Elbow Disability Research Articles

Surgical approaches to the capitellum: a comparative anatomic study

Osteochondritis dissecans (OCD) of the humeral capitellum is an important cause of elbow disability in young athletes. Large and unstable lesions sometimes require joint reconstruction with osteochondral autograft. Several approaches have been described to expose the capitellum for the purpose of treating OCD. The posterior anconeus-splitting approach and the lateral approach with or without release of the lateral ligamentous complex are the most frequently used for this indication. The surface accessible by these approaches has not been widely studied. This study compared the extent of the articular surface of the capitellum that could be exposed with the Kocher approach (without ligament release) vs. the posterior anconeus-splitting approach. A secondary outcome was the measurement of any additional area that could be reached with lateral ulnar collateral ligament release (Wrightington approach). The 3 approaches were performed on 8 adult cadaveric elbows: first, the Kocher approach; then, the anconeus-splitting approach; and finally, the Wrightington approach. The visible articular surface was marked out after completion of each approach. The mean articular surface of the capitellum was 708 mm2 (range, 573-830 mm2). The mean visible articular surface was 49% (range, 43%-60%) of the total surface with the Kocher approach, 74% (range, 61%-90%) with the posterior anconeus-splitting approach, and 93% (range, 91%-97%) with the Wrightington approach. Although the Kocher approach provided access to the anterior part of the capitellum, the anconeus-splitting approach showed adequate exposure to the posterior three-quarters of the articular surface and overlapped the most posterior part of the Kocher approach. A combination of the 2 lateral ulnar collateral ligament-preserving approaches allowed access to 100% of the joint surface. Most OCD lesions are located in the posterior area of the capitellum and can therefore be reached with the anconeus-splitting approach. When OCD lesions are located anteriorly, the Kocher approach without ligament release is efficient. A combination of these 2 approaches enabled the entirety of the joint surface to be viewed.

Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: systematic review and meta-analysis

Objective: To evaluate the effectiveness of extracorporeal shockwave therapy compared with other interventions on pain, grip strength and disability in patients with lateral elbow tendinopathy. Data Sources: MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, Cochrane Library and clinical trial registries. Review methods: We included randomized controlled trials assessing the effectiveness of extracorporeal shockwave therapy alone or as an additive intervention compared with sham or other interventions. Pain intensity, grip strength and elbow disability were used as primary outcome measures. We assessed methodological quality with the PEDro score and quality of evidence with the GRADE approach. Results: Twenty-seven studies with 1871 patients were finally included. Extracorporeal shockwave therapy reduced pain intensity at mid-term follow-up (standardized mean difference: −1.21, 95% confidence interval:−1.53, −0.89, P < 0.001) and improved grip strength at very short- (mean difference:3.92, 95% confidence interval: 0.91, 6.94, P = 0.01) and short-term follow-up (mean difference:4.87, 95% confidence interval:2.24, 7.50, P < 0.001) compared with sham treatment. However, no clinically significant results were found between comparators in all outcomes and follow-up times. Extracorporeal shockwave therapy presented clinically better compared to Laser in grip strength at short-term (mean difference:3.50, 95% confidence interval:2.40, 4.60, P < 0.001) and ultrasound in pain intensity at very-short-term follow-up (standardized mean difference: −1.54, 95% confidence interval: −2.60, −0.48, P = 0.005). Conclusion: Low to moderate certainty of evidence suggests that there are no clinical benefits of extracorporeal shockwave therapy compared to sham interventions or corticosteroid injections. Based on very-low and moderate certainty of evidence, extracorporeal shockwave therapy outperforms against Laser and ultrasound, respectively. Level of Evidence: Therapy, level 1a.

Preseason Neck Mobility Is Associated With Throwing-Related Shoulder and Elbow Injuries, Pain, and Disability in College Baseball Pitchers.

Background:Shoulder and elbow injuries in baseball pitchers, which can lead to significant pain and disability, have been on the rise at all levels of play for 3 decades. Despite anatomic and neurophysiological relationships, neck mobility has not been explored as a contributor to shoulder and elbow injuries in baseball pitchers.Hypothesis:Impaired neck mobility will increase the risk of shoulder and elbow injuries in college baseball pitchers.Study Design:Cohort study; Level of evidence, 2.Methods:Posture, neck mobility, and shoulder passive range of motion were measured in healthy college baseball pitchers during the 2018 preseason. Time loss (days lost because of shoulder or elbow injuries) and patient-reported disability via Functional Arm Scale for Throwers (FAST) scores were used to dichotomize pitchers into injured and uninjured groups. Receiver operating characteristic curves were generated, and accuracy values and risk ratios (RRs) were calculated to assess the diagnostic utility of the physical measures. Time-to-injury analysis was conducted to assess the timing of injuries.Results:A total of 49 pitchers (mean age, 19.92 ± 1.48 years; mean height, 187.04 ± 6.02 cm; mean weight, 89.14 ± 12.08 kg) completed the study. There were 10 pitchers (20.4%) who sustained a time-loss injury >7 days because of a shoulder or elbow injury. A Cervical Flexion-Rotation Test (CFRT) finding on the dominant side of ≤39° resulted in over 9 times the increased risk of time-loss injuries (RR, 9.38 [95% CI, 1.28-68.49]). Time-to-injury analysis demonstrated differences between the 2 groups (χ2 = 7.667; P = .01). Pitchers with a >39.25° finding on the CFRT played a mean 109.4 of 112 days (95% CI, 105-114) before the injury, while pitchers with ≤39.25° only played 83.6 of 112 days (95% CI, 68-99). A CFRT finding of ≤38° (RR, 3.91 [95% CI, 1.23-12.39]), cervical flexion range of motion of ≤64° (RR, 10.56 [95% CI, 1.50-74.34]), and weight of >86.9 kg (RR, 10.42 [95% CI, 1.14-213.70]) were also associated with an increased risk of patient-reported pain and disability on the FAST pitcher module.Conclusion:College baseball pitchers with less neck mobility during the preseason had an increased risk of time loss and shoulder and elbow disability during the season. The predictive value of these measures as part of a risk screening profile should be further explored.

Osteochondritis Dissecans of the Capitellum :Review of the Literature.

Osteochondritis dissecans (OCD) of the capitellum is a leading cause of elbow disability in adolescent baseball players. Previous studies have not found an association of player position with capitellar OCD. Elbow pain and a longer playing history might be related to progression of capitellar OCD but do not in themselves increase the risk of development of the condition. The cause of capitellar OCD is likely to include a combination of repetitive microtrauma and internal factors, such as ischemia and genetic predisposition. A combination of radiography, computed tomography, magnetic resonance imaging, and ultrasonography have aided our understanding of the pathology of capitellar OCD. Screening using ultrasonography enables early detection and provides an opportunity for successful conservative treatment. Treatment has conventionally included both operative and nonoperative measures based on the stage and size of the lesion, skeletal maturity, subjective symptoms, and structural integrity of the cartilage. Early-stage lesions respond better to nonoperative treatment than those in more advanced stages. Operative indications include persistent symptoms despite nonoperative treatment, symptomatic loose bodies, and displacement or detachment of fragments. J. Med. Invest. 67 : 217-221, August, 2020.

Arthroscopic Management of Acute Traumatic Primary Anterior Shoulder Dislocation

AbstractBackground: Glenohumeral joint is the most mobile and most commonly dislocated joint in the human body. The patient's age at the time of injury is inversely related to the incidence of dislocation recurrence rate. Recurrence rate in athletes younger than 20, may be as high as 90%. Arthroscopic stabilization is usually successful in preventing the recurrence of shoulder dislocations leads to reduced recurrence, improved functional outcome.Aim of Study: The aim of this study is to asses the benefits of Bankart repair using suture anchors in treating patient with first time anterior traumatic shoulder instability.Patients and Methods: This prospective study was per-formed on 30 patients having anterior primary shoulder dislocation. All cases were managed by arthroscopic repair of the anterior labral lesion using suture knotted anchors.Results: Patients were assessed pre and post operatively by modified Rowe scale and ASES (American shoulder and Elbow disability system).Conclusion: Primary arthroscopic repair for first-time traumatic anterior shoulder dislocation provided satisfactory functional outcomes and improved quality of life. Primary arthroscopic stabilization can be considered best treatment option in patients younger than 30 years with first time shoulder dislocation.

Acute effects of one session dry needling on a chronic golfer's elbow disability.

A 40-year-old retired male elite athlete with more than 20 years’ experience in wrestling and bodybuilding with mild elbow pain and disability of 2 years presented to our clinic reporting an acute pain in medial aspect of the elbow. Physical examination revealed symptoms of left Golfer’s elbow during target-directed movements. The results of sonography in left elbow showed low level of hypo echo irregularity and increased blood flow in color Doppler mode in the common flexor origin. The pain amplitude was moderate at rest and extremely high during kinetic and intentional movements. During last 2 years, the patient tried different types of therapy including manual therapy, Transcutaneous electrical nerve stimulation and also received a variety of injections none of which were effective for reducing pain and disability. This is the first study showed that one sessions of dry needling improved both pain and disability and helped to return to a normal life and exercise training.

Functional outcomes following lateral ulnar collateral ligament reconstruction for symptomatic posterolateral rotatory instability of the elbow in an athletic population

The purpose of this investigation was to characterize the functional and surgical outcomes following lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability in an athletic population. All US military service members who underwent LUCL reconstruction between 2008 and 2013 were identified. A retrospective chart review was performed, and the prospective Mayo Elbow Performance Score and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were obtained. The primary outcomes were return to preinjury activity and resolution of symptoms. We identified 23 patients with a mean age of 31.6 ± 7.2 years (range, 19-46 years), and 87% were men. A history of instability and/or dislocation was reported by 11 patients (48%), and 8 patients (35%) had undergone prior elbow surgery. At final follow-up of 4.6 ± 1.8 years (range, 2.2-7.6 years), all patients demonstrated significant decreases in pain (average pain score, 4 vs 1.34) with resolution of instability and achieved a functional arc of motion. After surgical reconstruction, 83% were able to return to prior activity, whereas 4 patients (17%) underwent medical separation, including 3 with elbow disability precluding continued service (13%). Overall 83% of patients reported good to excellent outcomes by the Mayo Elbow Performance Score, and 96% of patients reported no significant disability by the QuickDASH disability evaluation. Postoperatively, 4 patients (17%) experienced complications, with 3 (13%) requiring reoperation. Although the diagnosis and surgical management of isolated LUCL injury are relatively infrequent, LUCL reconstruction for posterolateral rotatory instability offers a reliable return to preinjury level of function among active individuals with intense upper extremity demands. However, although function reliably improves, the rate of perioperative complications is greater than 15%.

Performance Characteristics of the Verbal QuickDASH

To quantify the performance of the verbally administered Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire by assessing its replication of self-administered scores, its test-retest reliability, and its rate of scorable completion compared with its self-administered, written administration. Fifty patients presenting for initial visits to a hand clinic were enrolled regardless of diagnosis. All patients completed a written and a verbal QuickDASH 1 day apart (25 patients written first; 25 patients verbal first). Intraclass correlation coefficients quantified the verbal questionnaire's ability to reproduce written scores. Participants verbally completed the questionnaire a final time, 5 months later, to assess test-retest reliability. To quantify the usability of survey data, we compared percentages of scorable surveys between written and verbally administered QuickDASH questionnaires in this study and in prior studies within our division. The intraclass correlation coefficient between the 2 QuickDASH administration types for the entire sample was 0.91. Across all participants, there was a minimal change in mean score from a patient's written QuickDASH to that patient's first verbal QuickDASH score. Scoring consistency between QuickDASH administrations was similar for each administration sequence (phone followed by written vs. written followed by phone) and by diagnosis. Test-retest reliability between the 2 verbal administrations demonstrated good reliability and a minimal difference between scores. In this study, no written or verbal surveys were incomplete. Reviewing our practice, 17% of 258 written questionnaires produced unscorable data compared with 0% of 239 verbally administered surveys. Our results indicate that verbal administration of the QuickDASH replicates clinically relevant scores of the written QuickDASH, has good test-retest performance, andmay minimize unusable data. These data allow researchers greater flexibility in gatheringpatient outcome data in both retrospective and prospective studies. Diagnostic II.

Outcomes and Failure Factors in Surgical Treatment for Osteochondritis Dissecans of the Capitellum

Osteochondritis dissecans (OCD) of the capitellum is an intra-articular lesion and one of the leading causes of permanent elbow disability. The treatment of advanced capitellar OCD remains challenging because of the limited potential of the articular cartilage for self-repair. The purpose of this study was to investigate the outcome of surgical treatment for OCD of the capitellum. From 2000 to 2010, 32 male patients who had advanced lesions of capitellar OCD were treated operatively. The mean age of the patients was 14.4 years at the time of surgery. Twenty-nine patients played baseball and 3 played other sports. The lesions were of the centralized type in 9 patients, the lateral type in 4 patients, and the widespread type in 19 patients. For the surgical procedure, osteochondral peg fixation was selected for 13 patients and osteochondral autograft transplantation for 19 patients. Clinical outcome was measured with the elbow rating system including range of motion, and the number of patients who returned to active sports participation within 1 year after surgery was determined. The mean total arc of elbow motion increased from 123±17 degrees preoperatively to 132±14 degrees postoperatively. The mean clinical score improved significantly from 133±24 to 177±27. Within the first year after surgery, 81.3% of the patients returned to active sports playing. However, 4 of 8 patients (50%) in which osteochondral peg fixation was performed for lesions of the lateral widespread type required reoperation. Our results indicate that osteochondral peg fixation and osteochondral autograft transplantation may improve elbow rating score, and may facilitate a return to active sports participation. However, osteochondral peg fixation may be insufficient for lesions of the widespread type because of their poor stability. The large lateral condyle lesions had a worse outcome, and future studies will need to develop improved treatment for these defects. Level IV (case series).

The effects of corticosteroid injection versus local anesthetic injection in the treatment of lateral epicondylitis: a randomized single-blinded clinical trial

This study seeks to compare two treatment methods of lateral epicondylitis: corticosteroid injection (CSI) and a local anesthetic injection (LAI). In this single-blinded randomized clinical trial, 138 patients with the diagnosis of lateral epicondylitis were assigned either into CSI group receiving methylprednisolone 1 ml (49 patients) or LAI group (51 patients) receiving procaine 1 ml 2 % in a single dose at the maximal point tenderness site. The primary outcome measure was elbow disability using Quick DASH, and secondary outcome measures were pain intensity using Visual Analogue Scale (VAS) and recurrence rate at pretreatment visit and at 3-, 6- and 12-week post-treatment visits. There were no significant differences between the patients in both groups for demographic factors including age, gender, dominant hand, involved hand, and work pressure. Before treatment, the patients in both groups were suffering from the same rates of elbow disability and pain as measured by Quick DASH and VAS, respectively, (p > 0.05). In general, the recovery rate (comparison between pretreatment visit and last post-treatment visit) was significantly more effective and higher in CSI than LAI. CSI was dramatically more effective at 3-week visit, but less and less effective at 6- and 12-week visits. At 12-week visit the recurrence rate was 34.7 % (17 patients) in CSI group. For lateral epicondylitis, CSI has the best short-term treatment results yet the highest recurrent rates. The combination of CSI with other treatment option or with a change in injection technique from single injection to peppering injection may be promising.

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

To determine if subgroups of patients with tennis elbow respond differently in treatment. 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. 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. 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.

Elbow injuries.

The elbow is a commonly injured joint, yet physicians may be less comfortable treating injuries to the elbow compared with knee and shoulder injuries. Common injuries involving the elbow are tendinosis, instability, tendon ruptures, osteochondritis dissecans, and fractures. Tendinosis is a common overuse injury and may occur on the lateral, medial, or infrequently, the posterior side of the elbow. Injury to the medial or lateral ulnar collateral ligaments may result in instability. Repetitive trauma from overuse is the most common etiologic factor in athletes. Distal biceps and triceps tendon injuries may result in elbow disability in active individuals. Partial tears are more difficult to diagnose than complete ruptures. Osteochondritis dissecans of capitellum affects adolescents involved in overhead throwing athletics. Fractures about the elbow most commonly involve the radial head in adults, and the distal humerus in children. Athletes are prone to elbow injuries resulting from both overuse and acute trauma. Our purpose is to describe the diagnosis and treatment of these common elbow injuries in athletes of all ages.

Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial

Lateral epicondylitis is generally treated with corticosteroid injections or physiotherapy. Dutch clinical guidelines recommend a wait-and-see policy. We compared the efficacy of these approaches. Patients with lateral epicondylitis of at least 6 weeks' duration were recruited by family doctors. We randomly allocated eligible patients to 6 weeks of treatment with corticosteroid injections, physiotherapy, or a wait-and-see policy. Outcome measures included general improvement, severity of the main complaint, pain, elbow disability, and patient satisfaction. Severity of elbow complaints, grip strength, and pressure pain threshold were assessed by a research physiotherapist who was unaware of treatment allocation. We assessed all outcomes at 3, 6, 12, 26, and 52 weeks. The principal analysis was done on an intention-to-treat basis. We randomly assigned 185 patients. At 6 weeks, corticosteroid injections were significantly better than all other therapy options for all outcome measures. Success rates were 92% (57) compared with 47% (30) for physiotherapy and 32% (19) for wait-and-see policy. However, recurrence rate in the injection group was high. Long-term differences between injections and physiotherapy were significantly in favour of physiotherapy. Success rates at 52 weeks were 69% (43) for injections, 91% (58) for physiotherapy, and 83% (49) for a wait-and-see policy. Physiotherapy had better results than a wait-and-see policy, but differences were not significant. Patients should be properly informed about the advantages and disadvantages of the treatment options for lateral epicondylitis. The decision to treat with physiotherapy or to adopt a wait-and-see policy might depend on available resources, since the relative gain of physiotherapy is small.

MS1: COST-EFFECTIVENESS OF INTERVENTIONS FOR LATERAL EPICONDYLITIS: RESULTS FROM A RANDOMIZED CONTROLLED TRIAL IN PRIMARY CARE

OBJECTIVES: In 1997, the Dutch College of General Practitioners in the Netherlands issued guidelines which recommend a wait-and-see policy for patients with lateral epicondylitis. However, these guidelines are not evidence-based. This paper presents the results of an economic evaluation in conjunction with a randomized controlled trial to evaluate the effects of three interventions for patients with lateral epicondylitis. METHODS: 185 Patients with pain at the lateral side of the elbow were randomized to one of three interventions: a wait-and-see policy (n = 59), corticosteroid injections (n = 62) or physiotherapy (n = 64). Clinical outcomes included general improvement, pain during the day, elbow disability and quality of life (EuroQol). Direct and indirect costs were measured by means of cost diaries over a period of 12 months. Differences in mean costs between groups were evaluated by applying non-parametric bootstrap techniques. RESULTS: After 12 months, the success rate in the physiotherapy group (91%) was significantly higher than in the injection group (69%), but only slightly higher than in the wait-and-see group (83%). With regard to pain during the day and elbow disability, physiotherapy differed significantly over time, comparing to injection group, for these clinical outcomes. The mean total costs per patient for corticosteroid injections were Euro 430, compared to Euro 631 for the wait-and-see policy and Euro 921 for physiotherapy. These differences were statistically significant for corticosteroid injections compared to physiotherapy. The cost-effectiveness ratios showed no statistically significant differences between the three groups. The cost-utility ratio comparing physiotherapy and wait-and-see policy was 34,461 (1,982; 9,535,522); the other cost-utility ratios were not statistically significant. CONCLUSIONS: The results of this economic evaluation provide no reason to update or amend the Dutch guidelines for general practitioners, which recommend a wait-and-see policy for patients with lateral epicondylitis.