Extensor Carpi Radialis Brevis Tendon Research Articles

The Efficacy of Different Tenotomies in the Treatment of Lateral Epicondylitis: A Systematic Review

Background: Lateral epicondylitis impacts 1–3% of the population. It affects nearly half of all tennis players, primarily due to repetitive forearm muscle use leading to pain at the lateral elbow, particularly at the extensor carpi radialis brevis tendon. While conservative treatments resolve most cases, 4–11% of patients with persistent pain require surgery. Tenotomy is the gold standard for repair, but the research comparing the benefits of specific types of tenotomies (open, arthroscopic, percutaneous, ultrasonically assisted, and Tenex forms) is lacking. Methods: PubMed and Embase searches were conducted for articles focused on four tenotomy techniques. The inclusion criteria allowed for the use of randomized controlled trials (RCTs), prospective cohort studies, and comparative observational studies, while the exclusion criteria excluded meta-analyses. Following the PRISMA guidelines, the initial search resulted in 2327 articles. Once the inclusion and exclusion criteria were applied, 1702 articles underwent abstract screening. Finally, 232 articles proceeded to full-text screening, resulting in 37 articles undergoing data extraction. Results: The primary outcomes included functional improvement, pain relief, overall performance, and postoperative disability. The secondary outcomes included patient-reported satisfaction, return-to-work timeframes, and procedural complications. Conclusions: The tenotomy outcomes were similar, regardless of the method, indicating that discussions with patients about their specific outcome preferences may help guide tenotomy method selection.

Effectiveness of Ultrasound In Tennis Elbow Patients: Literature Review

Lateral Epicondylitis, commonly known as Tennis Elbow, is caused by tension in the common extensor tendon, particularly at the origin of the extensor carpi radialis brevis tendon. This condition leads to pain and reduced hand grip strength, as well as impaired elbow function. This study aims to evaluate the effectiveness of Ultrasound therapy in managing pain, improving grip strength, and enhancing elbow functionality in patients diagnosed with Tennis Elbow. The method employed is a systematic literature review, analyzing relevant studies from various scientific databases. The results show that ultrasound therapy, applied consistently over several weeks, significantly reduces pain levels, improves hand grip strength, and enhances the functional movement of the elbow. The effectiveness of ultrasound treatment is supported by the statistical significance of p<0.01, indicating a strong reduction in pain and improvements in physical function. The findings suggest that Ultrasound therapy is an effective, non-invasive modality for treating Tennis Elbow, offering substantial improvements in patient recovery.

Fetal development and growth of extensor tendons and their sheaths in the dorsal side of the wrist and hand: a histological study.

To understand considerable variations in number of adult extensor ten-dons at the dorsal side of the wrist and hand. We examined histological sections from 30 human fetuses of gestational age 7-39 weeks and crown-rump length 22-323 mm. At the carpal level, earlier or smaller fetuses showed a simpler configuration with fewer tendon slips, whereas later or larger fetuses had a greater number of tendon slips with considerable variations in number and topographical relationships. Tendon slips of the early extensor digitorum to the middle and ring fingers were always 1 or 2, but were seven or more at late term. A tendon of the extensor digitorum to the little fin-ger could not be distinguished from other tendons at the carpal bone level. At the meta-carpal bone level, however, it extended from the ring finger tendon toward two slips of the extensor digiti minimi tendon. At the distal carpal level at midterm and late term, in which the tendon sheath was lost, each of the extensor digitorum tendon slips further divided to provide a mediolateral linear cluster of thin bundles. This large number of tendon components joined and united together to provide a single tight tendon at the level of the metacarpophalangeal joints. The extensor pollicis longs tendon usually lost a membranous septation when it crossed the extensor carpi radialis brevis tendon. Tendon slips in the fourth and fifth canals of the sheath were most likely to reduce in number after birth depending on the mechanical demand.

Dorsal Wrist Impingement Syndrome Pain After Ganglion Cyst Removal

A ganglion cyst is a benign fluid-filled sac that typically appears on the dorsal aspect of the wrist, arising idiopathically near the joint capsule or tendon sheath. Diagnosis is primarily clinical, with MRI and ultrasound serving as confirmation tools. Treatment options range from immobilization, aspiration, hydrossection, steroid or hyaluronidase injection, to surgical intervention. Although relatively uncommon, Dorsal Ganglion Cysts (DGC) can lead to Dorsal Wrist Impingement (DWI) syndrome. This syndrome results from the thickening of the wrist capsule due to overuse, injury, or repetitive activities. This thickening can lead to the compression of the extensor carpi radialis brevis (ECRB) tendon during wrist extension and produce tenderness around the lunate. In some refractory cases, MRI findings may show recurrent ganglion cysts, while in others, they may appear "normal." Consequently, the diagnosis remains clinical, and imaging is primarily employed to rule out secondary causes. Management strategies encompass rest, immobilization, occupational therapy, non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections, and, in certain instances, surgical intervention. Despite the clinical significance of these conditions, limited studies have explored their interrelationship. In this context, we present a rare case involving a 23-year-old female with recurrent DGC accompanied by DWI syndrome. Initially, the patient reported idiopathic left dorsal wrist pain localized around the tendon sheath. Her initial X-ray did not reveal any abnormalities, but MRI identified two ganglion cysts. A series of treatments were initiated, including left tendon sheath hydrossection, corticosteroid injections into the left wrist, and the excision of ganglion cysts from the left wrist. Furthermore, occupational therapy, oral Meloxicam, and Voltaren gel treatments were integrated into the management plan. Subsequent imaging confirmed the resolution of the cysts and an overall enhancement in the range of motion and wrist strength. However, the patient experienced only minimal pain relief, and pain was still elicited during end-range wrist extension and upon dorsal wrist palpation. An electromyography (EMG) test ordered to rule out neuropathic causes did not yield any conclusive results. Nonetheless, a repeat X-ray revealed mild soft tissue swelling on the dorsal side of the wrist, and a follow-up MRI detected ganglion cysts on the dorsal aspect of the lunate and the ECRB tendons. These findings indicated a re-accumulation of dorsal ganglion cysts with a concurrent dorsal impingement syndrome component. Consequently, the patient was referred to an orthopedic surgeon for evaluation and potential revision surgery. This unique case underscores the possibility of developing DWI Syndrome after the removal of a DGC. The diagnosis of this syndrome can be elusive, particularly when X-rays, MRIs, and EMGs yield negative results. Trauma, such as repeated hand surgery or recurrent ganglion cysts, may exacerbate wrist pain despite improvements in range of motion and strength. Special consideration should be given to patients who undergo surgical cyst excisions, as this procedure heightens the risk of recurrence and can irritate the tendon sheath. Collaborative efforts between Physical Medicine and Rehabilitation (PM&R), Occupational Therapy (OT), and surgical teams may play a pivotal role in managing pain associated with these conditions. We propose that future research endeavors should focus on establishing guidelines for the management of this unique condition.

Effectiveness of Mulligan Mobilization Technique Versus Cyriax Technique for Lateral Epicondylitis: A Pilot Study

Background: Eccentric loading of extensor carpi radialis brevis tendon near its origin causes tennis elbow, alsoknown as lateral epicondylitis. Tennis elbow is primarily caused by repetitive wrist extension or loaded grippingoveruse injuries and when playing tennis, badminton, or any sport are more likely to experience it. The goal of thestudy was to determine whether tennis elbow pain might be decreased and improve the functional status. Subjectsare divided into two groups, Mulligan mobilization technique and Cyriax technique along with ultrasound.Purpose: To find out the effects of Mulligan mobilization technique and Cyriax technique along with ultrasoundin the management of lateral epicondylitis.Materials and Methods: Twenty individuals were chosen with tennis elbow (11 males and 9 females) and receivedtreatment for four times/week for two weeks in RENU’S Physiotherapy & Rehabilitation Centre according to theinclusion and exclusion criteria, explained about the procedure and obtained signed informed consent. Subjectswere divided into two groups by simple random sampling -Mulligan mobilization technique of Movement withMobilization(MWM) and Cyriax technique of Deep Tendon Friction(DTF) massage with Mill’s manipulationalong with ultrasound.Result: Statistical analysis had slight significant difference between Cyriax and Mulligan group for NPRS andPRTEE. Noticeably Cyriax had more improvement in pain reduction than Mulligan group, while Mulligan hadimprovement in functional impairment than Cyriax, with a p value of <0.0001.Conclusion: Mulligan mobilization and Cyriax method with ultrasound both reduced discomfort and enhancedfunctional status.

Efficacy of Scapular Strengthening Exercise and Eccentric Forearm Exercise on Functional Recovery in Subjects with Lateral Epicondylitis

Background: Inflammation of the extensor Carpi Radialis Brevis tendon causes lateral epicondyle discomfort.Patients on the dominant side were more affected than those on the nondominant side. And also proximal muscleweakness or instability places an additional load on the distal joint, leading to distal conditions, such as lateralepicondylitis.Purpose: To evaluate the effectiveness of scapular strengthening exercise and forearm eccentric exercise onfunctional recovery in subjects with lateral epicondylitis.Materials and Methods: Thirty participants were randomly assigned to experimental (scapular strengtheningwith eccentric exercise) and conventional (eccentric exercise) groups. Pain-rated tennis elbow evaluation (PRTEE),the numerical pain rating scale (NPRS), and grip strength measurement using a hand dynamometer were usedto evaluate the pre-test. The same test was used to determine post-treatment values after five weeks of treatment.Results: A substantial difference was seen between the experimental and control groups (P = 0.0001). Scapularstrengthening and eccentric exercises were effective in patients with lateral epicondylitis.Conclusion: Scapular muscle strengthening and eccentric forearm training are effective in individuals with lateralepicondylitis.

Anconeus Muscle Transfer to Correct or Prevent Wrist Radial Deviation in Radial and Posterior Interosseous Nerve Injuries

Wrist radial deviation is a possible complication of tendon transfer for restoration of wrist extension in cases of radial nerve paralysis. In posterior interosseous nerve (PIN) injury, this is because of the imbalance caused by the intact extensor carpi radialis longus and paralysis of the extensor carpi ulnaris (ECU). This deformity may also occur following transfer of the pronator teres (PT) to the extensor carpi radialis brevis (ECRB) for radial nerve palsy. To address wrist radial deviation, we propose transferring the anconeus muscle, extended by the intermuscular septum between the ECU and the flexor carpi ulnaris (FCU), to the ECU tendon. Through an incision over the ulna, the intermuscular septum between the ECU and FCU is harvested at the level of the periosteum and left attached to the anconeus proximally. The anconeus muscle is then released from the ulna, and the intramuscular septum extension is sutured to the ECU tendon under maximal tension. Anconeus muscle transfer was performed on two patients to correct chronic wrist radial deviation following PT to ECRB tendon transfer for radial nerve injury, as well as on two patients with PIN paralysis. In four patients, transfer was performed in addition to standard tendon transfers for radial nerve paralysis to prevent radial wrist deviation deformity. Wrist radial deviation was corrected or prevented in all but one patient at an average follow-up of 10 months. Patients with PIN lesions and those who had anconeus transfer concomitantly with radial nerve tendon transfers were capable of active ulnar deviation. No patient experienced elbow extension weakness, pain, or instability. Anconeus muscle transfer extended by intermuscular septum presents a viable alternative for addressing radial deviation of the wrist in cases of PIN nerve lesions or following PT to ECRB tendon transfer in radial nerve paralysis. Therapeutic V.

The Green Transfer—Long-Term Results

The purpose of this study was to determine the long-term results of the Green transfer (flexor carpi ulnaris to extensor carpi radialis brevis) for patient-reported outcomes, wrist position, and range of motion. We re-examined 13 patients from a previous prospective study involving surgery for hemiplegia that included a Green transfer. The average follow-up was 8 years with the range from 5 to 11 years. The wrist range of motion and the postoperative position of the wrists were measured. The surgical outcomes were measured via the Pediatric Orthopedic Data Collection Instrument, the Shriner's Hospital Upper Extremity Evaluation, Pediatric Quality of Life, and visual analog score for appearance from the patient and the parent. At this follow-up, only 7 of the 13 patients had a wrist position near neutral with the ability to flex and extend the wrist. Wrist range of motion was improved in four, decreased in four, and stayed the same in five patients. In contrast to these positional wrist results, statistically significant improvements were noted in several aspects of the Pediatric Orthopedic Data Collection Instrument, visual analog scores, and Shriner's Hospital Upper Extremity Evaluation scores. Long-term follow-up of the flexor carpi ulnaris to extensor carpi radialis brevis tendon transfer in hemiplegic patients reveals the results to be variable but favorable from a patient-reported outcome standpoint. Therapeutic IV.

Correction of Complex Clawing after Cerebral Infarct via All-Dorsal ECRB Tendon Transfer using Four-Tailed Plantaris Autograft

Clawing refers to pathologic hand posture of metacarpophalangeal joint hyperextension and proximal interphalangeal joint flexion, with variable presentation in appearance and functional deficits depending on underlying etiology, chronicity, and attempts at treatment. Characteristic deficits include the clawed appearance, loss of synchronous finger flexion, weakened grip and pinch strength, and impaired dexterity from loss of fine motor control. Surgical treatment varies for simple versus complex clawing, with additional nuances for associated pathology such as extensor mechanism attenuation, flexor myotendinous tightness, and intrinsic joint contracture. Conditions such as stroke or combined ulnar and median neuropathy require special consideration, as median-innervated myotendinous donors are not suitable. The present technique describes all dorsal extensor carpi radialis brevis tendon transfer via four-tailed plantaris autograft to the lateral bands for treatment of complex clawing after cerebral infarct.

Long-term Results of the Treatment of Scapholunate Instability with Dynamic Extensor Carpi Radialis Brevis Tenodesis

Background: Scapholunate dissociation is the most common form of carpal instability. This retrospective case series aimed to assess long-term results obtained by treating scapholunate instability with dynamic tenodesis using the entire extensor carpi radialis brevis tendon, which is detached from the base of the third metacarpal, rerouted in the third extensor compartment, and fixed at the distal portion of the scaphoid to maintain reduced rotatory subluxation. Methods: Nine patients with scapholunate instability were treated. We reviewed eight patients with a mean follow-up of 12 years. One subgroup of four patients was affected by static scapholunate instability, and the other by dynamic scapholunate instability. Disability of the Arm, Shoulder, and Hand score, Patient Rated Wrist Evaluation score, modified Mayo score, and radiographs were used to determine functional and anatomical outcomes. Results: Excellent functional results did not correlate with radiological outcome in patients with static scapholunate instability. In this subgroup, scapholunate angle and gap and radiolunate angle improved in average but remained in the pathologic range. In only one of these patients, osteoarthritis was observed. In the subgroup of patients affected by dynamic instability, very good functional outcomes correlate with radiological results, except in one patient who developed arthritic changes. Conclusions: Dynamic tethering of the scaphoid with the extensor carpi radialis brevis tendon might be indicated in the treatment not only in patients affected by dynamic scapholunate instability but also in patients with static instability. Prospective studies with a larger number of patients are required to evaluate this method.

Turnover Tendon Lengthening Does Not Alter Biomechanical Strength of Pronator Teres-to-Extensor Carpi Radialis Brevis Tendon Transfer.

The pronator teres (PT) to extensor carpi radialis brevis (ECRB) tendon transfer reestablishes wrist extension. Occasionally, the PT periosteal extension is of suboptimal quality to support a strong transfer. In these instances, turnover lengthening techniques can increase usable tendon length. This study characterized the optimal length of tendon turnover and the effect of lengthening on transfer strength. Twenty-seven cadaveric extensor tendons were lengthened using the turnover lengthening technique with 1 to 3 cm of tendon overlap. PT-to-ECRB tendon transfers were performed with native or lengthened ECRB tendons. Tensile testing was used to evaluate stress relaxation and load to failure. The median maximum load to failure increased with increasing overlap length, measuring 35.6 N (quartile 1, 30.2 N; quartile 3, 38.6 N) for 1 cm, 66.0 N (quartile 1, 59.1 N; quartile 3, 74.7 N) for 2 cm, and 96.6 N (quartile 1, 85.9; quartile 3, 114.9 N) for 3 cm of overlap ( P < 0.05). Failure occurred most frequently at the junction of the central overlap and native tendon. Tendons lengthened with 2 and 3 cm of overlap displayed greater stiffness than those with 1 cm ( P < 0.05). Lengthening the ECRB tendon with 2 or 3 cm of overlap did not disrupt the strength or stiffness of subsequent PT-to-ECRB tendon transfers. Turnover tendon lengthening does not detrimentally affect PT-to-ECRB tendon transfer. Greater overlap lengthening distance confers greater stiffness and resistance to rupture. When the periosteal extension of the PT tendon avulses or is of poor quality, the ECRB tendon can be lengthened using the turnover tendon lengthening technique to facilitate a robust transfer.

Rupture of the extensor carpi radialis longus and extensor carpi radialis brevis tendons following conservative treatment of a distal radius fracture: a case report

Conservative treatment shows favorable results for minimally displaced fractures of the distal radius. A commonly reported complication associated with distal radius fractures is delayed tendon rupture. The extensor pollicis longus tendon is the tendon that has most commonly been reported to be injured in distal radius fractures. This report provides a new case of delayed rupture of the extensor carpi radialis longus and extensor carpi radialis brevis tendons after conservative treatment of a distal radius fracture, along with a review of the literature.

Open Debridement Alone Versus Open Debridement With Tendon Repair for Lateral Epicondylitis: A Comparison of Complications and 5-Year Reoperation Rates From a Large Insurance Database.

Background:Open debridement (OD) of the extensor carpi radialis brevis tendon, both with and without repair to the lateral epicondyle, are effective treatments for recalcitrant lateral epicondylitis. However, few comparative studies exist within the literature.Purpose:To (1) compare the 5-year reoperation rates of patients who underwent OD alone versus OD with tendon repair (ODR) and (2) identify the 90-day adverse event rates, total same-day reimbursement amounts, and national usage trends for these 2 procedures from 2010 to 2019.Study Design:Cohort study; Level of evidence, 3.Methods:The PearlDiver MUExtr database was reviewed for patients diagnosed with lateral epicondylitis who underwent OD alone and ODR or reattachment between January 2010 and December 2019. These patients were stratified into 2 cohorts: the OD cohort and ODR cohort. The 5-year reoperation rates were assessed and compared, and the incidence of 90-day postoperative complications and risk factors were identified. The number of ODs and ODRs performed each year and the mean same-day reimbursement amounts (in US$) for both procedures were assessed.Results:Overall, 41,932 lateral epicondylitis patients who underwent debridement were identified, with 17,139 OD patients and 24,793 ODR patients. There were no significant changes in the proportion of OD versus ODR procedures performed during the study period (P = .18). A significantly higher incidence of hematoma was seen after OD compared with ODR (0.19% vs 0.12%; P = .04), but ODR had a significantly lower 5-year reoperation rate than OD (2.8% vs 3.9%; P = .006), with an absolute risk reduction of 1.1% and a number needed to treat of 91. Finally, ODR ($1683.17 ± $12.15) had a higher mean same-day reimbursement than OD ($1479.05 ± $15.78) (P = .001).Conclusion:Both OD and ODR had low complication rates. The 5-year reoperation rates were low for both procedures, but they were significantly higher for OD. Over the 10-year study period, there were no significant changes in the relative percentages of OD versus ODR performed. ODR had a significantly higher mean same-day reimbursement.

Multiple Perforations of the ECRB Tendon Using an Innovative Standardized, Reproducible Technique; A Cadaveric Study on Accuracy and Prospective Clinical Safety Assessment Pilot Study. No Adverse Effects in the First 122 Patients with Lateral Epicondylitis.

In LE (Lateral Epicondylitis) otherwise known as Tennis Elbow, the Extensor Carpi Radialis Brevis (ECRB) tendon is most commonly involved. In the majority of studies, injections are performed with a lack of standardization. The Instant Tennis Elbow Cure (ITEC) device has been developed to perform reproducible and standardized perforations by multiple needles. The goal of this pilot study was to estimate the accuracy of this ITEC device by means of a cadaveric study and to assess the clinical safety of this procedure. Ten cadaveric arms were injected using the ITEC device. The location and depth of the ECRB tendon was measured by ultrasound imaging. The accuracy of the infiltration was assessed by locating the injected dye through dissection and arthrotomy of the cadaveric elbow. A prospective clinical pilot study was conducted to assess the safety of the ITEC device in treating patients with chronic LE. An optional infiltration with an injection fluid was carried out?? Primary outcome measures were side effects and complications of the ITEC device occurring within a follow up period of 8 weeks after treatment. In all cadaveric elbows the injection fluid ( in this case an injection fluid) was located at the ECRB tendon. In one cadaver, a minimal amount of dye was found intra-articular and in 3 cadavers a small quantity was located in the surrounding tissue of the ECRB tendon. 122 patients with LE were treated with the ITEC device. No adverse effects or complications were reported at 8-week follow up. Treatment of LE using the ITEC device appears accurate and safe. It may improve future research since it is reproducible and it can be performed in a standardized way.

Ultrasound-Guided Injection Approach of Treating Tennis Elbow and Elbow Joint Synovitis Simultaneously Under One Needle Insertion Point.

A 52-yr-old man with right elbow pain for 6 mos visited an outpatient rehabilitation clinic. An obvious tender spot at the lateral epicondyle area was palpated with positive Cohen test.1 The patient had received autologous platelet-rich plasma injection but without much improvement.2 Musculoskeletal ultrasound images revealed thickening of the common extensor tendon, combined with diffuse heterogeneity and focal hypoechogenicity. Bony irregularity was observed at the tendon insertion site. The diagnosis of lateral epicondylitis, also known as “tennis elbow,” is a common cause of elbow pain. The exact pathogenesis remains elusive and is often difficult to treat. Ultrasound-guided injection to the bone and common extensor tendon interface may not be effective as many patients are also bothered with elbow joint synovitis.3 As a result, this article describes an important ultrasound-guided injection approach to treat tennis elbow and joint synovitis simultaneously under one needle insertion point. When applying ultrasound-guided injection to treat tennis elbow, the elbow is flexed at a 90-degree angle. The ultrasound linear probe is placed over the lateral epicondyle, along the longitudinal axis of the common extensor tendon origin. Under this sonographic view, the common extensor tendon, the lateral epicondyle, and the elbow joint can be observed. Conventionally, injection can be done under the longitudinal view, in a distal-to-proximal or proximal-to-distal direction, by guiding the needle to the bone tendon (extensor carpi radialis brevis tendon) interface.4 For patients who are also bothered with elbow joint synovitis, simultaneous injection to the bone-tendon interface, and aspiration of the joint fluid followed by the injection of an injectant may be needed (Figs. 1A, B).3 However, under the in-plane or longitudinal view, needle insertion into the elbow joint can be difficult because of the convex curvature of the radial head (Fig. 1B). Therefore, a different injection approach is recommended. Similar to the conventional method, the linear probe is placed longitudinally on top of the elbow joint. The needle is then inserted in a lateral-to-medial direction under the out-of-plane approach or short-axis view into the elbow joint (Figs. 2A, B). The needle is observed as a hyperechoic dot inside the elbow joint. Aspiration of the joint fluid followed by injection can then be performed. Still under the short-axis view, the needle is retracted and then guided in a slightly obliqued direction to the bone-tendon interface to commence subsequent injection treatment (Figs. 3A, B). Steroid was the injectant used. Elbow pain was greatly improved after the treatment.FIGURE 1: A, The linear ultrasound transducer is placed longitudinally on top of the right elbow to visualize the lateral epicondyle, common extensor tendon, bone-tendon (extensor carpi radialis brevis) interface, and the elbow joint. Conventionally, injection can be done under the longitudinal view and in a distal-to-proximal direction by guiding the needle to the bone-tendon interface. B, The needle is accurately guided to the bone-tendon (extensor carpi radialis brevis) interface (*). Due to synovitis, increased hypoechogenicity (resembling fluid accumulation) can be observed in the elbow joint (+). Using the distal-to-proximal direction needle approach, insertion into the elbow joint can be difficult because of the convex curvature of the radial head.FIGURE 2: A, With the linear ultrasound transducer placed longitudinally on top of the right elbow, the needle is inserted in a short-axis or out-of-plane view relative to the transducer and guided into the elbow joint (pink area). B, Under the short-axis view, the injection needle can be visualized as a hyperechoic dot inside the elbow joint.FIGURE 3: A, After completing elbow joint injection, the needle is then retracted and the syringe is moved slightly in a distal direction to guide the needle to the lateral epicondylar area (curved white arrow). B, Still under the short-axis view or slightly obliqued short-axis view, the needle is guided to the bone-tendon interface.

Hand-Grip Strength and Return to Heavy Manual Work at a Mean 5-Year Follow-up After Arthroscopic Release of Recalcitrant Lateral Epicondylitis

Background:Lateral epicondylitis of the elbow is a common degenerative disorder in middle-aged patients. Surgery is reserved for patients who do not respond to nonoperative treatment.Purpose:To evaluate hand-grip strength and return to heavy manual activities in patients engaged in work requiring heavy lifting after arthroscopic release of refractory lateral epicondylitis.Study Design:Case series; Level of evidence, 4.Methods:The study included consecutive patients who underwent arthroscopic release of the extensor carpi radialis brevis tendon to treat recalcitrant lateral epicondylitis of the elbow, with a minimum 48-month follow-up. Functional outcome measures included assessment of hand-grip strength, visual analog scale for pain, and Mayo elbow performance score. The recorded measurements were compared at postoperative 1 and 6 months and the final assessment. Pre- and postoperative data were compared using the paired t test, and the various postoperative assessments were compared using 1-way analysis of variance.Results:A total of 22 patients (mean ± SD; age, 34.6 ± 5.9 years) with a mean follow-up of 60.5 ± 4.7 months were included in our study. There were highly significant improvements between preoperative and 1-month postoperative results regarding hand-grip strength (17.5 ± 4.1 kg to 34.4 ± 6.8 kg), visual analog scale score for pain (7.86 ± 1.2 to 1.8 ± 1.09), and Mayo score (57.1 ± 7.9 to 89.3 ± 4.9; P < .00001 for all). Significant improvements were found on all 3 functional measures between 1 and 6 months postoperatively (P ≤ .05 was statistically significant), and there were nonsignificant improvements on all measures from 6-month to final follow-up. The patients regained 96.4% of their hand strength as compared with the unaffected side and returned to their previous activities without reporting serious complications.Conclusion:Minimally invasive arthroscopic release of recalcitrant lateral epicondylitis of the elbow provided a satisfactory functional result, as shown by regaining of hand-grip strength in patients engaged in heavy manual occupations without significant morbidities.

Predictive value of magnetic resonance imaging in outcomes of nonsurgical treatment of lateral epicondylitis.

BackgroundThe diagnosis of lateral epicondylitis is typically made on the basis of clinical history and examination. However, magnetic resonance imaging (MRI) is often used to supplement evaluation of the patient with a painful elbow and can identify extensor carpi radialis brevis (ECRB) tendon tears. The objective of this study was to determine if ECRB tear size on MRI could be used as a prognostic indicator for patients with recalcitrant lateral epicondylitis and partial ECRB tears.MethodsForty-one patients with recalcitrant lateral epicondylitis and a partial ECRB tear on MRI were identified (22 men and 19 women; age: 49 ± 8 years; height: 165 ± 36 mm; weight: 73 ± 18 kg). Patients were divided into two groups based on whether they underwent surgery or not. Nonsurgical treatment was evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire, and surgery was considered a failure of nonsurgical treatment. Nonsurgical treatment was variable and included a mixture of physical therapy, rest, injection therapy, and splinting.ResultsOf the 41 patients, 5 patients opted for immediate surgery and 36 patients were treated nonsurgically. Of those 36 patients, 11 patients had symptom relief, 19 patients had subsequent surgery, and 6 patients chose not to have surgery despite continued symptoms. Tear size on MRI did not differ significantly between the patients who had symptom relief with nonsurgical treatment and the other patients (7.7 ± 4.3 mm vs. 9.7 ± 2.5 mm, P = .07).DiscussionOnly 11 of 41 patients (27%) with recalcitrant lateral epicondylitis and ECRB tear had symptom relief with nonsurgical treatment. However, ECRB tendon defect size on MRI did not predict success or failure of nonsurgical treatment.

Magnetic resonance imaging and clinically controlled improvement of a combined autologous conditioned plasma combined with rh collagen type I injections in lateral epicondylitis.

The purpose of the study was to investigate the effect of combined autologous conditioned plasma and recombinant human collagen type I injections on lateral epicondylitis. Outcome was measured in 5 patients before the single application of ACP+rhCollagen type I (Arthrex ACP® Tendo) and after 10.60±3.58wks by means of (i) the Visual Analogue Scale for pain, (ii) range of motion for wrist extension/flexion as well as supination/pronation, and (iii) MRI-scans. VAS-scores significantly decreased from 6.40±1.14 at baseline to 1.80±2.49 at follow- up, and the effect was very large (p=0.04, dz=2.22). In addition, range of motion either improved or remained unrestricted, and MRI-scans showed healing of the extensor carpi radialis brevis tendon in most cases. A combined ACP+rhCollageninjection successfully reduces pain in lateral epicondylitis. Due to the small sample size, however, these promising preliminary results need further investigation in future research.

Arthroscopic Recession Technique in the Surgery of Tennis Elbow by Sharp Cutting the Extensor Carpi Radialis Brevis (ECRB) Tendon Origin.

The aim of this study was to assess the functional outcomes and time to improve after the modified arthroscopic technique (recession technique) by using a knife to sharply cut the extensor carpi radialis brevis (ECRB) tendon origin in patients with recalcitrant tennis elbow. In a prospective study, we included 11 consecutive patients. Following the routine elbow arthroscopy and after exposing the ECRB tendon, we used a knife (no. 11 blade) to cut the tendon at the level of radiocapitellar articulation while avoiding the lateral collateral ligament, which is considered a tendon recession as is done in spastic muscles. Patients were followed up for 1, 3, 6, and 12 month intervals and were asked to fill the Mayo Elbow Performance Index (MEPI), Quick Disabilities of the Arm Shoulder Hand (QuickDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE). The mean PRTEE, QuickDASH, and MEPI scores showed significant improvement over time (P<0.001). There were 5 excellent, 5 good and 1 fair results based on MEPI. The patient with fair result was the only patient with existing varus instability on examination under anesthesia although we could not elicit the test positive on clinical examination. Substantial functional and pain improvement was reported almost 6 months after surgery. We did not find any nerve injury or post-operative infection. Arthroscopic recession surgery by using a knife is a safe and effective way in managing recalcitrant tennis elbow although patients should be informed of the expected time to improve. A simple tendon recession by a sharp cut is a time-saving technique that works effectively and is comparable with the piecemeal shaving. The modified muscle recession technique is a rapid and safe way to manage the recalcitrant tennis elbow arthroscopically while the outcomes are comparable to the routine piecemeal shaving of the pathologic tissue.

The expression of substance P and calcitonin gene-related peptide is associated with the severity of tendon degeneration in lateral epicondylitis

BackgroundIn this study, we investigated whether substance P (SP) or calcitonin gene-related peptide (CGRP) expression is associated with tendon degeneration in patients with lateral epicondylitis.MethodsTwenty-nine patients who underwent surgical treatment for lateral epicondylitis were enrolled in the final analyses. Extensor carpi radialis brevis tendon origins were harvested for histological analysis.ResultsSP and CGRP immunostaining were negative in healthy tendons but positive in degenerative tendons; moreover, their immunoreactivity increased with degeneration severity. Univariate analysis indicated that variables such as the preoperative visual analog scale (VAS) score or SP or CGRP expression levels were significantly associated with the Movin score. However, multivariate analysis revealed that only higher SP and/or CGRP signals were associated with higher Movin scores. Elevations in SP or CGRP expression were also linked with significantly severe preoperative VAS scores.ConclusionWe demonstrated that tendon degeneration severity is associated with increased SP and CGRP expression in the biopsy samples of lateral epicondylitis.