Body Stuff bibliografia sobre epicondilite

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Bibliografia sobre epicondilite lateral

Lateral Epicondylitis

Tennis Elbow (American Academy of Orthopaedic Surgeons)

Tennis Elbow (American Society for Surgery of the Hand)

What is tennis elbow? (Nicholas Institute of Sports Medicine and Athletic Trauma ) - muito bom material sobre re-habilitação e prevenção

An alternative approach to treating lateral epicondylitis. A randomized, placebo-controlled, double-blinded study.

Reza Nourbakhsh M, Fearon FJ.

Department of Physical Therapy, North Georgia College and State University, Georgia, USA. mrnourbakhsh@ngcsu.edu.

Objective: To investigate the effect of noxious level electrical stimulation on pain, grip strength and functional abilities in subjects with chronic lateral epicondylitis.Design: Randomized, placebo-control, double-blinded study.Setting: Physical Therapy Department, North Georgia College and State University.Subjects: Eighteen subjects with chronic lateral epicondylitis between the ages of 24 and 72 years participated in this study. Subjects were randomly assigned into treatment or placebo groups.Interventions: Subjects received six sessions of low-frequency electrical stimulation over the palpated tender points. The intensity of electrical stimulation was set at 0 in the placebo group.Main measurements: Grip strength, functional status, pain intensity and limited activity due to pain were assessed before and after treatment. Six-month follow-up data were collected in treatment group only.Results: Both clinically and statistically significant improvements in average grip strength were found (treatment group: 28% increase; placebo group: 2.5% decrease; P=0.04), functional activity (treatment group: 110% increase; placebo group: 22% increase; P= 0.003), pain intensity (treatment group: 3.1 point decrease; placebo group: 0.2 point increase; P=0.01) and activity limitation due to pain (treatment group: 4.1 points increase; placebo group: 1.9 point decrease; P= 0.003) between the treatment and placebo groups. Follow-up data showed that 100% of subjects maintained the improved function, and 83% remained pain-free for at least six months post treatment.Conclusion: The results of this study indicated that symptoms of chronic lateral epicondylitis could be effectively treated by noxious level low-frequency electrical stimulation.

PMID: 18586811 [PubMed - in process]

: Effectiveness of physical therapy treatments on lateral epicondylitis.

Kohia M, Brackle J, Byrd K, Jennings A, Murray W, Wilfong E.

Rockhurst University Physical Therapy Department in Kanas City, MO, USA. mohamedkohia@rockhurst.edu

OBJECTIVE: To analyze research literature that has examined the effectiveness of various physical therapy interventions on lateral epicondylitis. DATA SOURCES: Evidence was compiled with data located using the PubMed, EBSCO, The Cochrane Library, and the Hooked on Evidence databases from 1994 to 2006 using the key words lateral epicondylitis, tennis elbow, modalities, intervention, management of, treatment for, radiohumeral bursitis, and experiment. STUDY SELECTION: The literature used included peer-reviewed studies that evaluated the effectiveness of physical therapy treatments on lateral epicondylitis. Future research is needed to provide a better understanding of beneficial treatment options for people living with this condition. DATA SYNTHESIS: Shockwave therapy and Cyriax therapy protocol are effective physical therapy interventions. CONCLUSIONS: There are numerous treatments for lateral epicondylitis and no single intervention has been proven to be the most efficient. Therefore, future research is needed to provide a better understanding of beneficial treatment options for people living with this condition.

PMID: 18515912 [PubMed - in process]

3: BMC Musculoskelet Disord. 2008 May 29;9:75.

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A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow).

Bjordal JM, Lopes-Martins RA, Joensen J, Couppe C, Ljunggren AE, Stergioulas A, Johnson MI.

Institute of Physiotherapy, Faculty of Health and Social Sciences, Bergen University College, Moellendalsvn, 6, 5009 Bergen, Norway. jmb@hib.no

BACKGROUND: Recent reviews have indicated that low level level laser therapy (LLLT) is ineffective in lateral elbow tendinopathy (LET) without assessing validity of treatment procedures and doses or the influence of prior steroid injections. METHODS: Systematic review with meta-analysis, with primary outcome measures of pain relief and/or global improvement and subgroup analyses of methodological quality, wavelengths and treatment procedures. RESULTS: 18 randomised placebo-controlled trials (RCTs) were identified with 13 RCTs (730 patients) meeting the criteria for meta-analysis. 12 RCTs satisfied half or more of the methodological criteria. Publication bias was detected by Egger's graphical test, which showed a negative direction of bias. Ten of the trials included patients with poor prognosis caused by failed steroid injections or other treatment failures, or long symptom duration or severe baseline pain. The weighted mean difference (WMD) for pain relief was 10.2 mm [95% CI: 3.0 to 17.5] and the RR for global improvement was 1.36 [1.16 to 1.60]. Trials which targeted acupuncture points reported negative results, as did trials with wavelengths 820, 830 and 1064 nm. In a subgroup of five trials with 904 nm lasers and one trial with 632 nm wavelength where the lateral elbow tendon insertions were directly irradiated, WMD for pain relief was 17.2 mm [95% CI: 8.5 to 25.9] and 14.0 mm [95% CI: 7.4 to 20.6] respectively, while RR for global pain improvement was only reported for 904 nm at 1.53 [95% CI: 1.28 to 1.83]. LLLT doses in this subgroup ranged between 0.5 and 7.2 Joules. Secondary outcome measures of painfree grip strength, pain pressure threshold, sick leave and follow-up data from 3 to 8 weeks after the end of treatment, showed consistently significant results in favour of the same LLLT subgroup (p < 0.02). No serious side-effects were reported. CONCLUSION: LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses.

Publication Types:

Research Support, Non-U.S. Gov't

PMID: 18510742 [PubMed - in process]

PMCID: PMC2442599

: Clinical outcome of fragment fixation for osteochondritis dissecans of the elbow.

Nobuta S, Ogawa K, Sato K, Nakagawa T, Hatori M, Itoi E.

Department of Orthopaedic Surgery, Tohoku Rosai Hospital, Sendai, Miyagi 981-8563, Japan. nobutays@jc5.so-net.ne.jp

BACKGROUND: The choice of surgical or non-surgical treatments for osteochondritis dissecans (OCD) of the humeral capitellum is still controversial. The purpose of this study was to assess the efficacy of fragment fixation for OCD of the humeral capitellum. METHODS: We reviewed 28 patients with OCD of the humeral capitellum after a mean follow up of 17 months. All patients were men and mean age was 14 years. Twenty-seven patients had a history of repetitive overuse of the elbow with baseball pitching, one with tennis. Mean duration of overuse of the elbow was four years. All patients had elbow pain and difficulty in throwing, with a mean duration of symptoms for 17 months. The mean arc of flexion before surgery ranged from 11 degrees to 126 degrees. Radiographs of the elbow showed a radiolucent cystic area of the humeral capitellum in one patient, a non-displaced split type fragment in 12 patients, and a slightly displaced split type fragment in 15 patients. Fragment fixation surgery was performed in all patients by lateral arthrotomy including drilling and fixation of the fragment with a double wiring technique using flexible wire or thread under direct vision. Sport activities using upper extremities were restricted for four to six months until the lesion healed in radiograph. RESULTS: Post-operatively, 25 patients had no pain and three decreased pain. Average arc of flexion was one to 132 degrees, an improvement of 16 degrees compared with the pre-operative arc. Radiographic findings showed complete healing of the lesion in 11 patients, partial healing in 12, unchanged in three, and loose body formation in two. By Tivnon's evaluation of the elbow function, results were excellent in 19 patients, good in five, fair in two, and poor in two. The ratio of complete or partial healing of the lesion was 100 percent in 16 patients in whom the thickness of the lesion was less than 9 mm on pre-operative radiograph, and 58 percent in 12 patients in whom the lesion thickness was 9 mm or more, which showed a significant difference (p<0.01). CONCLUSIONS: Fragment fixation for OCD of the humeral capitellum was effective in patients whose lesion thickness was less than 9 mm. Fixation by flexible wire or thread and revascularization by drilling for the fragment were considered to be insufficient for large lesions with a thickness of 9 mm or more.

PMID: 18509814 [PubMed - in process]

: Improved intramuscular blood flow and normalized metabolism in lateral epicondylitis after botulinum toxin treatment.

Oskarsson E, Piehl Aulin K, Gustafsson BE, Pettersson K.

Department of Clinical Medicine, School of Health and Medical Sciences, Orebro University, Orebro, Sweden.

Lateral epicondylitis is a common cause of elbow pain, and decreased microcirculation in extensor carpi radialis brevis (ECRB) has recently been suggested to contribute to the symptoms. The purpose of this pilot study was to investigate the treatment response after injection of botulinum toxin type A. Ten patients with unilateral epicondylitis and decreased intramuscular blood flow in ECRB participated. Handgrip, 2-pinch grip and muscle strength during radial deviation and dorsal extension of the wrist were recorded. Perceived pain during contraction was evaluated with the Visual Analogue Scale (VAS) and function in daily activities was assessed using the Disability of Arm, Shoulder and Hand instrument (DASH) and the Canadian Occupational Performance Measure instrument (COPM). Intramuscular blood flow was recorded by laser Doppler flowmetry, and microdialysis was used to analyze muscle metabolism. The difference in intramuscular blood flow between the control and the affected side had decreased 3 and 12 months after treatment (P=0.03). Lactate concentration at the 12-month follow-up had decreased (P=0.02); perceived pain was reduced and function in daily activities had improved. Injection of botulinum toxin is an alternative treatment for epicondylitis. Symptom relief may be due to enhanced microcirculation causing an aerobic metabolism.

PMID: 18435689 [PubMed - as supplied by publisher]

: Median and radial nerve compression about the elbow.

Tsai P, Steinberg DR.

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

It is important for physicians who treat upper extremity disorders to understand motor palsy or pain syndromes caused by compression of the median and radial nerves about the elbow and forearm. Patients with anterior interosseous nerve syndrome may report hand weakness, whereas those with pronator syndrome may present with pain and paresthesia that can be confused with carpal tunnel syndrome. Patients with posterior interosseous nerve syndrome report hand weakness, whereas those with radial tunnel syndrome report pain in the lateral elbow and forearm, which may be confused with lateral epicondylitis. Because each syndrome has overlapping symptoms, serial examinations are needed to determine the correct diagnosis.

PMID: 18399579 [PubMed - in process]

: Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices.

Altan L, Kanat E.

Rheumatic Disease and Hydrotherapy Section, Atatürk Rehabilitation Center, Uludağ University Medical Faculty, Bursa, Turkey, lalealtan@uludag.edu.tr.

We investigated the effectiveness of braces in the treatment of lateral epicondylitis and compared the effects of two different types of most frequently used braces. A total of 50 patients (seven males and 43 females) with an age range of 34 to 60 who had the diagnosis of lateral epicondylitis were included in the study. The patients were distributed into two groups. In group I, 25 patients (21 females and four males) were given a lateral epicondyle bandage. In group II, 25 patients (22 females and three males) were given a wrist resting splint holding the wrist in slight dorsiflexion. Evaluations of the patients were done before treatment and at the second and sixth weeks of treatment. Evaluation parameters were pain during rest and movement, sensitivity, algometer score, hand grip strength, and evaluation of the response to treatment. The response to treatment was evaluated according to the following categories: excellent, good, medium, and bad. In group I, only pain during rest and movement significantly decreased at 2 weeks while significant improvement was obtained for all parameters at 6 weeks. In group II, all parameters except for algometric sensitivity showed significant improvement at 2 weeks. Significant improvement was obtained for all parameters at 6 weeks in this group. Comparison of the two groups showed significantly better improvement in resting pain in group II at 2 weeks while there was no difference for other parameters including response to treatment at either evaluation stage. Braces might be a good strategy to help wait out the natural course of tennis elbow complaints. Although epicondyle bandage was not found to be superior to wrist splint in our study, we may suggest that it could be favored over splint since it is more practical and cosmetically acceptable.

PMID: 18365136 [PubMed - in process]

: Assessment of functional recovery in tennis elbow.

Alizadehkhaiyat O, Fisher AC, Kemp GJ, Vishwanathan K, Frostick SP.

Musculoskeletal Science Research Group, University of Liverpool, Liverpool L69 3GA, UK.

Objectives: (a) To investigate changes in muscular strength, fatigue and activity in recovered tennis elbow (RTE); (b) to assess the appropriateness of EMG and strength measurements in monitoring functional recovery in tennis elbow (TE). Methods: Study included three age-matched female groups of Control (C) (n=8, no history of musculoskeletal problems), TE (n=7, local tenderness at the lateral epicondyle and pain with resisted wrist and middle finger extension) and RTE (n=6, asymptomatic for at least 6 months, no lateral epicondyle tenderness). Measurements included metacarpophalangeal (MCP), wrist, shoulder and grip isometric strength and EMG measures of muscle fatigue and activity for five forearm muscles (wrist extensors and flexors). Results: Strength was greater (p<0.05) for all measurements in C compared to RTE and TE except for MCP extension. Only MCP extension was stronger in RTE than TE. EMG revealed increased activity of extensor carpi radialis (ECR) in RTE, decreased in TE. Conclusions: Despite attenuation of pain, global upper limb weakness in RTE indicated incomplete functional recovery. Increased strength of MCP extension may protect weakened wrist extensors from further injury. Monitoring the ECR activity as well as strength measurements may provide a useful assessment of functional recovery in TE.

PMID: 18343158 [PubMed - as supplied by publisher]

9: Chir Organi Mov. 2008 Jan;91(1):35-40. Epub 2008 Feb 10.

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No effect of forearm band and extensor strengthening exercises for the treatment of tennis elbow: a prospective randomised study.

Luginbühl R, Brunner F, Schneeberger AG.

Uniklinik Balgrist, Department of Orthopaedic Surgery, University of Zurich, Zurich, Switzerland.

The objective of this prospective randomised study was to analyse the effect of the forearm support band and of strengthening exercises for the treatment of tennis elbow. Twenty-nine patients with 30 tennis elbows were randomised into 3 groups of treatment: (I) forearm support band, (II) strengthening exercises and (III) both methods. The patients had a standardised examination at their first visit, and then after 6 weeks, 3 months and 1 year. At the latest follow-up, there was a significant improvement of the symptoms compared to before treatment (p<0.0001), considering all patients independently of the methods of treatment. However, no differences in the scores were found between the 3 groups of treatment (p=0.27), indicating that no beneficial influence was found either for the strengthening exercises or for the forearm support band. Improvement seems to occur with time, independent of the method of treatment used.

Publication Types:

PMID: 18320371 [PubMed - indexed for MEDLINE]

10: Br J Sports Med. 2008 Apr;42(4):267-71. Epub 2008 Jan 23.

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Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study.

Zeisig E, Fahlström M, Ohberg L, Alfredson H.

Sports Medicine Unit, Department of Surgical and Perioperative Science, Umeå University, 901 87 Umeå, Sweden. eva.zeisig@vll.se

BACKGROUND: "Tennis elbow" is a difficult condition to treat. Ultrasonography (US) and colour Doppler (CD) guided injections with polidocanol targeting the area with increased blood flow in the extensor origin have shown promising clinical results. OBJECTIVE: To evaluate and compare effects of US and CD guided intratendinous injections with sclerosing polidocanol and a local anaesthetic (lidocaine + epinephrine), in patients with tennis elbow. DESIGN: Prospective, randomised, controlled, double-blind, crossover study. SETTING: Sports Medicine Unit, Umeå University. PATIENTS: 32 patients (36 elbows), age range 27 to 66 years, with a long duration of elbow pain diagnosed as tennis elbow, were included in the study. All patients were followed up 3 and 12 months after treatment. Two patients were excluded due to other interventions during the study. INTERVENTIONS: One US and CD guided injection with the sclerosing agent polidocanol (group 1) or the local anaesthetic lidocaine plus epinephrine (group 2). At the 3 month follow-up, additional injections with polidocanol were offered to both groups (crossover for group 2). MAIN OUTCOME MEASURES: Satisfaction with treatment (Yes/No), elbow pain during activity (visual analogue scale), and maximum voluntary grip strength. RESULTS: There were no significant (p<0.05) differences in the outcome between group 1 and group 2. In both groups, there was a significantly lower VAS at the 3-month and 12-month follow-ups, and grip strength was significantly higher at the 12-month follow-up. CONCLUSIONS: US and CD guided intratendinous injections gave pain relief in patients with tennis elbow. Polidocanol and lidocaine plus epinephrine injections gave similar results.

Publication Types:

PMID: 18216158 [PubMed - indexed for MEDLINE]

11: J Hand Ther. 2008 Jan-Mar;21(1):63-7; quiz 68.

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The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial.

Oken O, Kahraman Y, Ayhan F, Canpolat S, Yorgancioglu ZR, Oken OF.

Ankara Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Division of Hand Rehabilitation, Ankara, Turkey. okenoznur@yahoo.com

The aims of this study were to evaluate the effects of low-level laser therapy (LLLT) and to compare these with the effects of brace or ultrasound (US) treatment in tennis elbow. The study design used was a prospective and randomized, controlled, single-blind trial. Fifty-eight outpatients with lateral epicondylitis (9 men, 49 women) were included in the trial. The patients were divided into three groups: 1) brace group-brace plus exercise, 2) ultrasound group-US plus exercise, and 3) laser group-LLLT plus exercise. Patients in the brace group used a lateral counterforce brace for three weeks, US plus hot pack in the ultrasound group, and laser plus hot pack in the LLLT group. In addition, all patients were given progressive stretching and strengthening exercise programs. Grip strength and pain severity were evaluated with visual analog scale (VAS) at baseline, at the second week of treatment, and at the sixth week of treatment. VAS improved significantly in all groups after the treatment and in the ultrasound and laser groups at the sixth week (p<0.05). Grip strength of the affected hand increased only in the laser group after treatment, but was not changed at the sixth week. There were no significant differences between the groups on VAS and grip strength at baseline and at follow-up assessments. The results show that, in patients with lateral epicondylitis, a brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy is more effective than the brace and US treatment in improving grip strength.

Publication Types:

PMID: 18215753 [PubMed - indexed for MEDLINE]

12: J Hand Ther. 2008 Jan-Mar;21(1):4-13; quiz 14.

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Comment in:

J Hand Ther. 2008 Jan-Mar;21(1):15-7.

The effect of oscillating-energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study.

Nourbakhsh MR, Fearon FJ.

Department of Physical Therapy, North Georgia College and State University, Dahlonega, Georgia 30597, USA. mrnourbakhsh@ngcsu.edu

Symptoms of lateral epicondylitis (LE) are attributed to degenerative changes and inflammatory reactions in the common extensor tendon induced by microscopic tears in the tissue after repetitive or overload functions of the wrist and hand extensor muscles. Conventional treatments, provided on the premise of inflammatory basis of LE, have shown 39-80% failure rate. An alternative approach suggests that symptoms of LE could be due to active tender points developed in the origin of hand and wrist extensor muscles after overuse or repetitive movements. Oscillating-energy Manual Therapy (OEMT), also known as V-spread, is a craniosacral manual technique that has been clinically used for treating tender points over the suture lines in the skull. Considering symptoms of LE may result from active tender points, the purpose of this study was to investigate the effect of OEMT on pain, grip strength, and functional abilities of subjects with chronic LE. Twenty-three subjects with chronic LE (>3mo) between ages of 24 and 72 years participated in this study. Before their participation, all subjects were screened to rule out cervical and other pathologies that could possibly contribute to their lateral elbow pain. Subjects who met the inclusion criteria were randomized into treatment and placebo treatment groups by a second (treating) therapist. Subjects were blinded to their group assignment. Subjects in the treatment group received OEMT for six sessions. During each treatment session, first a tender point was located through palpation. After proper hand placement, the therapist focused the direction of the oscillating energy on the localized tender point. Subjects in the placebo group underwent the same procedure, but the direction of the oscillating energy was directed to an area above or below the tender points, not covering the affected area. Jamar Dynamometer, Patient Specific Functional Scale (PSFS), and Numeric Rating Scale (NRS) were used to measure grip strength, functional status, and pain intensity and limited activity due to pain, respectively. The screening therapist who was blinded to the subjects' group assignment performed pretest, posttest, and six-month follow-up measurements. Subjects in the treatment group showed both clinically and statistically significant improvement in grip strength (p=0.03), pain intensity (p=0.006), function (p=0.003), and limited activity due to pain (p=0.025) compared with those in the placebo group. Follow-up data, collected after six months, showed no significant difference between posttest and follow-up measurements in functional activity (p=0.35), pain intensity (p=0.72), and activity limitation due to pain (p=0.34). Of all the subjects contacted for follow-up assessment, 91% maintained improved function and 73% remained pain free for at least six months. OEMT seems to be a viable, effective, and efficient alternative treatment for LE.

Publication Types:

Randomized Controlled Trial

PMID: 18215746 [PubMed - indexed for MEDLINE]

: Arthroscopic, macroscopic, and microscopic anatomy of the synovial fold of the elbow joint in correlation with the common extensor origin.

Tsuji H, Wada T, Oda T, Iba K, Aoki M, Murakami G, Yamashita T.

Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan.

PURPOSE: The objective of our study was to clarify the arthroscopic, macroscopic, and microscopic anatomy of the radiocapitellar synovial fold of the elbow joint in correlation with the common extensor origin. METHODS: We performed arthroscopy in 14 fresh-frozen cadaveric elbows and found the synovial fold covering the radial head or interposing in the radiocapitellar joint in 6. The fold was tagged with loop suture under arthroscopy to identify its exact location in gross anatomy. The radiocapitellar joint capsule was then resected without disturbing the continuity of the common extensor and lateral epicondyle. Macroscopic and histologic evaluation was performed for the lateral elbow capsular complex. RESULTS: The synovial fold was found to be a triangular-shaped thickening of the capsule located on the proximal edge of the annular ligament. The mean distance between the lateral epicondyle and the base of the fold at the anterior edge, middle part, and posterior edge was 23 mm, 8 mm, and 13 mm, respectively. This structure was distinct from the annular ligament but was continuous with the radiocapitellar joint capsule. The joint capsule and the common extensor tendon blended with each other imperceptibly and formed a single enthesis at the lateral epicondyle. CONCLUSIONS: The synovial fold identified by arthroscopy is a physiologic capsular tissue located on the proximal edge of the annular ligament. It is distinct from the annular ligament but has a close correlation with the common extensor tendon enthesis at the lateral epicondyle. CLINICAL RELEVANCE: The synovial fold belongs to the lateral epicondyle enthesis, which is a composite of the common extensor tendon, undersurface capsule, and bone. Therefore, lateral epicondylitis with degenerative lesions in the area of the common extensor origin may involve the synovial fold and induce hypertrophic changes.

PMID: 18182199 [PubMed - indexed for MEDLINE]

14: J Am Acad Orthop Surg. 2008 Jan;16(1):19-29.

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Management of lateral epicondylitis: current concepts.

Calfee RP, Patel A, DaSilva MF, Akelman E.

Department of Orthopaedic Surgery, University of Cincinnati, OH, USA.

Lateral epicondylitis, or tennis elbow, is a common cause of elbow pain in the general population. Traditionally, lateral epicondylitis has been attributed to degeneration of the extensor carpi radialis brevis origin, although the underlying collateral ligamentous complex and joint capsule also have been implicated. Nonsurgical treatment, the mainstay of management, involves a myriad of options, including rest, nonsteroidal anti-inflammatory drugs, physical therapy, cortisone, blood and botulinum toxin injections, supportive forearm bracing, and local modalities. For patients with recalcitrant disease, the traditional open débridement technique has been modified by multiple surgeons, with others relying on arthroscopic or even percutaneous procedures. Without a standard protocol (nonsurgical or surgical), surgeons need to keep abreast of established and evolving treatment options to effectively treat patients with lateral epicondylitis.

Publication Types:

Review

PMID: 18180389 [PubMed - indexed for MEDLINE]

15: Croat Med J. 2007 Dec;48(6):767-78.

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Overuse injuries in female athletes.

Ivković A, Franić M, Bojanić I, Pećina M.

Center for Molecular Orthopedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

The last three decades have witnessed a tremendous increase in female sports participation at all levels. However, increased sports participation of female athletes has also increased the incidence of sport-related injuries, which can be either acute trauma or overuse injuries. Overuse injuries may be defined as an imbalance caused by overly intensive training and inadequate recovery, which subsequently leads to a breakdown in tissue reparative mechanisms. This article will review the most frequent overuse injuries in female athletes in the context of anatomical, physiological, and psychological differences between genders.

Publication Types:

Review

PMID: 18074410 [PubMed - indexed for MEDLINE]

PMCID: PMC2213798

: Activation of forearm muscles for wrist extension in patients affected by lateral epicondylitis.

Rojas M, Mañanas MA, Muller B, Chaler J.

Dept. Automatic Control, Biom. Eng. Research Center (CREB), Technical University of Catalonia, UPC, Barcelona, Spain. monica.rojas@upc.edu

Work related upper extremity disorders are associated with cumulative trauma resulting from the continuous use of forearm muscles rather than from a specific incident. The aim of this work is to compare wrist extensor muscles activation between patients with lateral epicondylitis and healthy subjects. Differences can be used in the design of rehabilitation or injury prevention programs according to biomechanical deficits. Surface EMG signals from three forearm extensor muscles (Carpi Radialis-ECR, Digitorum Communis-EDC and Carpi Ulnaris-ECU) were recorded by linear electrode arrays in wrist extension as well as during selective contractions. Average Rectified Values (ARV) were calculated in order to identify the contribution of each muscle to different tasks. On the other hand, Muscle Fiber Conduction Velocity, Mean and Median Frequencies and also ARV were studied to obtain fatigue indexes related to metabolic changes in the muscles during a high force sustained contraction. Results showed muscular imbalance with lower ECR activity compensated by higher ECU activation, and higher fatigue indexes in patients with lateral epicondylitis.

PMID: 18003094 [PubMed - indexed for MEDLINE]

: A critical review of the current conservative therapies for tennis elbow (lateral epicondylitis).

Viola L.

The pathogenesis, pathology, natural course, and in particular the treatment of lateral epicondylitis (tennis elbow) remains controversial. An extensive review of the scientific literature with respect to the conservative treatment of tennis elbow, revealed that acceptable epidemiological techniques of the prospective randomised control trials or case controlled studies are scarce. While administration of steroid compounds has traditionally been the mainstay of conservative treatment of tennis elbow, the high recurrence rate of side effects and structural tissue changes associated with steroid therapy, leaves this modality as the most controversial approach in the treatment of tennis elbow. In contrast, in some studies evidence in favour of a role for classical acupuncture, ultrasound and low level laser as effective therapeutic means in the treatment of tennis elbow has been provided. As these modalities have not been associated with any side effects, in view of the ease of application, low cost and good curative effects, their increased application has been suggested by some authors. This proposition, however, remains rather conjectural until it could be convincingly substantiated by future studies with appropriate epidemiological design.

PMID: 17987156 [PubMed - in process]
PMCID: PMC2050803

: Fractional lengthening of forearm extensors for resistant lateral epicondylitis.

Wang AW, Erak S.

Department of Orthopaedic Surgery, Queen Elizabeth Medical Centre, Perth, Western Australia, Australia. allanwang@aapt.net.au

BACKGROUND: This study presents the surgical technique of fractional lengthening of extensor carpi radialis brevis, extensor digitorum communis and the superficial head of supinator, for chronic lateral epicondylitis. The anatomical basis for this surgical approach is reviewed. The results of surgical treatment in a consecutive series of patients with severe chronic lateral epicondylitis are reviewed. METHODS: Twenty-one elbows in 17 subjects underwent surgery. All elbows had severe resistant symptoms, unresponsive to a minimum 6 months (mean 14 months) of a non-operative treatment protocol. All elbows showed either tendonopathy or a partial tear in the common extensor tendon origin at preoperative imaging. RESULTS: All subjects were examined at a minimum of 1 year after surgery. The mean visual analogue pain (VAS) score reduced from 7.6 (maximum 10) preoperatively to 1.3 postoperatively (P<0.01). The mean preoperative ability to carry out normal work duties reduced from 4.3 (maximum 5) preoperatively to 1.5 postoperatively (P<0.01). Grip strength improved or remained equivalent following surgery. The mean VAS for patient satisfaction with surgery was 8.8 (maximum score 10). Using the Roles and Maudsley classification, 14 patients (82%) were rated good or excellent. Three subjects were rated fair or poor, were undergoing treatment for other pathology in the ipsilateral extremity and had ongoing compensation claims. CONCLUSION: Fractional lengthening of forearm extensors is effective treatment for severe and chronic lateral epicondylitis. Outcomes following fractional lengthening surgery are less predictable when other pathology in the upper extremity requires concomitant treatment.

PMID: 17931261 [PubMed - indexed for MEDLINE]

19: J Hand Surg [Am]. 2007 Oct;32(8):1271-9.

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Lateral epicondylitis: review and current concepts.

Faro F, Wolf JM.

Department of Orthopaedics, University of Colorado Health Sciences Center, 4200 E. 9th Avenue, Denver, CO 80262, USA.

Lateral epicondylitis is a painful and functionally limiting entity affecting the upper extremity and is frequently treated by hand surgeons. The anatomic basis of the injury to the extensor carpi radialis brevis origin appears to be multifaceted, involving hypovascular zones, eccentric tendon stresses, and a microscopic degenerative response. Although many treatments have been advocated, there is little clear consensus on which modality works best, for both conservative and operative options. In this article, we present an overview of this difficult problem and an evidence-based review of treatment choices.

Publication Types:

Review

PMID: 17923315 [PubMed - indexed for MEDLINE]

20: Rheumatology (Oxford). 2007 Oct;46(10):1601-5.

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Conservative treatments for tennis elbow do subgroups of patients respond differently?

Bisset L, Smidt N, Van der Windt DA, Bouter LM, Jull G, Brooks P, Vicenzino B.

School of Health and Rehabilitation Sciences, University of Queensland, Queensland, Australia.

OBJECTIVES: To determine if subgroups of patients with tennis elbow respond differently in treatment. METHODS: This study used individual patient data (n = 383) from two randomized controlled trials that investigated a wait-and-see policy, corticosteroid injections and physiotherapy. Common outcome measures were: pain severity, global improvement, severity assessed by a blinded assessor, elbow disability and pain free grip strength. Subgroup analyses for previous history of elbow pain, baseline pain severity, duration of the current episode and employment status were performed at 6 and 52 weeks. RESULTS: Patients' age, previous elbow symptoms and baseline pain severity were similar between trials, but other characteristics differed between trial populations. Based on individual patient data from both trials, we found that corticosteroid injections were statistically and clinically superior at 6 weeks, but significantly worse at 52 weeks compared with both wait-and-see and physiotherapy. Subgroup effects were scarce and small. Patients with higher baseline pain score showed less benefit on pain outcomes between physiotherapy and a wait-and-see policy at 6 weeks. It also appeared that non-manual workers who had an injection were the only work subgroup to follow the general trend that injections were significantly worse than a wait-and-see policy on global improvement at 52 weeks. CONCLUSION: The treatment outcomes were largely similar between trials and not different between most subgroups studied. In tennis elbow, it would appear that patient characteristics play only a small role in predicting treatment outcomes, which supports the generalizability of individual trial results.

Publication Types:

PMID: 17890274 [PubMed - in process]

: Anatomic factors related to the cause of tennis elbow.

Bunata RE, Brown DS, Capelo R.

John Peter Smith Affiliated Orthopedic Residency Program, University of North Texas Health Science Center, Fort Worth, TX 76109, USA. rbunata@hsc.unt.edu

BACKGROUND: The pathogenesis of lateral epicondylitis remains unclear. Our purpose was to study the anatomy of the lateral aspect of the elbow under static and dynamic conditions in order to identify bone-to-tendon and tendon-to-tendon contact or rubbing that might cause abrasion of the tissues. METHODS: Eighty-five cadaveric elbows were examined to determine details related to the bone structure and musculotendinous origins. We identified the relative positions of the musculotendinous units and the underlying bone when the elbow was in different degrees of flexion. We also recorded the contact between the extensor carpi radialis brevis and the lateral edge of the capitellum as elbow motion occurred, and we sought to identify the areas of the capitellum and extensor carpi radialis brevis where contact occurs. RESULTS: The average site of origin of the extensor carpi radialis brevis on the humerus lay slightly medial and superior to the outer edge of the capitellum. As the elbow was extended, the undersurface of the extensor carpi radialis brevis rubbed against the lateral edge of the capitellum while the extensor carpi radialis longus compressed the brevis against the underlying bone. CONCLUSIONS: The extensor carpi radialis brevis tendon has a unique anatomic location that makes its undersurface vulnerable to contact and abrasion against the lateral edge of the capitellum during elbow motion.

PMID: 17768192 [PubMed - indexed for MEDLINE]

22: Br J Sports Med. 2007 Nov;41(11):820-3. Epub 2007 Jul 17.

Related Articles, Links

Biomechanics of the elbow joint in tennis players and relation to pathology.

Eygendaal D, Rahussen FT, Diercks RL.

Amphia Hospital, Teteringen, The Netherlands. denise@eygendaal.nl

Elbow injuries constitute a sizeable percentage of tennis injuries. A basic understanding of biomechanics of tennis and analysis of the forces, loads and motions of the elbow during tennis will improve the understanding of the pathophysiology of these injuries. All different strokes in tennis have a different repetitive biomechanical nature that can result in tennis-related injuries. In this article, a biomechanically-based evaluation of tennis strokes is presented. This overview includes all tennis-related pathologies of the elbow joint, whereby the possible relation of biomechanics to pathology is analysed, followed by treatment recommendations.

Publication Types:

Review

PMID: 17638843 [PubMed - indexed for MEDLINE]

23: Br J Sports Med. 2007 Nov;41(11):816-9. Epub 2007 Jul 6.

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Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment.

De Smedt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F.

University Hospital Antwerp, Antwerp, Belgium. thomasdesmedt1@yahoo.com

Lateral epicondylitis (tennis elbow) is the most frequent type of myotendinosis and can be responsible for substantial pain and loss of function of the affected limb. Tennis biomechanics, player characteristics and equipment are important in preventing the condition. This article presents an overview of the current knowledge on lateral epicondylitis, and focuses on treatment strategies. Conservative and surgical treatment options are discussed, and recent techniques are outlined.

Publication Types:

Review

PMID: 17616547 [PubMed - indexed for MEDLINE]

: The effectiveness of phonophoresis with ketoprofen in the treatment of epicondylopathy.

Cabak A, Maczewska M, Lyp M, Dobosz J, Gasiorowska U.

Wydział Rehabilitacji, Akademia Wychowania Fizycznego, Warszawa.

Background. This article examines the therapeutic effects of phonophoresis with ketoprofen in gel form in patients with enthesopathy of the elbow. Ultrasonic therapy and phonophoresis have their primary application in the physical therapy of this disorder. The main aim of this study was to assess the effectiveness of phonophoresis. Material and methods. The research group consisted of 19 patients diagnosed with enthesopathy of the lateral and medial epicondyle. In the statistical analysis we included 28 elbow joints treated with phonophoresis. The effects of therapy were compared with a control group of 20 patients who were treated with only ultrasound therapy. The therapeutic series consisted of 10 treatments, using the pulse mode of ultrasound and an intensity of 0.8 W/cm2 in both groups. The clinical examination (objective assessment) and interview (subjective assessment) consisted of specific tests, and were separately collected. Reasults. The positive effects of phonophoresis using a pharmacologically active gel with ketoprofen were shown to be highly significant in both assessments, objective and subjective. The pain symptoms in the elbow resolved in most of the patients. There were statistically significant differences between phonophoresis and ultrasound therapy. Conclusions. Our results support the application of phonophoresis with ketoprofen in the treatment of epicondylitis.

PMID: 17611432 [PubMed - in process]

25: J Hand Surg [Am]. 2007 Jul-Aug;32(6):882-6.

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Effect of elbow position on grip strength in the evaluation of lateral epicondylitis.

Dorf ER, Chhabra AB, Golish SR, McGinty JL, Pannunzio ME.

University of Virginia Hand Center, Charlottesville, VA, and Reconstructive Hand Surgeons of Indiana, Carmel, IN, USA.

PURPOSE: This study evaluated the maximum grip strength in a position of elbow extension versus flexion as a diagnostic tool in the assessment of a patient with suspected lateral epicondylitis (LE). METHODS: From our database we identified 81 patients with grip strength measurements and the diagnosis of LE. From these patient records we collected grip strength measurements with the elbow in full extension and with the elbow in 90 degrees of flexion for the affected and the healthy extremity. We then compared 2 values: the pretreatment grip strength in flexion and extension for the affected extremity and the pretreatment grip strengths of the nonaffected extremity compared with the affected extremity. Grip strengths were compared with paired and unpaired 2-tailed t tests. RESULTS: Grip strength was no different in flexion and extension for the healthy extremity and 29% stronger in flexion than in extension for the affected extremity. The affected arm averaged 50% of the strength of the healthy arm in extension and 69% of the strength of the healthy arm in flexion. These differences were statistically significant. An 8% difference in grip strength between flexion and extension was found to be 83% accurate in distinguishing the affected from the unaffected extremities. CONCLUSIONS: The measurement of extension grip strength is a useful objective tool to aid in the diagnosis of LE. In patients with LE, the grip strength decreases as one moves from a position of flexion to a position of extension.

Publication Types:

PMID: 17606071 [PubMed - indexed for MEDLINE]

: Pain, functional disability, and psychologic status in tennis elbow.

Alizadehkhaiyat O, Fisher AC, Kemp GJ, Frostick SP.

Musculoskeletal Science Research Group, Royal Liverpool University Hospital, Liverpool, UK. omid1348@liv.ac.uk

OBJECTIVES: First to compare pain and functional disability in tennis elbow (TE) patients with healthy controls. Second, to evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE. METHODS: Sixteen TE patients were recruited from 46 consecutive attendees at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localized lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups. RESULTS: Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11). DISCUSSION: TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of "upper limb" and "psychologic" assessment tools.

PMID: 17575487 [PubMed - indexed for MEDLINE]

27: Schmerz. 2008 Feb;22(1):9-15.

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[Evidence for laser acupuncture in cases of orthopedic diseases : a systematic review]

[Article in German]

Schüller BK, Neugebauer EA.

Institut für Forschung in der operativen Medizin (IFOM), Fakultät für Medizin der Universität Witten/Herdecke, Ostmerheimer Str. 200, 51109, Köln, Deutschland.

BACKGROUND AND OBJECTIVES: The aim of this review is to evaluate the evidence for laser acupuncture in selected orthopaedic diseases. MATERIAL AND METHODS: Randomized controlled studies, meta-analyses and systematic reviews were identified by a systematic search strategy in Medline and the Cochrane library. The studies were evaluated using the quality criteria of the Oxford Centre of Evidence Based Medicine. RESULTS: For the selected orthopedic diseases (medial and lateral epicondylitis, myofascial pain syndrome of the neck, back and shoulder and osteoarthritis), meta-analyses, systematic reviews and eight randomized controlled studies were found. All other published studies used laser therapy without consideration of classical acupuncture points. All studies had significant drawbacks in methodological quality and the number of patients included. In more recent trials, improvement towards higher methodological quality was obvious. Although current evidence is equivocal, positive effects can be assumed in myofascial pain syndromes of the neck, back and shoulder. Laser acupuncture is advantageous in terms of side effects compared to classical acupuncture techniques. CONCLUSION: Better, well designed randomized studies with higher power are mandatory in orthopedic diseases.

Publication Types:

PMID: 17530300 [PubMed - indexed for MEDLINE]

28: J Shoulder Elbow Surg. 2007 Sep-Oct;16(5 Suppl):S208-14. Epub 2007 May 16.

Related Articles, Links

Oxygen free radicals and tendon healing.

Murrell GA.

Orthopaedic Research Institute, St George Hospital Campus, University of New South Wales, Sydney, Australia. admin@ori.org.au

Nitric oxide is a small free radical generated by a family of enzymes, the nitric oxide synthases (NOSs). In a series of experiments performed over the last 15 years, we showed that nitric oxide is induced by all 3 isoforms of NOS during tendon healing and that it plays a crucial beneficial role in restoring tendon function. In normal tendons, very little NOS activity was found, whereas in injured rat and human tendons, NOS activity was expressed in healing fibroblasts in a temporal fashion. In healing rat Achilles tendon fibroblasts, the first isoform to be expressed was endothelial NOS, followed by inducible NOS and then brain or neuronal NOS. Systemic inhibition of NOS activity decreased the cross-sectional area and mechanical properties of the healing rodent Achilles tendons. The addition of nitric oxide via nitric oxide-flurbiprofen enhanced rat Achilles tendon healing. The addition of nitric oxide to cultured human tendon cells via chemical means and via adenoviral transfection enhanced collagen synthesis, suggesting that one mechanism for the beneficial effect of nitric oxide on tendon healing might be via matrix synthesis. Most recently, 3 randomized, double-blind clinical trials evaluated the efficacy of nitric oxide donation via a patch in the management of the tendinopathy. In all 3 clinical trials, there was a significant positive beneficial effect of nitric oxide donation to the clinical symptoms and function of patients with Achilles tendinopathy, tennis elbow, and supraspinatus tendinitis.

Publication Types:

Randomized Controlled Trial

PMID: 17509903 [PubMed - indexed for MEDLINE]