Common Extensor Research Articles

Efficacy of Radial Extracorporeal Shock Wave Therapy on Lateral Epicondylosis, and Changes in the Common Extensor Tendon Stiffness With Pretherapy and Posttherapy in Real-Time Sonoelastography

Efficacy of Radial Extracorporeal Shock Wave Therapy on Lateral Epicondylosis, and Changes in the Common Extensor Tendon Stiffness With Pretherapy and Posttherapy in Real-Time Sonoelastography

Diagnostic Performance of Superb Microvascular Imaging and Other Sonographic Modalities in the Assessment of Lateral Epicondylosis.

The aim of this study was to compare the diagnostic performance of different sonographic modalities for diagnosing lateral epicondylosis. A total of 50 symptomatic and 50 asymptomatic common extensor tendons in 44 patients with lateral epicondylosis, and 25 healthy participants were prospectively examined by B-mode sonography, color Doppler imaging, power Doppler imaging, Superb Microvascular Imaging (SMI; Toshiba Medical Systems Corporation, Tokyo, Japan), and strain elastography. We evaluated blood flow in common extensor tendons by using a grading system with color Doppler imaging, power Doppler imaging, and SMI. The diagnostic performance of the modalities was compared. When a cutoff value of hypoechogenicity was used for the mean strain ratio, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rates were 92.0%, 94%.0, 93.9%, 92.2%, and 93.0%, respectively. When a cutoff point of grade 1 was used, the sensitivity, specificity, PPV, NPV, and accuracy rates were 26.0%, 10.0%, 10.0%, 57.5%, and 63.0, for color Doppler imaging; 40.0%, 10.0%, 10.0%, 62.5%, and 70.0% for power Doppler imaging; and 84.0%, 94.0%, 93.0%, 85.5%, and 89.0% for SMI. When a cutoff value of 3.94 was used for the mean strain ratio, the sensitivity, specificity, PPV, NPV, and accuracy rates were 78.0%, 92.0%, 90.7%, 80.7%, and 85.0%, respectively. A statistically significant correlation was detected between SMI, strain elastography, and visual analog scale scores (P < .001). The combination of SMI and B-mode sonography was found to have excellent diagnostic performance for lateral epicondylosis. Neovascularzation in patients' tendons with lateral epicondylosis was identified much better with SMI compared to color or power Doppler imaging.

The relative compliance of energy-storing tendons may be due to the helical fibril arrangement of their fascicles.

A nonlinear elastic microstructural model is used to investigate the relationship between structure and function in energy-storing and positional tendons. The model is used to fit mechanical tension test data from the equine common digital extensor tendon (CDET) and superficial digital flexor tendon (SDFT), which are used as archetypes of positional and energy-storing tendons, respectively. The fibril crimp and fascicle helix angles of the two tendon types are used as fitting parameters in the mathematical model to predict their values. The outer fibril crimp angles were predicted to be 15.1° ± 2.3° in the CDET and 15.8° ± 4.1° in the SDFT, and the average crimp angles were predicted to be 10.0° ± 1.5° in the CDET and 10.5° ± 2.7° in the SDFT. The crimp angles were not found to be statistically significantly different between the two tendon types (p = 0.572). By contrast, the fascicle helix angles were predicted to be 7.9° ± 9.3° in the CDET and 29.1° ± 10.3° in the SDFT and were found to be statistically highly significantly different between the two tendon types (p < 0.001). This supports previous qualitative observations that helical substructures are more likely to be found in energy-storing tendons than in positional tendons and suggests that the relative compliance of energy-storing tendons may be directly caused by these helical substructures.

Proximity and Risks of the Anterior Neurovascular and Tendinous Anatomy of the Distal Leg Relative to Anteriorly Applied Distal Locking Screws for Tibia Nailing: A Plea for Open Insertion.

To determine the proximity and potential risks to distal leg anatomy from anterior to posterior (A-P) applied distal tibia locking screws for tibial nailing. Retrospective. ACS level I trauma center. Twenty consecutive adult patients undergoing computed tomograms with intravenous contrast (computed tomography angiograms) on uninjured legs. Simulated 5-mm distal interlocking screws placed in the A-P axis of an ideally placed tibial nail at 10-mm increments from the tibial plafond (10-40 mm) were studied in relation to the distal leg's anterior anatomy. All A-P screws (80/80, 100%) impacted the tibialis anterior tendon, extensor hallucis longus tendon, and/or anterior tibial neurovascular (NV) bundle between 10 and 40 mm cranial to the plafond. The NV bundle was impacted in 53% of cases. The medial extent of the tibialis anterior tendon was greatest 10 mm cranial to the plafond and averaged 27 degrees (95% confidence interval, 22-33 degrees) medial to the A-P line. The maximum lateral border of the foot's common extensors, found 40 mm cranial to the plafond, averaged 71 degrees (95% confidence interval, 62-80 degrees) lateral to the A-P line. The anterior tibial NV bundle and foot and ankle extensor tendons are at high risk from A-P-directed distal locking screws. The tendinous anatomy of the distal leg is at risk between 33 degrees medial and 80 degrees lateral to the A-P axis of a tibial nail. Distal locking screws placed from the A-P direction should be thoughtfully applied and an open approach should be strongly considered.

Ultrasonographic Evaluation of Acupuncture Effect on Common Extensor Tendon Thickness in Patients with Lateral Epicondylitis: A Randomized Controlled Study.

To explore the effect of acupuncture on common extensor tendon (CET) thickness in patients with lateral epicondylitis (LE). Additionally, to identify whether clinical and ultrasonographic changes showed any correlation. Forty-one patients were randomly assigned to acupuncture and control groups. Conventional treatment (rest, NSAİİ, bracing, exercise) methods for LE were applied to all patients. In addition to this, the acupuncture treatment was applied to the acupuncture group. The visual analog scale (VAS) for pain, the Duruoz Hand Index (DHI) for functioning of the affected limb, the pressure pain threshold, and CET thickness (via ultrasound imaging) were assessed before and end of the treatment in both groups. The VAS and DHI scores in both groups decreased. The pressure pain threshold and CET thickness only demonstrated improvement in the acupuncture group. These findings show that the CET thickness was reduced after 10 sessions of acupuncture treatment in LE patients.

Advances on open surgery of tennis elbow

Currently, surgical treatments in tennis elbow include open, arthroscopic and percutaneous procedures. Open surgery, having definite curative effects, is commonly used. There are different surgical methods based on different hypotheses about the pathogenesis of tennis elbow, such as detachment of common extensor origin, resection of annular ligament, denervation surgery and resection of microvascular nerve bundle. There is a huge difference in open surgery of tennis elbow between China and abroad. Debriding or releasing extensor carpi radialis brevis and common extensor tendon are mostly used abroad though it re-mains controversial whether we should release or debride with tendon, as well as whether it is better to decorticate on lateral epi-condyle or not. In China, tennis elbow is treated with resection of microvascular nerve bundle except for debridement and release of tendon. As for evaluation criteria, the following methods, grip strength, grading system and visual analogue scale have been used in researches. However, cure rate and response rate are valuation criteria for resection of microvascular nerve bundle in China. The evaluation criteria are different among various surgical methods, even in the methods, especially for grading system. Each re-search has unique standards to define excellent, good, fair and poor outcomes. Complications of tennis elbow open surgery are rare, while subcutaneous hematoma is the common complication.

Ultrasonographic Characteristics of the Common Extensor Tendon of the Elbow in Asymptomatic Individuals: Thickness, Color Doppler Activity, and Bony Spurs.

Background:Ultrasonography (US) of the common extensor tendon (CET) of the elbow is often part of the assessment of patients with lateral epicondylitis. This US assessment is currently based on general tendinopathy references and not well-defined US entities.Purpose:To describe CET thickness, color Doppler activity, and bony spurs on US in asymptomatic volunteers and to investigate the influence of sex, age, height, body mass index (BMI), weight, and elbow dominance on the measurements.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Tendon thickness, color Doppler activity, and bony spurs of the CET were measured sonographically in 264 adults (50% women) aged 20 to 96 years. Two different tendon-thickness measuring techniques were applied, labeled the “plateau measure” and the “1-cm measure.” Color Doppler activity was based on a 0 to 4 rating scale (negative, grades 0 and 1; positive, grades 2-4). A bony spur was defined as a bony outgrowth (≥0.3 mm) arising at the insertional site of the CET.Results:With both tendon-thickness measuring techniques, the CET in the dominant elbow was thicker than that in the nondominant elbow, and male tendons were thicker than female tendons (all P ≤ .03). In regression analysis, tendon thickness correlated with weight, color Doppler activity, and arm dominance for both measuring techniques in multiple regression analysis. In addition, the plateau measure correlated with height and the presence of bony spurs. No correlations were observed regarding BMI, sex, or age. Positive color Doppler activity was found in 9% of examined elbows, with no difference between the sexes regarding dominant versus nondominant elbows (all P ≥.20). Bony spurs were found to increase with age, from 23% for people in their 20s to 74% in people older than 70 years. Bony spurs were more common in the dominant elbow (P ≤ .01). Women had a higher prevalence of bony spurs than men, but only in the dominant elbow (P = .03).Conclusion:This study presents the US characteristics and normal values of the CET. In 264 asymptomatic participants, the CET was found to be thicker in men and in the dominant elbow. No difference in tendon thickness could be demonstrated with regard to different age groups. Color Doppler activity was found to be positive in nearly 1 of 10 asymptomatic subjects. Bony spurs were a common finding; they increased in prevalence with every decade in age and were considered part of the aging process. Normal variations in CET morphologic characteristics should therefore be considered when implementing US in trials and clinical practice.

Elbow MRI Findings Do Not Correlate With Future Placement on the Disabled List in Asymptomatic Professional Baseball Pitchers.

Background:Injury rates among professional baseball players may reach as high as 5.8 per 1000 encounters, with pitchers being most vulnerable on account of the excessive biomechanical load on the upper extremity during the throwing motion. Anatomically, the shoulder is the most common site of pitching-related injury, accounting for 30.7% of injuries, closely followed by the elbow at 26.3%. Characteristic valgus loading imparts a predictable constellation of stresses on the joint, including medial tension, lateral compression, and posterior medial shearing. The degenerative cohort of tissue changes that result are readily detected on magnetic resonance imaging (MRI). It is not yet known whether such findings predict future placement on the disabled list (DL) in asymptomatic Major League pitchers.Hypothesis:Abnormal soft tissue and osseous changes detected on MRI of the throwing elbow in asymptomatic professional pitchers will impart an increased risk of subsequent transfer to the DL in the season after MRI.Study Design:Retrospective cohort study.Level of Evidence:Level 3.Methods:The study aimed to examine a potential association between the total number of innings pitched (approximate lifetime valgus load) and the typical MRI degenerative changes, hypothesizing a rejection of the null hypothesis. A total of 26 asymptomatic professional pitchers from a single Major League Baseball (MLB) organization and its various minor league affiliates underwent MRI of their dominant elbow from 2003 to 2013 as a condition of their contract signing or trade. Twenty-one of those pitchers played at the Major League level while 5 played with the team’s minor league affiliates including both the AA and AAA levels. Asymptomatic was defined as no related stints on the DL due to elbow injury in the 2 seasons prior to MRI. A fellowship-trained musculoskeletal radiologist reevaluated the studies after being blinded to patient name, injury history, and baseball history. A second investigator collected demographic data; this included total career number of innings pitched and any subsequent DL reports for each subject while remaining blinded to the MRI results.Results:The mean age at the time of MRI was 29.6 years (range, 19-39 years). The mean number of innings pitched was 1111.7. Of the 26 pitchers, 13 had scar remodeling of the anterior bundle of the ulnar collateral ligament (UCL). Of those, 4 had partial-thickness tears of the anterior bundle of the UCL, ranging from 10% to 90% of the total thickness. Twelve had articular cartilage loss within the posteromedial margin of the ulnohumeral joint, and 12 had posteromedial olecranon marginal osteophytes. Seven pitchers had degeneration of the common extensor tendon origin, 10 had degeneration of the flexor pronator mass, 9 had insertional triceps tendinosis, 2 had enthesopathic spurs at the sublime tubercle, 3 had osteochondral intra-articular bodies, and 2 subjects had joint effusions. In the year after MRI, 6 pitchers were placed on the DL for elbow-related injuries. There was no robust correlation between any single MRI finding and subsequent transfer to the DL, and no statistically significant correlation between number of innings pitched and MRI findings, although some trends were observed for both.Conclusion:MRI findings in asymptomatic MLB pitchers were not associated with placement on the DL within the subsequent year. While a trend was observed with olecranon osteophytes and subsequent DL placement (P = 0.07), this finding did not reach statistical significance. Furthermore, there was no robust correlation between the number of innings pitched with the presence of any of the aforementioned degenerative changes on MRI.Clinical Relevance:The characteristic structural transformation that occurs in the throwing elbow of professional pitchers is predictable and readily detectable on MRI. However, this study suggests that these changes are not predictive of near-term placement on the DL in those who are asymptomatic. Abnormal findings on MRI, even high-grade partial UCL tears, do not correlate with near-term placement on the DL, mitigating their potential negative impact on signing decisions.

Ultrasound of the Knee: Common Pathology Excluding Extensor Mechanism.

Ultrasound can be used to diagnose many types of pathology and guide various diagnostic or therapeutic procedures. The most common applications for musculoskeletal ultrasound of the knee include evaluation of the joint recesses, the extensor mechanism, and bursae including Baker's cyst. However, a role exists for ultrasound in the evaluation of cartilage, other tendons, ligaments, peripheral nerves, osseous structures, and vasculature. This article reviews common pathologies of these structures as seen with ultrasound. In addition, various ultrasound-guided procedures pertaining to these pathologies are introduced. The importance of a comprehensive evaluation is also emphasized as a method to maximize information gained from the ultrasound examination.

Role of Ultrasound Guided Platelet-Rich Plasma (PRP) Injection in Treatment of Lateral Epicondylitis

BackgroundLateral epicondylitis is referred to a degenerative disorder that affects the common extensor tendon (CET) where it attaches to the lateral epicondyle of the humerus. Nowadays, one of minimally invasive interventions is platelet-rich plasma (PRP) injection that had been explored in some controlled clinical studies to show its effectiveness in treating lateral epicondylitis through inducing inflammation rather than suppressing it. ObjectivesThe aim of our study was to investigate the effectiveness of ultrasound guided platelet-rich plasma (PRP) injection in treating chronic lateral epicondylitis in addition to identifying the potential sonographic morphological changes in the common extensor tendon (CET) after PRP injection. ResultsStatistical analysis showed high significant improvement in all ultrasound findings of common extensor tendon (CET) including echotexture, thickness, cross section, partial tear and calcification in majority of patients. ConclusionWe concluded that US-guided platelet-rich plasma (PRP) injection for treatment of lateral epicondylitis was a safe, minimally invasive and effective procedure in improving the sonographic and pathological changes of common extensor tendon (CET).

Row acupuncture at the gaps between phalanges for dorsal stretch of fingers after cerebral infarction

To compare the effect differences between row acupuncture at the gaps between phalanges and physical therapy for the dorsal stretch of fingers after cerebral infarction. Seven-one cases were randomized into a row acupuncture at the gaps between phalanges group (group A, 37 cases) and a physical therapy group (group B, 34 cases). Body acupuncture was applied in the two groups. Row acupuncture at the 1st, 2nd, and 3rd gaps between phalanges was used in the group A, with continuous wave of electroacupuncture. The two electrodes of nerve injury therapeutic apparatus were put in the muscle belly center of extensor digitorum of forearm in the group B. All the treatments were given for 30 min in the two groups, once a day and 10 times as one course. Three courses were required with 3 d at the interval. The dorsal stretch of metacarpophalangeal joints and the muscle force of common extensor of fingers were compared between the two groups before and after treatment. Compared with those before treatment, the dorsal stretch of metacarpophalangeal joints and the muscle force of common extensor of fingers were improved after treatment in the two groups (all P<0.05). There existed better effects in the group A on the dorsal stretch of the forefinger, middle finger and ring finger of metacarpophalangeal joints, as well as the muscle force of common extensor of fingers (all P<0.05). Row acupuncture at the gaps between phalanges achieves better effect than physical therapy for the dorsal stretch of fingers after cerebral infarction, based on body acupuncture.

Clinical Examination, Ultrasound and MRI Imaging of The Painful Elbow in Psoriatic Arthritis and Rheumatoid Arthritis: Which is Better, Ultrasound or MR, for Imaging Enthesitis?

IntroductionThe purpose of the current study was to examine the painful elbow, and in particular enthesitis, in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) using clinical examination, ultrasonography (US) and magnetic resonance imaging (MRI).MethodsPatients with elbow pain (11 with PsA and 9 with RA) were recruited. Clinical examination, US and MRI studies were performed on the same day. For enthesitis, the common extensor and flexor insertions and the triceps insertion were imaged (20 patients, giving a total of 60 sites with comparative data). Imaging was performed with the radiologists blinded to the diagnosis and clinical findings. US was used to assess ‘inflammatory activity’ (Power Doppler signal, oedema, tendon thickening and bursal swelling) and ‘damage’ (erosions, cortical roughening and enthesophytes). MRI was used to assess ‘inflammation’ (fluid in paratenon, peri-entheseal soft-tissue oedema, entheseal enhancement with gadolinium, entheseal oedema and bone oedema) and ‘damage’ (erosion, cortical roughening and enthesophyte).ResultsComplete scan data were not available for all patients as one patient could not tolerate the MRI examination. No significant differences in imaging scores were found between PsA and RA. Analysis of damage scores revealed complete agreement between US and MRI data in 43/55 (78%) comparisons; in 10/55 (18%) cases the US data were abnormal but the MRI data normal; in 2/55 (4%) cases, the MRI data were abnormal and the US data normal. Analysis of the inflammation scores revealed complete agreement between US and MRI data in 33/55 (60%) comparisons; in 3/55 (5%) cases US data were abnormal but MRI data normal; in 19/55 (35%) cases the MRI data were abnormal and the US data normal. There was a poor relationship between assessments based on clinical examination and imaging studies. Readers could not accurately identify the disease from imaging findings.ConclusionBased on our results, at the elbow, US and MR have different roles in assessing enthesitis, with US apparently the better diagnostic tool for assessing damage and MR the better tool for assessing inflammation. In this study enthesitis and synovitis in the painful elbow were found equally in cases of established RA and PsA.

Efficacy of Radial Extracorporeal Shock Wave Therapy on Lateral Epicondylosis, and Changes in the Common Extensor Tendon Stiffness with Pretherapy and Posttherapy in Real-Time Sonoelastography: A Randomized Controlled Study.

To investigate the effects of radial extracorporeal shock wave therapy (rESWT) and to determine the posttreatment common extensor tendon stiffness among patients with lateral epicondylosis. Thirty patients with lateral epicondylosis were randomly divided into experimental and control groups. Participants in the experimental group received rESWT plus physical therapy, and those in the control group received sham shock wave plus physical therapy for 3 weeks. Visual analog scale; grip strength dynamometer; Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; and ultrasonography in 2-dimensional image, and real-time sonoelastography were used in the assessments at baseline and after 6, 12, and 24 weeks (T3). The experimental group had more significant pain reduction at T3 than the control group. Compared with the control group, the experimental group had significantly higher maximal grip strength at 12 and 24 weeks, with significant increases. Compared to baseline, the experimental group had significantly lower Taiwan version DASH disability/symptom scores and work module scores at all posttreatment follow-up points. Five participants in the experimental group had partial tear within common extensor tendon at their involved elbow, and all the tears totally healed at T3. However, the inter-rater reliabilities for real-time sonoelastography were poor to fair. Patients with lateral epicondylosis had better and faster pain reduction, grip strength increase, and functional improvement after receiving rESWT in addition to physical therapy than those who received physical therapy only.

Outcome of Percutaneous Release of Tennis Elbow: A Non-Randomized Controlled Trial Study

BackgroundTennis elbow is a common disorder of the upper extremity. It can be treated conservatively in the majority of patients, but some resistant cases eventually can be treated by percutaneous release with good functional outcome.Materials and methodsThis non-randomized control trial was conducted at the Department of Orthopaedics Surgery in a tertiary care hospital from July 2015 to June 2016 on 50 patients who underwent percutaneous release of the common extensor origin using an 18 gauge hypodermic needle. These patients did not respond to conservative treatment including rest, nonsteroidal anti-inflammatory drugs (NSAIDS) and local steroid injections. The outcome was graded as Excellent, Good, Fair, and Poor.ResultsFifty patients (50 elbows) were included in the study. Thirty-two patients were female (64%), and 18 were male (36%). The right side was affected in 37 patients (74%) and left side in 13 (26%). The time taken to achieve a completely pain-free elbow ranged from one day to two months (average of 26.2 days). Those who did not achieve a pain-free elbow had a residual pain of 1.5 to six on the visual analogue scale (VAS) (average 2.32). Excellent outcome was noticed in 24 patients (48%); Good result in eight patients (36% ); Fair in four patients (eight percent) and Poor in four patients (eight percent).ConclusionTennis elbow probably results from the degenerative tear of the common extensor origin, and a percutaneous tenotomy using an 18 gauge hypodermic needle is a simple, safe, patient-friendly, efficient, and easily reproducible method of treating tennis elbow in those who are resistant to conservative treatment, and it can be done as an outpatient procedure.

Ultrasound measures of tendon thickness: Intra-rater, Inter-rater and Inter-machine reliability.

Ultrasound imaging is often used by physiotherapists and other healthcare professionals but the reliability of image acquisition with different ultrasound machines is unknown. The objective was to compare the intra-rater, inter-rater and intermachine reliability of thickness measurements of the plantar fascia (PF), Achilles tendon (AT), patellar tendon (PT) and elbow common extensor tendon (ECET) with musculoskeletal ultrasound imaging (MSUS). Tendon thickness was measured in four anatomical structures (14 participants, 28 images per tendon) by two sonographers and with two different ultrasound machines. Intraclass Correlation Coefficients (ICCs) and Bland-Altman plots were calculated. The standard error of measurement (SEM) and minimum detectable difference (MDD) were calculated. Inter-rater reliability was excellent for AT (ICC=0.98; 95% CI= 0.96-0.99) and very good for PT (ICC=0.85; 95% CI = 0.67-0.93) and ECET (ICC=0.81; 95% CI= 0.72-0.94). Reliability for PF was moderate, with an ICC of 0.63 (CI 95%= 0.20-0.83). Bland-Altman plot for inter-machine reliability showed a mean difference of 1 m for PF measurements and a mean difference of 4 m and 20 m for AT and PT. The relative SEMs were below 7% and the MDCs were below 0.7 mm. The MSUS reliability in measuring thickness of the four tendons is confirmed by the homogeneous readings intra sonographers, between operators and between different machines. Level of evidence: Tendon thickness can be measured reliably on different ultrasound devices, which is an important step forward in the use of this technique in daily clinical practice and research. III.

Real-time sonoelastography: principles and clinical applications in tendon disorders. A systematic review.

Sonoelastography (SE) is a new ultrasound-based method adopted in an increased number of scientific reports to analyse normal and pathological tendons. The aim of this study is to provide a systematic overview of clinical applications of SE in normal and pathological tendons. A systematic research of PubMed, Ovid, and Cochrane Library electronic databases was performed according to PRISMA guideline. Two Authors searched and evaluated the articles independently; a third Author was involved to solve any disagreement. The Oxford Level of Evidence (LoE) was used to assess each article. There is an increasing interest in the application of SE in the evaluation of healthy and diseased tendons. Many different tendons are amenable for SE evaluation, such as the Achilles and patellar tendons, rotator cuff, common extensor tendons, quadriceps tendon, and the plantar fascia. SE appears to be a very useful diagnostic tool, in particular in tendon pathology. This is a dynamic examination, provides an immediate evaluation of the tissue elasticity, and may be useful in recognizing tendon abnormalities and in implementing the information available with conventional US. IV.

Optimizing the rehabilitation of elbow lateral collateral ligament injuries: a biomechanical study

Elbow lateral collateral ligament (LCL) injury may arise after trauma or lateral surgical approaches. The optimal method of rehabilitating the LCL-insufficient elbow is unclear. Therapists often prescribe active motion exercises with the forearm pronated. Recently, overhead exercises have become popular as they may enable gravity to compress the elbow joint, improving stability, although this has not been proved biomechanically. This investigation aimed to quantify the effects of several variables used in LCL injury rehabilitation on elbow stability. Seven cadaveric specimens were tested in a custom elbow motion simulator in 3 arm positions (overhead, dependent, and varus) and 2 forearm positions (pronation and supination) during passive and simulated active elbow extension. Three injury patterns were studied (intact, LCL injury, and LCL with common extensor origin injury). An electromagnetic tracking device measured ulnohumeral kinematics. Following combined LCL and common extensor origin injury, overhead positioning enhanced elbow stability relative to the other arm positions (P < .01 in pronation; P = .04 in supination). Active motion stabilized the LCL-deficient elbow in the dependent (P = .02) and varus (P < .01) positions. Pronation improved stability in the overhead (P = .05), dependent (P = .06), and varus (P < .01) positions. Rehabilitation with the arm overhead improves elbow stability after LCL injury. Initiating earlier range of motion in this "safe position" might decrease elbow stiffness and allow optimal ligament healing. If exercises are done in the dependent position, active motion with forearm pronation should be encouraged. Varus arm positioning should be avoided.

The Three-Portal Technique in Arthroscopic Lateral Epicondylitis Release.

Lateral epicondylitis, commonly referred to as tennis elbow, is a syndrome characterized by pain over the origin of the common extensor muscles of the fingers, hand and wrist at the lateral epicondyle. Reports of 70-90% response to conservative treatment at one year have been documented in the literature though refractory cases often require surgical management. Arthroscopic treatment of lateral epicondylitis allows for intra-articular visualization for concomitant pathology and localization of the Extensor Carpi Radialis Brevis tendon. Additionally, compared to the open technique, the arthroscopic technique has a lower morbidity and an earlier return to work and activity. Here we describe a three portal technique for improved visualization in arthroscopic lateral epicondylitis release.

Pulsed electromagnetic field versus microcurrent electrical nerve stimulation in patients with lateral epicondylopathy

Background: Lateral epicondylopathy is a frequent overload injury of the common wrist extensor tendons. This study was designed to compare between the effects of the pulsed electromagnetic field (PEMF) and microcurrent electrical nerve stimulation (MENS) on improving pain intensity, threshold, and grip strength in patients with lateral epicondylopathy. Methods: Eighty-four subjects were randomly assigned into three equal groups. Group 1 received PEMF and exercises, group 2 received MENS and exercises, and group 3 received exercises. All subjects received three visits a week for 4 weeks. The visual analogue scale, the disabilities of the arm, shoulder and hand questionnaire and the hand dynamometer were used to measure pain intensity, disability and grip strength. Results: There were improvements in all dependent variables. Also, subjects who received PEMF and exercises had the most significant effects. PEMF may be more effective than MENS in treating lateral epicondylopathy by reducing pain intensity, disability and increasing grip strength. Conclusions: PEMF may be more effective than MENS in treating lateral epicondylopathy by reducing pain intensity, disability and increasing grip strength.

Efficacy evaluation of combined anterior-lateral approach for treatment of elbow triad injuries

Objective To discuss the surgical techniques and results of internal fixation supplemented with soft tissue repair of triad injury of the elbow via the combined anterior-lateral approach. Methods A retrospective analysis was done on 15 patients with triad injury of the elbow treated from January 2011 to August 2014. There were 10 males and 5 females, aged 38.4 years (range, 20-61 years). Injury resulted from traffic accidents in nine patients, high-level falls in three and ground-level falls in three. Radial head fractures were Mason type Ⅰ in five patients, type Ⅱ in eight, and type Ⅲ in two. Fractures of the coronoid process of the ulna were Regan-Morrey typeⅠ in four patients, type Ⅱ in ten and type Ⅲ in one. Time interval between injury and operation was 8.5 d. All patients were firstly operated on through the anterior approach to have Herbert screw fixation or anterior capsule suture lasso fixation of the coronoid fracture as well as Herbert screw fixation of the radial head fracture. And then, elbow lateral incision was made to repair lateral collateral ligament complex and common extensor tendon by 2-0 Ethibon suture. Elbow flexion-extension, forearm pronation-supination and Mayo elbow performance score (MEPS) were used to evaluate the clinical elbow functions. Complications were recorded after operation. Results All patients were followed up for mean 19.6 months (range, 12-30 months). All coronoid fractures healed. Radial head fractures in 14 patients healed. Comparison of preoperative to final follow-up variables presented significant differences in elbow flexion-extension [(45.1±5.6)° ∶(129.5±9.3)°], forearm pronation-supination [(55.4±8.7)° ∶(140.5±10.3)°] and MEPS [(25.1±9.6)points ∶(91.2±5.2)points] (P<0.01). Complications included heterotopic ossification in one patient and nonunion of radial head fracture in one patient. No neurovascular injury of the elbow, elbow residual instability, dislocation, elbow stiffness and active pain occurred. Conclusion Combined anterior-lateral approach with internal fixation and soft tissue repair is a simple and safe method that effectively restore the elbow joint function. Key words: Elbow joint; Ulna fractures; Radius fractures; Fracture fixation, internal