patient-Rated Tennis Elbow Evaluation (PRTEE) score after treatment was statistically significant compared to pre-treatment for both groups (P < 0.001). Likewise, the decrease in visual analog scale (VAS) score after treatment was statistically significant compared to pre-treatment for both groups (P < 0.001). A significant difference was found between the CET SMI values of group 1 and group 2 after treatment, according to the chi-square test (P < 0.001). In the post-treatment VAS and PRTEE comparison of both groups, the score reduction in group 1 was higher than in group 2, and this decrease was statistically significant (P < 0.001).

CONCLUSION

We can evaluate CET vascularization with the SMI method as a new potential diagnostic tool in comparing the effectiveness of different treatments in cases of lateral epicondylitis.

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).

[MRI or ultrasound-which imaging technique do we need?]

Diagnostic imaging of epicondylitis is primarily performed using widely available, radiation-free ultrasound. The dynamic examination allows a rapid point-of-care assessment. Typical imaging findings of epicondylitis include intratendinous hypoechogenic foci at the humeral origin, ossification at the enthesis, intratendinous calcifications, or (partial) rupture. In particular, Doppler sonography increases sensitivity by assessing possible neovascularization within the tendon. When sonographic findings are unclear or extensive, or when ultrasound machines or the required expertise in elbow examinations are not available, magnetic resonance imaging is indicated. Here, the use of proton density-weighted sequences is appropriate for assessing bone marrow and soft tissue edema and tendon tears, while ossifications are best delineated in T1weighted sequences. Projection radiography and computed tomography can be helpful for larger ossifications, although they are not part of the standard imaging protocol.

Anatomy and Sonographic Examination for Lateral Epicondylitis: EURO-MUSCULUS/USPRM Approach

OBJECTIVE

The aim of the study is to define a standardized comprehensive sonographic approach for evaluating the different histoanatomical compartments of the lateral elbow.

DESIGN

Using high-frequency ultrasound probes, we tried to match the anatomical features of the lateral elbow and its different sonographic patterns in patients with the diagnosis of lateral epicondylitis. Moreover, high-sensitive color/power Doppler assessments have also been performed to evaluate the microcirculation.

RESULTS

Modern ultrasound equipment seems to provide an extremely detailed sonographic assessment of the different anatomical layers located in the lateral compartment of the elbow. Moreover, high-sensitive color/power Doppler imaging allows for clear visualization of the perfusion patterns in pathological conditions.

CONCLUSIONS

In clinical practice, high-frequency B-mode and high-sensitive color/power Doppler imaging can be integrated with the clinical findings to better define the pain generator(s) for optimizing the management of patients with lateral epicondylitis.

Ultrasonography for Injecting (Around) the Lateral Epicondyle: EURO-MUSCULUS/USPRM Perspective

Lateral epicondylitis (LE) is a very common and painful condition seen in the daily practice of musculoskeletal physicians. Ultrasound-guided (USG) injections are commonly performed to manage the pain, promote the healing phase, and plan a tailored rehabilitation treatment. In this aspect, several techniques were described to target specific pain generators i the lateral elbow. Likewise, the aim of this manuscript was to extensively review those USG techniques together with the patients' pertinent clinical/sonographic features. The authors believe that this literature summary could also be refined as a practical, ready-to-use guide for planning the USG interventions of the lateral elbow in clinical practice.

The effects of upper body blood flow restriction training on muscles located proximal to the applied occlusive pressure: A systematic review with meta-analysis

BACKGROUND

Blood flow restriction combined with low load resistance training (LL-BFRT) is associated with increases in upper limb muscle strength and size. The effect of LL-BFRT on upper limb muscles located proximal to the BFR cuff application is unclear.

OBJECTIVE

The aim of this systematic review was to evaluate the effect of LL-BFRT compared to low load, or high load resistance training (LL-RT, HL-RT) on musculature located proximal to cuff placement.

METHODS

Six electronic databases were searched for randomized controlled trials (RCTs). Two reviewers independently evaluated the risk of bias using the PEDro scale. We performed a meta-analysis using a random effects model, or calculated mean differences (fixed-effect) where appropriate. We judged the certainty of evidence using the GRADE approach.

RESULTS

The systematic literature searched yielded 346 articles, of which 9 studies were eligible. The evidence for all outcomes was of very low to low certainty. Across all comparisons, a significant increase in bench press and shoulder flexion strength was found in favor of LL-BFRT compared to LL-RT, and in shoulder lean mass and pectoralis major thickness in favor of the LL-BFRT compared to LL-RT and HL-RT, respectively. No significant differences were found between LL-BFRT and HL-RT in muscle strength.

CONCLUSION

With low certainty LL-BFRT appears to be equally effective to HL-RT for improving muscle strength in upper body muscles located proximal to the BFR stimulus in healthy adults. Furthermore, LL-BFRT may induce muscle size increase, but these adaptations are not superior to LL-RT or HL-RT.

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.

The Effect of Elbow and Forearm Position on the Resisted Wrist Extension Test and Incidence of Sensory Disturbance of the Superficial Radial Nerve in Patients with Lateral Epicondylitis

Background: The aim of this study is to determine the effect of elbow and forearm position on the resisted wrist extension test (RWET) in patients with lateral epicondylitis. We also looked at the incidence of associated sensory disturbance of the superficial radial nerve (SRN) and the effect of treatment of lateral epicondylitis on sensory disturbance.

Methods: Sixty-three consecutive patients (68 limbs) with lateral epicondylitis and an equal number of age and gender matched volunteers were investigated. Patients with lateral epicondylitis were subdivided into two groups based on history of corticosteroid injection. We performed the RWET in four limb positions namely elbow extended and forearm pronated (EP), elbow flexed and forearm pronated (FP), elbow extended and forearm supinated (ES), elbow flexed and forearm supinated (FS). Sensory disturbance in the SRN was assessed using a Wartenberg pin wheel.

Results: The positivity rate of the RWET was significantly higher in the EP position (100%) compared to the FP (66%), ES (62%) and the FS (24%) positions in limbs with lateral epicondylitis. The RWET was positive only in one subject in the EP position in the control group (1.5%). Sensory disturbance in the SRN territory was present in 63.2% of limbs and only two subjects (2.9%) in the control group. The incidence of sensory disturbance was significantly higher (74.5% vs. 48.3%, p < 0.05) in patients who did not have a corticosteroid injection.

Conclusions: The sensitivity and specificity of the RWET is better when it is performed with the elbow in extension with the forearm pronated (EP); 63.2% of limbs with lateral epicondylitis were noted to have an associated sensory disturbance of the SRN and a corticosteroid injection seems to decrease the incidence of sensory disturbances.

Level of Evidence: Level II (Diagnostic)

Effects of Heavy Slow Resistance Training Combined With Corticosteroid Injections or Tendon Needling in Patients With Lateral Elbow Tendinopathy: A 3-Arm Randomized Double-Blinded Placebo-Controlled Study

BACKGROUND

Lateral elbow tendinopathy is a disabling tendon overuse injury. It remains unknown if a corticosteroid injection (CSI) or tendon needling (TN) combined with heavy slow resistance (HSR) training is superior to HSR alone in treating lateral elbow tendinopathy.

PURPOSE/HYPOTHESIS

The purpose was to investigate the effects of HSR combined with either (1) a CSI, (2) TN, or (3) placebo needling (PN) as treatment for lateral elbow tendinopathy. We hypothesized that 12 weeks of HSR in combination with a CSI or TN would have superior effects compared with PN at 12, 26, and 52 (primary endpoint) weeks' follow-up on primary (Disabilities of the Arm, Shoulder and Hand [DASH] score) and secondary outcomes in patients with chronic unilateral lateral elbow tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 60 patients with chronic unilateral lateral elbow tendinopathy were randomized to perform 12 weeks of home-based HSR with elastic band exercises combined with either (1) a CSI, (2) TN, or (3) PN, and at 12, 26, and 52 weeks, we assessed the primary outcome, the DASH score, and secondary outcomes: shortened version of the DASH (QuickDASH) score, pain (numerical rating scale [NRS] score), pain-free grip strength, and hypervascularization (power Doppler area).

RESULTS

A CSI, TN, and PN improved patient outcomes equally based on the DASH (Δ20 points), QuickDASH (Δ21 points), and NRS (Δ2.5 points) scores after 12 weeks. Further, after 12 weeks, a CSI also resulted in decreased hypervascularization (power Doppler area) compared with PN (Δ-2251 pixels, P = .0418). Except for the QuickDASH score (CSI increased score by Δ15 points compared with PN; P = .0427), there were no differences between the groups after 52 weeks.

CONCLUSION

These results suggest that 12 weeks of HSR improved symptoms in both the short and the long term and that a CSI or TN did not amplify this effect. In addition, a CSI seemed to impair patient-reported outcomes compared with HSR alone at long-term follow-up.

REGISTRATION

NCT02521298 (ClinicalTrials.gov identifier).

The effect of leucocyte concentration of platelet-rich plasma on outcomes in patients with lateral epicondylitis: a systematic review and meta-analysis

HYPOTHESIS

The concentration of leukocytes influences the quality of platelet-rich plasma (PRP). However, there is no consensus on which type of PRP based on the concentration of leukocytes is the best for lateral epicondylitis (LE).

METHODS

We systematically searched the MEDLINE, Embase, and Cochrane Library databases until March 1, 2020. Studies involving randomized controlled trials, patients with LE, and treatment with PRP injections were included. PRP was classified into leukocyte-poor (LP) PRP and leukocyte-rich (LR) PRP. LR-PRP was defined as PRP with a white blood cell concentration exceeding that of whole blood (4.0-10.0 per μL³), whereas LP-PRP was defined as PRP with a lower white blood cell concentration than that of whole blood. The efficacy of PRP was assessed using the visual analog scale (VAS) and success rates.

RESULTS

Eleven randomized controlled trials (six involving LP-PRP and five involving LR-PRP) were eligible for inclusion in this review. Eight studies were included in the meta-analysis to evaluate the VAS score. Regarding short-term follow-up, there was no difference in the VAS scores between the LP-PRP and control groups (standard mean difference [SMD], 0.01; 95% confidence interval [CI], -0.29 to 0.30; P = 0.97), with no heterogeneity (I² = 0%). There was also no difference in the VAS scores between the LR-PRP and control groups (SMD, -0.19; 95% CI, -0.57 to 0.20; P = 0.34), with substantial heterogeneity (I² = 56.7%). Regarding long-term follow-up, there was no difference in the VAS scores between the LP-PRP and control groups (SMD, -0.73; 95% CI, -1.69 to 0.23; P = 0.134) with substantial heterogeneity (I² = 88.4%). The LR-PRP group had lower VAS scores than the control group (SMD, -1.06; 95% CI, -2.02 to -0.09; P = 0.032) with substantial heterogeneity (I² = 92%). In the LP-PRP group, there was no significant difference in the success rate (odds ratio, 1.08; 95% CI, 0.07-16.47; P = 0.956) with substantial heterogeneity (I² = 87.7%). In the LR-PRP group, however, the patients who received PRP had a higher success rate than those in the control group (odds ratio, 2.85; 95% CI, 1.67-4.85; P < 0.01) with substantial heterogeneity (I² = 82.9%).

CONCLUSION

LR-PRP may provide pain relief and successful outcomes for patients with LE compared with alternative local injections. Better results were observed with the use of LR-PRP than with the use of LP-PRP.