Chronic Lateral Elbow Tendinopathy Research Articles

A Comparison of the short-term effects of steroid injection, prolotherapy and home-based physiotherapy in patients with chronic lateral elbow tendinopathy

Aim: This study aims to compare the effects of steroid injection (SI), prolotherapy, and home-based physiotherapy on pain and function in short-term in chronic lateral elbow tendinopathy (LET) patients. Materials and Methods: Patients with chronic LET admitted to the orthopedic clinic between 2022 and 2023 were divided into SI (n=17), prolotherapy (n=17) and home-based physiotherapy (n=17) groups. Visual Analogue Scale (VAS), Quick Disability Assessment of Arm, Shoulder and Hand Problems (QuickDASH), and Health Assessment Questionnaire (HAQ) for pain and function before, two, and six weeks after treatment were compared. Results: Second and sixth-week VAS, QuickDASH and HAQ were significantly lower in SI and prolotherapy than home-based physiotherapy group (p=0.001). In the sixth week, sufficient improvement was achieved in VAS, QuickDASH and HAQ in SI compared to prolotherapy and home-based physiotherapy (p=0.001, η2=0.30-0.42). Conclusion: SI, prolotherapy, and home-based physiotherapy improved elbow pain and function in short-term, but SI was greater effective. SI may be effective for short-term improvement in chronic LET patients.

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

Weakness of the shoulder girdle muscles has been reported in patients with chronic lateral elbow tendinopathy. The aim of this study was to assess the short- and long-term effects of a conventional treatment plus scapular exercises program in patients with chronic lateral elbow tendinopathy. A single-group prestudy and poststudy were conducted. The primary outcome was the Patient-Rated Tennis Elbow Evaluation questionnaire score. Secondary outcomes were grip strength; Disabilities of the Arm, Shoulder, and Hand questionnaire score; Visual Analogue Scale score at rest and at grip, and presence of scapular dyskinesis. A total of 65 patients (72.3% females), with a mean age of 41.8years, were analyzed. At the end of 6weeks, the results showed clinically and statistically significant differences (P < .05). At 1-year follow-up, the differences were: Patient-Rated Tennis Elbow Evaluation -31 points (P < .001); grip strength +33.6% (P < .001); Disabilities of the Arm, Shoulder, and Hand -34.2 points (P < .001); Visual Analogue Scale at rest -2.5cm (P < .001); and Visual Analogue Scale at grip -2.3cm (P < .001). At the end of 6weeks and at 1-year follow-up, conventional treatment plus scapular exercises program showed statistically and clinically significant differences in all functional outcomes assessed in patients with lateral elbow tendinopathy.

Added value of ultrasound-guided percutaneous needle tenotomy over hydrodissection and physiotherapy in chronic lateral elbow tendinopathy: a pilot randomized controlled trial.

There is no consensus on the most suitable non-surgical treatment of chronic lateral elbow tendinopathy. The aim of this pilot randomized controlled trial was to evaluate the size of effect of ultrasound-guided percutaneous needle tenotomy. Three intervention arms were formed: 1) percutaneous needle tenotomy, hydrodissection, and physiotherapy; 2) hydrodissection and physiotherapy; and 3) physiotherapy alone. Patients with chronic lateral elbow tendinopathy were randomized. Clinical endpoints included multiple questionnaires after three months: Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Numeric Rating Scale (NRS) pain at rest and during activity, and EuroQol 5D-5L (EQ-5D-5L). Thirty patients were included of 128 screened. The QuickDASH score improved in the percutaneous needle tenotomy and physiotherapy group, but not in the hydrodissection group. The NRS pain at rest and during activity improved more in the percutaneous needle tenotomy (resp. -2 and -2) and hydrodissection (resp. -3 and -3) groups than in the physiotherapy (resp. +1 and -1) group. The EQ-5D-5L improved similarly in all groups. Patients receiving percutaneous needle tenotomy and/or hydrodissection may show better results in terms of pain but not in their functional outcomes compared to those who received physiotherapy alone. The size of effect, however, is small, so a large sample size is needed for a future randomized controlled trial to further investigate these results.

Chronic lateral elbow tendinopathy with a supervised graded exercise protocol

Study DesignProspective Case Series. BackgroundVariety of studies inquired the effectiveness of exercise treatment in LET (Lateral Elbow Tendinopathy). The research on the effectiveness of these approaches are still ongoing and very much needed due to the uncertainty of the subject. PurposeWe aimed to understand how the application of exercises in a graded manner affect the treatment outcomes in terms of pain and function. MethodsThis study is completed by 28 patients with LET and it was planned as a prospective case series. Thirty participants were included to participate in the exercise group. Basic Exercises (Grade 1) were performed for four weeks. Advanced Exercises (Grade 2) were performed for another four weeks. The VAS (Visual Analog Scale), pressure algometer, the PRTEE (Patient-Rated Tennis Elbow Evaluation) and a grip strength dynamometer were used to measure outcomes. The measurements were performed at baseline, at the end of four weeks and at the end of eight weeks. ResultsInvestigation of the pain scores revealed that all VAS scores (p < 0.05, ES = 1.35; 0.72; 0,73 activity, rest, and night respectively) and pressure algometer results were improved both during basic (p < 0.05, ES = 0.91) and advanced exercises (p < 0.05, ES = 0,41). PRTEE scores were found to be improved in patients with LET after basic and advanced exercises (p > 0.001, ES = 1.15; p > 0.001, ES = 1.56 respectively). The grip strength only changed after basic exercises (p = 0.003, ES = 0.56). ConclusionsThe basic exercises were beneficial for both pain and function. However, advanced exercises are required for obtaining further improvements in terms of pain, function, and grip strength.

A Progressive Loading Supervised Exercise Program and Manual Therapy for The Management of Lateral Elbow Tendinopathy: A Case Report

The purpose of the case study was to find out the effect of a supervised exercise program combined with Transverse Friction (TF) and Mulligan Mobilization With Movement (MMWM) on disability and pain in a patient experiencing chronic Lateral Elbow tendinopathy (LET). A patient with unilateral LET for 6 months was included in the present study. The patient followed the exercise program five times per week for 4 weeks. The programme was individualized on the basis of the patient’s description of pain experienced during the procedure. TF and MMWM were applied 3 times per weeks for 4 weeks, 12 sessions totally. Outcome measures were function using the Patient-Rated Tennis Elbow Evaluation, a visual analogue scale and the pain-free grip strength and pain using a visual analogue scale. The patient was evaluated at baseline (week 0), at week 4 (end of treatment), at week 8 (1 month after the end of the treatment) and at week 32 (six months after the end of treatment). At the end of the treatment and at the follow – up there was a rise in function and a decline in pain. The findings of the case report suggest that a physiotherapy approach as described in the present case report can produce significant improvements in terms of disability and pain in a patient with chronic LET

Promising improvement of chronic lateral elbow tendinopathy by using adipose derived mesenchymal stromal cells: a pilot study

PurposeStudy the effect of Adipose derived stromal cells (ASCs) injection as therapeutic procedure on the common extensor tendinopathy.MethodsEighteen Tennis players with chronic, recalcitrant LET (who have previously been unsuccessfully treated with nonoperative treatments) underwent clinical evaluation and magnetic resonance imaging (MRI) before intervention. Stromal vascular fraction cells (SVF) were expanded by in vitro culture and ASCs were obtained and characterized by flow cytometry. ASCs were injected into the site of tendinopathy (identified by ultrasound imaging at the origin of the common extensor tendon) on a single occasion followed by physiotherapy. Players underwent serial clinical evaluations during a 12-month period and repeated MRI at 6-month post-injection.ResultsAt 6-month clinical evaluation revealed significant improvements compared to baseline in mean Visual Analog Scale (VAS) scores for: (1) maximum pain score (from 6.28 ± 1.65, to 1.0 ± 0.43; p < .001); (2) Mean quick Disabilities of the Arm, Shoulder and Hand (QuickDASH-Compulsory score: 51.38 ± 12.02 to 12.33 ± 4.66; p < .001); (3) QuickDASH-Sport score: 56.94 ± 15.44 to 8.68 ± 8.86; p < .001). Validated MRI scoring system grade of tendinopathy also improved significantly: 4.22 ± 0.26 to 2.22 ± 0.10 (p < .001). At 12-month from injection, VAS maximun pain score further decreased to 0.74 ± 0.44 (p < .001) and QuickDASH-Compulsory score to 5.56 ± 3.58 (p < .001). Average time to return to play tennis was 3,31 ± 0,61 month post-intervention.ConclusionTennis players with recalcitrant LET showed significant clinical improvement and structural repair at the origin of the common tendon origin after injection of autologous ASCs. Results of this study are promising and open a new biological therapeutic modality to treat LET. Even if the results of this pilot study are positive, future well-designed studies, i.e. prospective randomized trials are needed to define the role of cell therapy in treating LET.

Thermal and Current Flow Effects of a Capacitive-Resistive Electric Transfer Application Protocol on Chronic Elbow Tendinopathy. A Cadaveric Study.

Lateral elbow tendinopathy, or “tennis elbow,” is a pathology that affects around 1.3% of the general population. Capacitive–resistive electric transfer therapy aims to provoke temperature and current flow changes in superficial and deep tissues. The aim of this in vitro study was to analyze the thermal behavior and transmission of electric current on the superficial and deep tissues of the elbow during the application of different modalities of a capacitive–resistive electric transfer treatment protocol for chronic elbow tendinopathy. A cross-sectional study was designed; five fresh cryopreserved cadavers (10 elbows) were included in this study. A 30 min intervention was performed based on a protocol commonly used in clinics for the treatment of chronic lateral elbow tendinopathy by diathermy using the “T-Plus.” Common extensor tendon, radiohumeral capsule, and superficial temperatures were registered after each application for the duration of the 30 min treatment protocol. During all applications, we observed a current flow of over 0.03 A. The protocol showed a statistically significant increase in superficial temperature by 24% (5.02°) (p < 0.005), the common extensor tendon by 19.7% (4.36°) (p < 0.007), and the radiohumeral joint capsule by 17.5% (3.41°) (p < 0.005) at the end of the 30 min protocol compared with the baseline temperature. The different applications of the protocol showed specific effects on the temperature and current flow in the common extensor tendon and radiohumeral capsule. All applications of the protocol produced a current flow that is associated with the generation of cell proliferation. These results strengthen the hypothesis of cell proliferation and thermal changes in deep and distal structures. More studies are needed to confirm these results.

The Patient-Rated Tennis Elbow Evaluation Questionnaire was successfully translated to Persian

IntroductionThe Patient-Rated Tennis Elbow Evaluation (PRTEE) is designed to evaluate pain and disability in subjects with lateral elbow tendinopathy. This questionnaire is available in Swedish, Italian, and some other languages. A Persian language version of the questionnaire is needed for both research and clinical purposes. Purpose of the StudyThe purpose of this study was to translate and cross-culturally adapt the PRTEE questionnaire into the Persian language and to determine its validity and reliability. MethodsThe PRTEE was translated and culturally adapted from English into Persian (PRTEE-P) according to the established guidelines. The PRTEE-P was completed by 68 Iranian subjects (44 women, 24 men) diagnosed with chronic lateral elbow tendinopathy. To assess test-retest reliability, all subjects filled out the PRTEE-P on a second admission within one week. The intraclass correlation coefficient (ICC) and Cronbach's alpha were measured to report reliability. The validity was determined by correlating the PRTEE-P questionnaire with the Persian version of the Disabilities of the Arm, Shoulder, and Hand questionnaire. ResultsThe Persian version of the PRTEE showed a high internal consistency with a Cronbach's alpha of 0.99, demonstrating good test-retest reliability (ICC = 0.99). It was well correlated with Disabilities of the Arm, Shoulder, and Hand (r = 0.80). ConclusionThe PRTEE-P is a reliable and valid tool designed for measuring pain and disability in subjects with lateral elbow tendinopathy.

Do hand therapists have a role in workplace-based education to manage tennis elbow? Beliefs about effective treatments among Australian hand therapists and medical practitioners.

Lateral elbow tendinopathy (LET), commonly known as tennis elbow, is a prevalent work-related upper extremity musculoskeletal disorder. Medical practitioners and hand therapists manage LET with commonly available clinic-based treatments, despite no sound evidence to suggest long-term relief and functional restoration for workers with LET. Workplace-based rehabilitation is effective for injured workers with other health conditions, but no studies have investigated this rehabilitation approach in the management of LET. (i) Identify, compare, and contrast Australian hand therapists' and medical practitioners' perceptions about the effectiveness of common treatments for LET, and (ii) obtain their views towards a hand therapist delivered workplace-based education approach. In this cross-sectional study, 38 medical practitioners from Western Australia and 104 hand therapists around Australia completed online surveys. Independent t-tests were used to identify between-group differences in responses. Despite some between-group differences regarding the perceived effectiveness of common LET treatments, both groups believed education about LET pathology, activity modification, postures, and workplace recommendations were most effective. Most medical practitioners (81%) and hand therapists (71%) believed workplace-based education delivered by a hand therapist would be beneficial for patients with acute and chronic LET. Australian hand therapists and medical practitioners believed educational approaches were the most important component in the management of LET, and supported workplace-based educational interventions provided by hand therapists in the management of LET.

Efficacy of physical therapy interventions for chronic lateral elbow tendinopathy: a systematic review

Study Design: Systematic review.Background: Existing systematic reviews and meta-analyses do not support a specific physical therapy treatment for lateral elbow tendinopathy (LET). The results of these studies, however, may not accurately represent the current state of evidence. This may be due, in part, to methodological limitations in these studies, specifically the lack of utilization of standardized and disease-specific outcome measures.Objectives: To determine the effectiveness of physical therapy interventions in treating chronic lateral elbow tendinopathy as assessed in randomized controlled trials (RCTs) using pain-free grip strength and/or patient-rated tennis elbow evaluation questionnaire as outcome measures.Methods: A search of PubMed, Physiotherapy Evidence Database (PEDro), Scopus database, Google Scholar and bibliography was conducted from inception to November 2018. The methodological quality of the identified RCTs were assessed using the PEDro scale and the modified Sackett scale was used to appraise findings based on the level of evidence.Results: A total of two thousand nine hundred and six citations were identified, however, only twenty-two RCTs matched the eligibility criteria and were included in the review. The identified studies varied in design, investigated diverse physical therapy modalities that were applied for dissimilar periods, assessed outcome measures at unalike periods, and showed inconsistent results.Conclusion: A rigorous review of literature showed insufficient evidence to support or refute the effectiveness of many of the current physical therapy interventions for chronic LET. Nevertheless, the results might suggest immediate efficacy of mobilization with movement of the elbow joint and short-term efficacy of myofascial release technique.Level of evidence: Therapy, level 1a-

The Nirschl procedure versus arthroscopic extensor carpi radialis brevis débridement for lateral epicondylitis

The Nirschl technique and arthroscopic débridement are common surgical procedures for chronic lateral elbow tendinopathy. The purpose of this study was to compare outcomes following the use of these techniques to treat chronic lateral elbow tendinopathy. We retrospectively reviewed 59 elbows of 55 patients who did not improve after conservative treatment. Twenty-nine elbows of 26 patients were treated with the Nirschl procedure (Nirschl group), and 30 elbows of 29 patients were treated with arthroscopic débridement (arthroscopy group). Outcomes were assessed subjectively with the quick Disabilities of the Arm, Shoulder and Hand questionnaire and the visual analog scale (VAS) for pain in 3 domains (overall pain, pain at rest, and pain during hard work) and objectively with pain-free grip strength. The Nirschl and arthroscopy groups showed significant improvements in subjective and objective outcomes at a mean of 28.5 months and 31 months, respectively (P <.05). No significant between-group differences were found in postoperative outcomes, including quick Disabilities of the Arm, Shoulder and Hand questionnaire scores; pain-free grip strength; and VAS scores for overall pain and pain at rest (P > .05). However, a small but significant difference was found in the postoperative VAS score for pain during hard work (1.6 ± 1.3 for Nirschl group vs 2.2 ± 2.0 for arthroscopy group, P = .042). Both techniques are comparable and highly effective for treating chronic recalcitrant lateral elbow tendinopathy. Although the Nirschl technique provides slightly superior pain relief during hard work, the effect size is very small and the difference does not appear to be clinically important.

Efficacy of betamethasone valerate medicated plaster on painful chronic elbow tendinopathy: a double-blind, randomized, placebo-controlled trial.

to investigate the efficacy and safety of a medicated plaster containing betamethasone valerate (BMV) 2.25 mg in patients with chronic elbow tendinopathy. randomized, double-blind, placebo-controlled study with assignment 2:2:1:1 to BMV medicated plaster applied daily for 12 hours, daily for 24 hours or matched placebo. 62 patients aged ≥18 years with chronic lateral elbow tendinopathy were randomized. The primary efficacy variable was pain reduction (VAS) at day 28. Secondary objectives included summed pain intensity differences (SPID), overall treatment efficacy and tolerability. mean reduction in VAS pain score at day 28 was greater in both BMV medicated plaster groups, -39.35±27.69 mm for BMV12-h and -36.91±32.50 mm for BMV24-h, than with placebo, -20.20±27.32 mm. Considering the adjusted mean decreases, there was a statistically significant difference between BMV12-h and placebo (p=0.0110). Global pain relief (SPID) and overall treatment efficacy were significantly better with BMV. BMV and placebo plasters had similar local tolerability and there were few treatment-related adverse events. BMV plaster was significantly more effective than placebo at reducing pain in patients with chronic elbow tendinopathies. The BMV plaster was safe and well tolerated.

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

Introduction. Patients with chronic lateral elbow (LE) tendinopathy, commonly known as tennis elbow, often experience prolonged symptoms and frequent relapses. Astym treatment, evidenced in animal studies to promote the healing and regeneration of soft tissues, is hypothesized to improve outcomes in LE tendinopathy patients. This study had two objectives: (1) to compare the efficacy of Astym treatment to an evidence-based eccentric exercise program (EE) for patients with chronic LE tendinopathy, and (2) to quantify outcomes of subjects non-responsive to EE who were subsequently treated with Astym treatment.Study Design. Prospective, two group, parallel, randomized controlled trial completed at a large orthopedic center in Indiana. Inclusion criteria: age range of 18–65 years old, with clinical indications of LE tendinopathy greater than 12 weeks, with no recent corticosteriod injection or disease altering comorbidities.Methods. Subjects with chronic LE tendinopathy (107 subjects with 113 affected elbows) were randomly assigned using computer-generated random number tables to 4 weeks of Astym treatment (57 elbows) or EE treatment (56 elbows). Data collected at baseline, 4, 8, 12 weeks, 6 and 12 months. Primary outcome measure: DASH; secondary outcome measures: pain with activity, maximum grip strength and function. The treating physicians and the rater were blinded; subjects and treating clinicians could not be blinded due to the nature of the treatments.Results. Resolution response rates were 78.3% for the Astym group and 40.9% for the EE group. Astym subjects showed greater gains in DASH scores (p = 0.047) and in maximum grip strength (p = 0.008) than EE subjects. Astym therapy also resolved 20/21 (95.7%) of the EE non-responders, who showed improvements in DASH scores (p < 0.005), pain with activity (p = 0.002), and function (p = 0.004) following Astym treatment. Gains continued at 6 and 12 months. No adverse effects were reported.Conclusion. This study suggests Astym therapy is an effective treatment option for patients with LE tendinopathy, as an initial treatment, and after an eccentric exercise program has failed.Registration/Funding. Ball Memorial Hospital provided limited funding. Trial registration was not required by FDAAA 801.Known about the Subject. Under the new paradigm of degenerative tendinopathy, eccentric exercise (EE) is emerging as a first line conservative treatment for LE tendinopathy. EE and Astym treatment are among the few treatment options aiming to improve the degenerative pathophysiology of the tendon. In this trial, Astym therapy, which has shown success in the treatment of tendinopathy, is compared to EE, which has also shown success in the treatment of tendinopathy.Clinical Relevance. There is a need for more effective, conservative treatment options. Based on the current efficacy study, Astym therapy appears to be a promising, non-invasive treatment option.

Effectiveness of botulinum toxin A in the treatment of chronic lateral elbow tendinopathy medical treatment resistant

Effectiveness of botulinum toxin A in the treatment of chronic lateral elbow tendinopathy medical treatment resistant

Cross-Cultural Adaptation and Measurement Properties of the Italian Version of the Patient-Rated Tennis Elbow Evaluation (PRTEE) Questionnaire

The Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire is a tool designed for self-assessment of forearm pain and disability in patients with lateral elbow tendinopathy (LET). However, an Italian version of this questionnaire has not been available. The aims of this study were: (1) to translate and cross-culturally adapt the PRTEE questionnaire into Italian and (2) to evaluate its measurement properties. This was a longitudinal, observational measurement study. The PRTEE questionnaire was cross-culturally adapted to Italian according to established guidelines. Ninety-five individuals (41 women, 54 men) with unilateral, imaging-confirmed, chronic LET were selected consecutively to assess the measurement properties of the PRTEE questionnaire. Internal consistency, test-retest reliability, construct validity, and responsiveness were estimated. The Italian version of the PRTEE displayed a high degree of internal consistency, with a Cronbach alpha of .95. The test-retest reliability was high for both short-term and medium-term, with intraclass correlation coefficients (2,1) of .95 and .93, respectively. The PRTEE exhibited a strong correlation (r=.77-.91, P<.0001) with the Disabilities of the Arm, Shoulder and Hand (DASH) at the baseline and a moderate correlation (r=.58-.74, P<.0001) at discharge. The responsiveness was higher for the PRTEE than for the DASH. Limitations A methodological limitation of the study is that due to the small sample size, a factor analysis was not performed to assess convergent validity. The Italian version of the PRTEE questionnaire is internally consistent, demonstrates expected correlations with other measures, and is more responsive than the DASH in Italian patients with chronic LET.

Validation of the Patient-rated Tennis Elbow Evaluation Questionnaire

The aim of this study was to determine the reliability, validity, and sensitivity of the Patient-rated Tennis Elbow Evaluation (PRTEE) Questionnaire in 78 tennis playing subjects who had chronic, unilateral, MRI-confirmed lateral elbow tendinopathy and who concomitantly participated in an outcome study. The PRTEE results were compared with results of the Visual Analog Scale (VAS); the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire; the Roles and Maudsley score; and the Upper Extremity Function Scale. Questionnaires were completed at baseline and 12 weeks. Reliability and internal consistency were excellent (PRTEE pain subscale, 0.94; PRTEE specific activities subscale, 0.93; PRTEE usual activities, 0.85). Correlations were good between the PRTEE subscales and total scale and the VAS and DASH. Standardized response means (SRM) were higher in the PRTEE (SRM = 2.1) than in the other outcome measures (SRM, 1.5–1.7). The PRTEE was a reliable, reproducible, and sensitive instrument for assessment of chronic lateral elbow tendinopathy in a tennis playing cohort. It was at least as sensitive to change as the other outcome tools tested. The PRTEE may become the standard primary outcome measure in research of tennis elbow.