ODG -TWC

ODG Treatment

Integrated Treatment/Disability Duration Guidelines

Elbow (Acute & Chronic)

Back to ODG - TWC Index

 

(updated 05/07/13)

 

CONTENTS

 

 

(1) Treatment Planning……………………………………………………………………...2

 

(2) Codes for Automated Approval………………………………………………………….7

 

(3) Procedure Summary…..………………………………………….……………………9

 

 

 

Reference Summaries…………………………………………………..……………….…52

(Including findings, evaluations, and ratings; click on PMID# for complete abstracts)

 

 

 

 

Explanation of Medical Literature Ratings:

 

Ranking by Type of Evidence:

1. Systematic Review/Meta-Analysis

2. Controlled Trial – Randomized (RCT) or Controlled

3. Cohort Study - Prospective or Retrospective

4. Case Control Series

5. Unstructured Review

            OTHER:

6. Nationally Recognized Treatment Guideline (from guidelines.gov)

7. State Treatment Guideline

8. Other Treatment Guideline

9. Textbook

10. Conference Proceedings/Presentation Slides

 

Ranking by Quality within Type of Evidence:

a. High Quality

b. Medium Quality

c. Low Quality

 

 

 

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ODG Integrated Treatment/Disability Duration Guidelines

Occupational Disorders of the Elbow

 

Note: The Treatment Planning section is not designed to be a rule, and therefore should not be used as a basis for Utilization Review. The Treatment Planning section outlines the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries for complete lists of the various options that may be available, along with links to the medical evidence. The Procedure Summaries are the most important section of ODG Treatment, and that section, not the Treatment Planning section, should be used as a basis for Utilization Review.

 

Initial Diagnosis

·        First visit: with Primary Care Physician MD/DO (100%)

·        Determine cause: Initial Evaluation:

o        Determine the type of trauma (fall, repetitive motion, twisting, etc.)

o        Determine whether the problem is acute, subacute, chronic, or of insidious onset.

o        Determine the severity and specific anatomic location of the pain.

o        Assess the ability of the patient to use the elbow, from no to full ability.

o        Search for any evidence of an open or penetrating wound.

o        Test the range-of-motion of the joint (normal, mild restriction, severe restriction).

o        Search for any evidence of vascular or nerve injury distal to the injury.

o        Determine any present medication.

o        Determine any previous medical history, history of systemic disease, previous elbow injury or disability, job requirements and hobbies.

·         Initial diagnosis:

o        Traumatic (Go to Fractures & dislocations):

·        Fracture or Dislocation [ICD-9 Codes: 812.4X, 812.5X, 813.0X, 813.1X, 813.21, 813.22, 813.23, 813.31, 813.32, 813.33, 832.X, 927.11]

o        Other (Go to Initial conservative treatment):

·        Sprain or Contusion [ICD-9 Codes: 841.X, 923.1X ]

·        Laceration [ICD-9 Codes: 881.01, 881.11, 881.21]

·        Epicondylitis, Medial [ICD-9 Code: 726.31]

·        Epicondylitis, Lateral [ICD-9 Code: 726.32]

·        Olecranon Bursitis [ICD-9 Code: 726.33]

·        Pronator syndrome [ICD-9 Code: 354.1]

·        Ulnar Nerve Entrapment (Cubital tunnel syndrome) [ICD-9 Code: 354.2]

·        Radial Nerve Entrapment [ICD-9 Code: 354.3]

 

Fracture or Dislocation of Elbow (35% of cases)

·        Definitive Evaluation:

o        Search for any evidence of an open wound in the vicinity of the fracture; if there is an open wound, treat for infection and examine for the presence of foreign bodies (visual, x-ray, etc)

o        Perform a clinical examination for deformity, tenderness, or ecchymosis, or associated nerve, neurovascular, or tendon injury. Also look for the inability to perform spontaneous movement of the elbow.

o        Search for any evidence of dislocation and arterial vascular compromise (cold, dusky hand and forearm with loss of sensation). If found, an immediate reduction should take place (prior to x-rays if necessary).

o        X-ray the elbow. Special views should be obtained when necessary.

·        Initial Therapy

o        Simple, undisplaced, stable fractures of the elbow can be treated by the primary care physician.

o        Apply a sling and/or a posterior splint with medial and lateral gutter splints. A portion of patients should be converted to a long arm cast after 10-14 days.

o        Ice and elevation whenever lying down for the first 72 hours.

o        Analgesics and/or nonsteroidal anti-inflammatory drugs for up to two weeks.

o        Aspirating the radiohumeral joint and injection of local anesthetic to evacuate hematoma is appropriate to relieve pain in selected cases of radial head fractures.

o        Physical therapy (3-6 visits) to teach patient range-of-motion and muscle-strengthening exercises out of the splint should begin as soon as tolerated at two to four weeks.

o        Recheck at seven days, then at two-week intervals until healed. Repeat x-rays at seven days and at two weeks to assure that the fracture has not slipped. X-ray again at five weeks.

o        Complex, displaced, or unstable fractures should be immobilized and referred to an orthopedic surgeon. Compound fractures, when appropriate, should have a tetanus toxoid injection before being referred to a surgeon.

o        Dislocations of the elbow are accompanied by significant ligament injuries. Even if full reduction has been achieved, orthopedic referral is appropriate.

ODG Return-To-Work Pathways -- Fracture

Stable, clerical/modified work: 2 days
Stable, manual work: 14 days
Reduction/manipulation, clerical/modified work: 14 days
Reduction/manipulation, manual work: 28 days
Reduction/manipulation, heavy manual work: 42 days

ODG Return-To-Work Pathways – Dislocation

Non-dominant arm, clerical/modified work: 0 days
Non-dominant arm, manual work: 10 days
Non-dominant arm, heavy manual work: 21 days
Dominant arm, clerical/modified work: 7 days
Dominant arm, manual work: 21 days
Dominant arm, heavy manual work: 42 days

(See ODG Capabilities & Activity Modifications for Restricted Work under “Work” in Procedure Summary)

·        Secondary Evaluation for patients with persistent symptoms or minimal improvement after six weeks of therapy

o        Review for compliance of the employee and employer to therapy programs and job modifications and restrictions. Also review for insurance company cooperation.

o        Evaluate for delayed union, malalignment, or signs of associated tendon or nerve injury.

o        Promptly refer to an orthopedic surgeon if one of these conditions is found.

 

Initial Conservative Treatment of Disorders other than Fractures (65% of cases)

·        Definitive Evaluation:

o        Typical symptoms of lateral epicondylitis (“tennis elbow”) include pain in the lateral aspect of the elbow with pain or burning radiating to the forearm (and occasionally proximal radiation). With medial epicondylitis (“golfers elbow”) the pain is on the inside of the elbow (versis outside of the elbow for tennis elbow). There may be loss of grip strength due to forearm pain with hand grip. Pain is usually insidious in onset but may be provoked by an acute trauma or strain. Initial complaints may be vague, such as a dull forearm ache.

o        Specific attention should be directed towards confirming occupational risk factors such as repetitive, sustained or forceful wrist dorsiflexion, power grip, exposure to vibration, repetitive extended elbow reach with forceful pulling, and repetitive pronation and supination of the forearm against resistance.

o        Rule out non-occupational activities that could be causing or aggravating the condition, such as activities that require gripping or hyperextending the wrist.

o        Olecranon bursitis may be secondary to systemic illness.

o        A physical examination should be performed with documentation of the following findings:

§         Inspection for: deformity, swelling or erythema.

§         Provocative maneuvers: such as the presence or absence of pain with resisted dorsiflexion of the wrist, passive wrist flexion with the elbow in full extension, resisted supination of the forearm, and Tinel's sign.

§         Range of motion: elbow flexion and extension, pronation and supination, wrist flexion and extension. Note any flexion contracture deformity of the elbow.

§         Palpation: Document the presence or absence of the following: elbow deformity, tenderness, heat or crepitus (including olecranon process and medial epicondyle). Also check the forearm for deformity, heat or tenderness.

§         Muscle strength testing of the entire upper extremity should be performed as relevant.

§         Appropriate distal extremity exam should include neurological testing. A routine examination of the shoulder, neck, and wrist, and hand (palpation, range of motion, strength testing) should be performed.

§         A differential diagnosis should be considered at this point: such as radiculopathy, or shoulder pathology with referred pain.

o        As a rule, the diagnosis of elbow problems does not require an imaging study.

o        Appropriate laboratory studies should be considered if there is evidence of an infectious or diffuse inflammatory process as a contributing or causative factor.

o        Nerve conduction studies may be indicated for elbow problems associated with neurological deficits.

o        Aspiration of the olecranon bursa is not routinely indicated unless there is suspicion of infection or metabolic disease

·        Initial Treatment

o        The purpose of the initial treatment is to reduce symptoms, optimize healing/function and increase work with appropriate modifications to minimize the risk factors that contributed to the injury.

o        All injured workers should receive instruction concerning the nature of their condition, its risk factors, preventive measures and goals of initial therapy. The injured worker should be instructed on how to eliminate or modify any aggravating non-occupational activities and sports during treatment.

o        Work restrictions or modifications that reduce the injured worker's exposure to the etiologic or aggravating activity are of central importance. Examples of such restrictions include preclusion from or reduction in time performing tasks requiring repetitive, sustained or repetitive forceful wrist or hand activities, repetitive elbow motion, prolonged elbow positioning or prolonged exposure to vibration.

o        Nonsteroidal antiinflammatory agents can be used. Acetaminophen is an analgesic that may be used as an adjunct or alternative to NSAIDs.

o        Physical treatments and passive modalities: If there is no improvement after 2 weeks the treatment should be modified. Use of thermal modalities in conjunction with physical treatment may be useful. Physical treatments for pain management splinting and/or functional retraining and instruction in a graded exercise program. Appropriate exercises may include, but are not limited to: 1) gentle muscle stretching; 2) flexibility; and 3) graduated strengthening. Care should be taken while incrementing exercises so that the condition is not aggravated. Appropriate manual therapies may include manipulation, or joint or soft tissue mobilization, supplemented by physical modalities and exercise.

o        Acupuncture: Use of acupuncture in the first 4 weeks of treatment as a part of an overall treatment plan.

o        Protective devices: The use of an elbow and/or wrist support for immobilization may be indicated for a brief period. The use of a splint at work must be carefully considered as it may put the injured worker at risk for further musculoskeletal injury by forcing the adoption of awkward compensatory postures. A forearm strap can be aggravating in the acute stage so its use should be individualized. It is contraindicated in the presence of nerve compression symptoms. Night splinting may be indicated for nerve entrapment syndromes.

o        Local corticosteroid injection: Local corticosteroid injections of the myofascial areas or bursae may be appropriate, especially if the pain is moderate to severe. Before the injection, it is important to be aware that the olecranon bursa may be the site of infection. In such an instance, a steroid injection would be contraindicated. Refer to orthopaedic surgeon if infection present.

o        Surgery is rarely indicated

·        Secondary Assessment

o        A reconsideration of the initial diagnosis is necessary at this stage and a differential diagnosis should be reviewed: cervical radiculopathy, shoulder pathology with referred pain and nerve entrapment.

o        Diagnostic imaging: Radiographic studies of the elbow and forearm may be considered if, on re-evaluation, the physician suspects morphologic pathology. The use of MRI and arthrography is rarely indicated except for the evaluation of intraarticular pathology.

o        Laboratory studies: Laboratory studies may be performed if there is evidence of an infectious or diffuse inflammatory process as a contributing pathology.

o        EMG/NCS to rule out other conditions: Electrodiagnostic studies should be considered if there is clinical evidence of nerve entrapment or cervical radiculopathy as alternative diagnoses.

o        Surgical referral: Orthopaedic surgical consultation may be recommended after failure of conservative treatment and indication of a surgically correctable condition.

 

ODG Return-To-Work Pathways – Sprain

Moderate, clerical/modified work: 4 days
Moderate, manual work: 21 days
Severe, clerical/modified work: 7 days
Severe, manual work: 35-42 days

ODG Return-To-Work Pathways – Contusion

Superficial contusions: 0 days
Deep contusions, clerical/modified work: 5 days
Deep contusions, manual work: 21 days

ODG Return-To-Work Pathways – Laceration

Minor: 0 days
Major, clerical/modified work: 3 days
Major, manual work: 8 days

ODG Return-To-Work Pathways – Epicondylitis, Medial

Without surgery, modified work: 0 day
Without surgery, regular manual work: 7 days
Without surgery, heavy manual work: 42 days

ODG Return-To-Work Pathways – Epicondylitis, Lateral

Without surgery, modified work: 0 day
Without surgery, regular manual work: 7 days
Without surgery, heavy manual work: 42 days
Without surgery, heavy manual vibrating work, if cause of disability: indefinite
With surgery (rare), modified work, non-dominant arm: 6 days
With surgery (rare), modified work, dominant arm: 21 days
With surgery (rare), regular work, non-dominant arm: 28 days
With surgery (rare), regular work, dominant arm: 42 days
Acupuncture (3-6 treatments): 7-21 days

ODG Return-To-Work Pathways – Olecranon Bursitis

Without surgery, modified work: 0 day
Without surgery, regular manual work: 4 days
Without surgery, heavy manual work: 35 days

ODG Return-To-Work Pathways – Ulnar Nerve Entrapment

Without surgery, modified work: 0 day
Without surgery, regular work: 14 days
With surgery, modified work: 14 days
With surgery, regular work, non-dominant arm: 21 days
With surgery, regular work, dominant arm: 49 days

ODG Return-To-Work Pathways – Radial Nerve Entrapment
Diagnostic testing: 0 days
Treatment, clerical/modified work: 14 days
Treatment, manual work: 42 days

 

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 Codes for Automated Approval

Note: Ideally each claim should be managed based on the details of the case using the Procedure Summary. The codes below are provided for payors without the resources to manage each case, who want to auto-pay the more routine claims based only on the diagnosis and procedure codes.

Diagnoses

ICD9 Code

Name

812.4x, 812.5x, 813.0x, 813.1x, 813.21, 813.22, 813.23, 813.31, 813.32, 813.33, 832.x, 927.11

Fracture or Dislocation

Procedures allowed:

 

CPT Code

 

Name

Maximum

Occurrences

99203

Office/outpatient visit new

1

99204

Office/outpatient visit new

99283

Emergency dept visit

1

99212

Office/outpatient visit est.

5

99213

Office/outpatient visit est.

99244

Office consult, mod complexity

1

73070

X-ray elbow 2 views

1

73080

X-ray elbow 3 views

25575

Treat fracture radius/ulna

1

97001

Physical therapy evaluation

1

97110

Physical therapy procedure

6

 

Diagnoses

ICD9 Code

Name

841.x, 923.1x

Sprain or Contusion

881.x

Laceration

726.31

Epicondylitis, Medial

726.32

Epicondylitis, Lateral

726.33

Olecranon Bursitis

354.2

Ulnar Nerve Entrapment

Procedures allowed:

 

CPT Code

 

Name

Maximum

Occurrences

99203

Office/outpatient visit new

1

99204

Office/outpatient visit new

99212

Office/outpatient visit est.

6

99213

Office/outpatient visit est.

99244

Office consult, mod complexity

1

73070

X-ray elbow 2 views

1

73080

X-ray elbow 3 views

73221

MRI w/o contrast any joint upper extrem

1

97001

Physical therapy evaluation

1

97110

Physical therapy procedure

6

98943

Manipulation, extraspinal

97002

Physical therapy re-evaluation

1

97530

Therapeutic activities/exercises

6

97810

Acupuncture

4

 

CPT © 2010 American Medical Association. All Rights Reserved.
No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association

 

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Procedure Summary - Elbow

Procedure/topic

Summary of medical evidence

Click to jump ahead: A | B | C | D | E | F | G | H | I | L | M | N | O | P | R | S | T | U | V | W | X

Acetaminophen

Recommended for acute pain. Acetaminophen is safer than NSAIDs (aspirin, ibuprofen). There is fair to good evidence that NSAIDs are effective for reducing pain in patients with acute musculoskeltal problems, and there is evidence that acetaminophen is comparable in efficacy to NSAIDs but with fewer side effects. (Kehlet, 2003) (Barden-Cochrane, 2004) See also Nonprescription medications.

Activity restrictions

See Work.

Acupuncture

Recommended only for short-term treatment of lateral epicondyle pain. No studies have demonstrated long-term relief. It is possible to tentatively conclude that acupuncture is an effective palliative treatment for epicondylitis; however, no trial assessed potential adverse effects. Further trials are needed before definitive conclusions can be drawn. In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (Trinh, 2004) (Bisset, 2005 ) (Boisaubert, 2004) Several trials have evaluated the effect of acupuncture on epicondylitis, and they report better short term global outcomes and greater pain relief for patients treated with acupuncture (vs. control). (Green-Cochrane, 2002) (AHRQ, 2002) (Fink, 2002) A recent review determined, with good evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. (Trudel, 2004) For an overview of acupuncture and other conditions in which this modality is recommended see the Pain Chapter.

ODG Acupuncture Guidelines:

Initial trial of 3-4 visits over 2 weeks

With evidence of objective functional improvement of VAS score, treatment can be approved up to a total of 8 visits over 4-6 weeks (Note: The evidence is inconclusive for repeating this procedure beyond an initial short course of therapy.)

Arthrocentesis /aspiration of joint

See Injections.

Arthroplasty (elbow)

See Total elbow replacement (TER).

Arthroscopy

Definition: An arthroscope is a tool like a camera that allows the physician to see the inside of a joint, and the surgeon is sometimes able to perform surgery through an arthroscope, which makes recovery faster and easier. Having started as a mainly diagnostic tool, arthroscopy provides the surgeon with a minimally invasive treatment option for a wide variety of indications. See the Surgery listings for detailed information on specific treatments that may be done arthroscopically.

Aspirin

See Nonprescription medications.

Augmented soft tissue mobilization (ASTM)

Under study. Insufficient evidence exists to evaluate many physical modalities used to treat disorders of the elbow, often employed based on anecdotal or case reports alone. In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999)

Autologous blood injection

Recommend single injection as a second-line therapy for chronic lateral epicondylitis after first-line physical therapy such as eccentric loading, stretching and strengthening exercises, based on recent research below. Recent studies report good outcomes in small groups of patients who underwent injection of their own blood into the location of lateral epicondylitis. These studies offer encouraging results of an alternative minimally invasive treatment that addresses the pathophysiology of lateral epicondylitis that has failed traditional nonsurgical modalities. (Most nonsurgical treatments for lateral epicondylitis have focused on suppressing an inflammatory process that does not actually exist in conditions of tendinosis.) More investigation is needed before this should be considered a standard treatment. This option is relatively low cost, but it is invasive and may have side effects. (Connell, 2006) (Edwards, 2003) This small lower-quality study concluded that the combined action of dry needling and autologous blood injection under ultrasound guidance appears to be an effective treatment for refractory medial epicondylitis as demonstrated by a significant decrease in VAS pain and a fall in the modified Nirschl scores. (Suresh, 2006) This review concluded that there is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of lateral epicondylosis (LE). Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies. (Rabago, 2009)

Recent research: In this RCT autologous blood was more effective than corticosteroid injection. (Kazemi, 2010) This RCT found the success rate of corticosteroid injection (50%) was significantly lower than the success rate for autologous blood injection (83.3%), and they recommend that the treatment of choice for lateral epicondylitis be autologous blood injection. (Ozturan, 2010) This RCT found success with both autologous blood and PRP, but PRP was superior to autologous blood in the short term. (Thanasas, 2011) In this RCT at 6 months the authors observed a 66% success rate in the platelet-rich plasma (PRP) injections group and 72% in the autologous blood injections (ABI) group, but there was a higher rate of conversion to surgery in the ABI group (20%) versus the PRP group (10%). In patients who are resistant to first-line physical therapy such as eccentric loading, ABI or PRP injections are useful second-line therapies to improve clinical outcomes. Up to seven out of 10 additional patients in this difficult to treat cohort benefit from these surgery-sparing interventions. (Creaney, 2011) (Bisset, 2011) See also Platelet-rich plasma (PRP).

Band

See Tennis elbow band.

Biofeedback

Not recommended. Insufficient evidence exists to evaluate many physical modalities used to treat disorders of the elbow, often employed based on anecdotal or case reports alone. In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999)

Bone growth stimulators

See Bone growth stimulators, electrical; & Bone growth stimulators, ultrasound.

Bone growth stimulators, electrical

Recommended as an option for non-union of long bone fractures. See the Knee Chapter for specific indications.

Bone growth stimulators, ultrasound

Recommended as an option for non-union of long bone fractures or fresh fractures with significant risk factors. See the Knee Chapter for indications and more information.

Botulinum toxin injection

Under study for lateral epicondylitis. The results of studies are conflicting, with some showing good outcomes and some not. This study found no significant evidence of a benefit from botulinum toxin injection in the treatment of chronic tennis elbow. (Hayton, 2005) According to another study, botulinum toxin injection may improve pain over a three-month period in some patients with lateral epicondylitis, but injections may be associated with digit paresis and weakness of finger extension. (Wong, 2005) This preliminary study of injections of botulinum toxin A in patients with chronic epicondylitis has shown promising results. (Placzek, 2007) A method for injecting botulinum toxin based on measurement of patients' forearm length has been found to effectively reduce pain at rest in patients with lateral epicondylitis, a new RCT suggests. The success rate of inducing paralysis in this study was 96%, as compared with less than 60% in previous studies, even in those that used considerably higher doses of botulinum toxin. The site of injection was chosen as a distance one-third the length of the forearm from the tip of the lateral epicondyle on the course of the posterior interosseus nerve. Compared with those patients receiving placebo, patients in the group given botulinum toxin had significantly reduced pain at rest during 4 to 16 weeks of follow-up; however, nearly all patients in the intervention group experienced weakness in the extension of the third and fourth fingers at week 4, although this resolved by week 16. In conclusion, botulinum toxin, although shown to reduce pain, may not be the right therapy for everyone because its effect on function, quality of life and pain-free grip is unknown, and it can cause partial loss of movement of the third and fourth fingers, which may be unacceptable for some people. (Espandar, 2010) See also injections.

Brace

See Splinting.

Causality (determination)

Recommended as indicated below. Determination of causation typically involves mechanism of injury, temporal relationship, and dose effect. In the design of computer workstations, screen below eye height is a significant predictor for elbow symptoms. (Juul-Kristensen, 2004) One study concluded that the predictive factors for persistent elbow tendonitis included older age, higher hand repetition level for their job(s), more deviation from a neutral wrist position during the work activity, and lower perceived decision authority on the job. Workers at highest risk for persistent elbow tendonitis should be placed at jobs with lower repetition levels and that use more neutral wrist postures. (Werner, 2005) Mouse and keyboard time seem to predict elbow and wrist/hand pain. (Lassen, 2004) Women and patients who report nerve symptoms are more likely to experience a poorer short-term outcome after PT management of lateral epicondylitis. Work-related onsets, repetitive keyboarding jobs, and cervical joint signs have a prognostic influence on women. (Waugh, 2004) Medial epicondylitis is clearly associated with forceful work (Descatha, 2003) Disappointing results of therapy were found in litigants with epicondylitis. (Kay, 2003) The incidence of cubital tunnel syndrome (overall 0.8%) is associated with one job related risk factor (holding a tool in position, repetitively, with an odds ratio of 4.1), plus obesity (4.3) and other upper-limb work-related musculoskeletal disorders, especially medial epicondylitis and other nerve entrapment disorders (cervicobrachial neuralgia and carpal and radial tunnel syndromes). (Descatha, 2004) See also Work; & ODG Capabilities & Activity Modifications for Restricted Work.

ODG Causality Likelihood. Based on the raw data, Causality Likelihood indicates the benchmark percentage of total lost workdays that are occupational in nature. This indicator may be used as an aid in evaluating causality, but any definitive determination requires detailed, case-specific analysis. See Preface for more information.

354.1 Other lesion of median nerve, Causality Likelihood: Zero

354.2 Lesion of ulnar nerve, Causality Likelihood: Under 5%

354.3 Lesion of radial nerve, Causality Likelihood: Under 5%

726.32 Lateral epicondylitis, Causality Likelihood: 6%

812 Fracture of humerus, Causality Likelihood: Under 5%

813 Fracture of radius and ulna, Causality Likelihood: Under 5%

832 Dislocation of elbow, Causality Likelihood: Under 5%

841 Sprains and strains of elbow and forearm, Causality Likelihood: Under 5%

881 Open wound of elbow, forearm, and wrist, Causality Likelihood: Under 5%

923 Contusion of upper limb, Causality Likelihood: Under 5%

927 Crushing injury of upper limb, Causality Likelihood: Under 5%

Chiropractic

See Manipulation.

Chronic pain programs

Recommended where there is access to programs with proven successful outcomes (i.e., decreased pain and medication use, improved function and return to work, decreased utilization of the health care system), for patients with conditions that have resulted in “Delayed recovery.” This study concluded that an interdisciplinary functional restoration program (FRP) is equally effective for patients with chronic upper extremity disorders, including the elbow, shoulder and wrist/hand, as for patients with lumbar spine disorders, regardless of the injury type, site in the upper extremity, or the disparity in injury-specific and psychosocial factors identified before treatment. (Howard, 2012) See the Chronic Pain Chapter for the specific ODG Criteria highlighted in blue, for the use of multidisciplinary pain management programs.

Coblation

See Radiofrequency epicondylitis treatment (Topaz procedure).

Cold packs

Recommended. Recommend at-home applications of cold packs during first few days; thereafter applications of either heat or cold packs to suit patient. (AHRQ, 2002) See also Heat packs.

Computed tomography (CT)

Recommended for indications below. While computed tomography (CT) and ultrasound (US) may be used for specific indications, magnetic resonance imaging should be used to display most abnormalities in the elbow. CT and CT arthrography with single-contrast (iodinated contrast or air) and double-contrast (iodinated contrast and air) techniques are superior to radiography for detecting a chondral or osteochondral lesion or Intra-articular Body (IAB). All of these studies have limitations; a small IAB may be obscured by contrast or confused with air bubbles (double-contrast arthrography). A CT air arthrogram can avoid confusion of air bubbles with IABs. CT is superior to radiography in the preoperative assessment of osteophytosis or heterotopic ossification in the patient with symptomatic stiff elbow. Primary bone tumors are characterized with radiography, CT, and MRI before and after intravenous gadolinium administration. The ulnar nerve is particularly vulnerable to trauma from a direct blow in the region of its superficial location in the restricted space of the cubital tunnel.  This diagnosis can be confirmed with MRI or CT using axial images with the elbow in flexion and extension. Initial evaluation of chronic elbow pain should begin with radiography. Chondral and osteochondral abnormalities can be further evaluated with MRI or CT. The addition of arthrography is helpful, especially for detecting intra-articular bodies. Radiographically occult bone abnormalities should be detected with MRI. Soft-tissue abnormalities (tendon, ligament, nerve, joint recess) are well demonstrated with MRI or US, but not CT. Dynamic assessment with US is effective for diagnosing nerve or muscle subluxation. (ACR, 2011)

Indications for imaging -- Computed tomography (CT) & CT arthrography:

- Suspect intra-articular osteocartilaginous body; radiographs nondiagnostic (CT elbow without contrast or CT arthrography elbow)

- Suspect unstable osteochondral injury; radiographs nondiagnostic (CT arthrography elbow)

- Elbow stiffness; suspect heterotopic ossification/osteophytosis by radiograph - Next test (CT elbow without contrast)

Corticosteroid injections

See Injections.

Decompression

See Surgery for cubital tunnel syndrome.

Deep transverse friction massage

Not recommended. Deep transverse friction massage (DTFM) combined with other physical therapy modalities did not show consistent benefit over the control of pain, or improvement of grip strength and functional status. (Brosseau-Cochrane, 2002) See also Massage.

Diathermy

Not recommended. Insufficient evidence exists to evaluate many physical modalities used to treat disorders of the elbow, often employed based on anecdotal or case reports alone. In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999)

Drug therapy

See Medications.

Dynamic extensor brace

See Brace.

Education

Recommended. Injured workers should receive instruction concerning the nature of their condition, risk factors, preventive measures, lifestyle changes and goals of therapy. They should be instructed in eliminating/modifying aggravating activities during treatment, educated in a home therapy routine, and informed of norms on disability duration (see ODG). (Denniston-ODG) (California, 1997) (Gabel, 1999) (Foley, 1993)

Elbow padding

See Splinting (padding).

Elbow extension test

Recommended for detecting elbow fracture. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. For detecting elbow fracture, the elbow extension test had sensitivity of 96.8% and specificity of 48.5%. (Appelboam, 2008)

Criteria for Elbow extension test

- Indications: Elbow trauma

- Technique: Patient asked to fully extend elbow

- Interpretation: Inability to extend elbow suggests need for Elbow XRay; Ability to fully extend elbow is reassuring that X-Ray not needed unless other indications

- Efficacy: Test Sensitivity: 96.8%; Test Specificity: 48.5%.

Electrical stimulation (E-STIM)

Not recommended. Despite the large number of studies, there is still insufficient evidence for most physiotherapy interventions for lateral epicondylitis due to contradicting results, insufficient power, and the low number of studies per intervention. (Smidt, 2003) (Bouter, 2000) In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999)

Epicondylitis supports

See Tennis elbow band.

Exercise

Recommended. Lateral epicondylitis and other disorders of the elbow can be treated conservatively with activity modification and exercise, including gentle muscle stretching, range-of-motion exercises, flexibility and graduated strengthening. As with any treatment, if there is no improvement after 2-3 weeks the protocol may be modified or re-evaluated. (Bisset, 2006) (Boisaubert, 2004) (Trudel, 2004) (Field, 1998) (California, 1997) (Pienimaki, 1998) (Solveborn, 1997) With regard to type of exercise, one trial concluded that stretching, concentric strengthening with stretching, and eccentric strengthening with stretching all show significant gains without significant differences with regard to pain-free grip strength, Patient-rated Forearm Evaluation Questionnaire, Disabilities of the Arm, Shoulder, and Hand questionnaire, Short Form 36, and visual analog pain scale. (Martinez, 2005) Only limited levels of evidence exist to suggest that eccentric exercise (EE) has a positive effect on clinical outcomes such as pain, function, and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound. More studies need to be conducted with regard to EE. (Woodley, 2006) Eccentric exercises with a simple wrist-extending rubber cylinder in a simple, home-based program could help alleviate pain for people with chronic lateral epicondylitis. The exercises involved twisting the cylinder with concentric wrist flexion of the noninvolved arm, and releasing the twist with eccentric wrist extension of the involved arm. The exercise was performed in 3 sets of 15 repetitions daily, and the intensity increased over the treatment period. The eccentric group had a significant improvement in the amount of disability, compared to the standard-treatment group, and there was also a significant decrease in pain, compared to the standard-treatment group. (Tyler, 2009)

Extracorporeal shockwave therapy (ESWT)

Not recommended. High energy ESWT is not supported, but low energy ESWT may show better outcomes without the need for anesthesia, but is still not recommended. Trials in this area have yielded conflicting results. The value, if any, of ESWT for lateral elbow pain, can presently be neither confirmed nor excluded. After other treatments have failed, some providers believe that shock-wave therapy may help some people with heel pain and tennis elbow. However, recent studies do not always support this, and ESWT cannot be recommended at this time for epicondylitis, although it has very few side effects. (Bisset, 2006) (Haake2, 2002) (Buchbinder-Cochrane, 2002) (Boddeker, 2000) (Ko, 2001) (Krischek, 1999) (Rompe, 2001) (Vogt, 2001) (Chung, 2002) (Wang, 2003) (Speed, 2002) (Crowther, 2002) (Blue Cross Blue Shield, 2003) (Chung, 2004) (Theis, 2004) (Stasinopoulos2, 2005) (Blue Cross/Blue Shield, 2005) (Bisset, 2005) The results from a recent double-blind study conclude that low-dose shock wave therapy without anesthetic is a safe and effective treatment for chronic lateral epicondylitis (Pettrone, 2005) while another high quality clinical trial concluded that high energy ESWT with anesthesia was ineffective in the treatment of lateral epicondylitis (Haake, 2002). Outcomes may be better in chronic cases (> 12 months) treated with low energy ESWT. (Rompe, 2004) It is not possible to draw firm conclusions concerning the effect of ESWT on tendinitis of the elbow from the conflicting data reported. This data parallels that for plantar fasciitis in that it is not known whether the different results are due to methodological bias or to differences in the population and intervention. (BlueCross BlueShield, 2004) Based upon systematic review of nine placebo-controlled trials involving 1006 participants, high-energy shock wave therapy provides little or no benefit in terms of pain and function in lateral elbow pain. There is evidence that steroid injection may be more effective than ESWT. (Buchbinder, 2005) (Buchbinder, 2006) A recent health technology review concluded that the lack of convincing evidence regarding its effectiveness does not support the use of ESWT for chronic lateral epicondylitis. (Ho, 2007) See also Radial shockwave therapy (RSWT). See also the Ankle & Foot Chapter, and the Shoulder Chapter.

Recent research: A recent double-blind, randomized, placebo-controlled trial to determine whether ultrasound-guided extracorporeal shock wave therapy (ESWT) reduced pain and improved function in patients with lateral epicondylitis (tennis elbow) in the short term and intermediate term found little evidence to support the use of ESWT. There were significant improvements in almost all outcome measures for both groups over the 6-month followup period, but there were no differences between the groups even after adjusting for duration of symptoms. (Staples, 2008)

Criteria for the use of Extracorporeal Shock Wave Therapy (ESWT):

If the decision is made to use this treatment despite the lack of convincing evidence.

(1) Patients whose pain from lateral epicondylitis (tennis elbow) has remained despite six months of standard treatment.

(2) At least three conservative treatments have been performed prior to use of ESWT. These would include: (a) Rest; (b) Ice; (c) NSAIDs; (d) Orthotics; (e) Physical Therapy; (e) Injections (Cortisone).

(3) Contraindicated in Pregnant women; Patients younger than 18 years of age; Patients with blood clotting diseases, infections, tumors, cervical compression, arthritis of the spine or arm, or nerve damage; Patients with cardiac pacemakers; Patients who had physical or occupational therapy within the past 4 weeks; Patients who received a local steroid injection within the past 6 weeks; Patients with bilateral pain; Patients who had previous surgery for the condition.

(4) Maximum of 3 therapy sessions over 3 weeks.

Fatty acid supplements

Not recommended. Essential fatty acids influence the production of prostaglandins, which is suggested to be of importance for the development of chronic degenerative changes in tendons. This clinical trial found that no effect on lateral epicondylitis was observed with a fatty acid supplement. (Roe, 2005)

Friction massage

Not recommended. Deep transverse friction massage (DTFM) combined with other physical therapy modalities did not show consistent benefit over the control of pain, or improvement of grip strength and functional status. (Brosseau-Cochrane, 2002) See also Massage.

Functional restoration programs (FRPs)

See Chronic pain programs.

Gravitational platelet gel suspension

See Platelet-rich plasma (PRP).

Growth factor injections

See Autologous blood injection; Platelet-rich plasma (PRP).

Gym memberships

Not recommended as a medical prescription unless a home exercise program has not been effective and there is a need for equipment. Plus, treatment needs to be monitored and administered by medical professionals. While an individual exercise program is of course recommended, more elaborate personal care where outcomes are not monitored by a health professional, such as gym memberships or advanced home exercise equipment, may not be covered under this guideline, although temporary transitional exercise programs may be appropriate for patients who need more supervision. See also the Low Back Chapter.

Heat packs

Recommended. Recommend at-home applications of cold packs during first few days; thereafter applications of either heat or cold packs to suit patient. (AHRQ, 2002) See also Cold packs.

Hivamat

Hivamat electrical stimulation is a sports injury modality used widely in Europe for muscle relaxation, edema control, and tissue healing. There are no published studies specific to Hivamat. See Electrical stimulation (E-STIM).

Home exercise

Recommended. See Exercise.

Hospital length of stay (LOS)

Recommend the median length of stay (LOS) based on type of surgery, or best practice target LOS for cases with no complications. For prospective management of cases, median is a better choice that mean (or average) because it represents the mid-point, at which half of the cases are less, and half are more. For retrospective benchmarking of a series of cases, mean may be a better choice because of the effect of outliers on the average length of stay. Length of stay is the number of nights the patient remained in the hospital for that stay, and a patient admitted and discharged on the same day would have a length of stay of zero. The total number of days is typically measured in multiples of a 24-hour day that a patient occupies a hospital bed, so a 23-hour admission would have a length of stay of zero. (HCUP, 2011)

ODG hospital length of stay (LOS) guidelines:

ORIF Broken Arm (icd 79.31 - Open reduction of fracture with internal fixation, humerus)

Actual data -- median 3 days; mean 4.1 (±0.1); discharges 34,549; charges (mean) $45,054

Best practice target (no complications) – 3 days

Closed Broken Arm, IF (icd 79.11 - Closed reduction of fracture with internal fixation, humerus)

Actual data -- median 1 day; mean 2.1 (±0.1); discharges 8,889; charges (mean) $21,028

Best practice target (no complications) – 1 day

Closed Broken Arm (icd 79.01 - Closed reduction of fracture without internal fixation, humerus)

Actual data -- median 3 days; mean 3.3 (±0.1); discharges 3,819; charges (mean) $22,862

Best practice target (no complications) – 3 days

Internal Fixation (icd 78.52 - Internal fixation of bone without fracture reduction, humerus)

Actual data -- median 3 days; mean 4.0 (±0.2); discharges 2,099; charges (mean) $39,642

Best practice target (no complications) – 3 days

Elbow Arthrotomy (icd 80.12 - Other arthrotomy, elbow)

Actual data -- median 4 days; mean 5.2 (±0.4); discharges 1,313; charges (mean) $33,000

Best practice target (no complications) – 4 days

Elbow Lesion (icd 80.82 - Other local excision or destruction of lesion of joint, elbow)

Actual data -- median 3 days; mean 5.5 (±0.5); discharges 1,280; charges (mean) $41,380

Best practice target (no complications) – 3 days

Total Elbow (icd 81.84 - Total elbow replacement)

Actual data -- median 2 days; mean 3.2 (±0.1); discharges 2,258; charges (mean) $50,339

Best practice target (no complications) – 2 days

Elbow Arthroplasty (icd 81.85 - Other repair of elbow)

Actual data – median 2 days; mean 3.0 (±0.2); discharges 1,091; charges (mean) $42,614

Best practice target (no complications) – 2 days

Revision of Arthroplasty (icd 81.97 - Revision of joint replacement of upper extremity)

Actual data -- median 2 days; mean 2.6 (±0.1); discharges 2,689; charges (mean) $49,121

Best practice target (no complications) – 2 days

Upper Arm Amputation (icd 84.07 - Amputation through humerus)

Actual data -- median 5 days; mean 9.1 (±1.6); discharges 311; charges (mean) $91,267

Best practice target (no complications) – 5 days

Humerus fracture surgery

See Open reduction internal fixation (ORIF). Most humerus (upper arm) fractures will heal without surgery. The majority of patients can be treated with a sling or brace, and with time the fracture will heal. Casting is not possible with most types of humerus fractures. Surgery may be required when the bone fragments are far out of position. Determining when the alignment is acceptable depends on a number of factors. Fractures close to the shoulder and elbow joints, especially fractures that extend into the joint, are more likely to require surgery. Conversely, fractures in the center of the shaft of the bone rarely require surgery; even with the bone fragments appear not perfectly aligned. The ODG Crosswalk UR Advisor® shows that for ICD9 diagnosis code 812 (Fracture of humerus), the CPT procedure codes 24515/6 (Treat humerus fracture - Open treatment of humeral shaft fracture with plate/screws) was done 4.22% of the time, with an average cost of $2,466.82, versus CPT procedure code 23600 (Treat humerus fracture - Closed treatment of proximal humeral surgical or anatomical neck fracture; without manipulation) was done 15.59% of the time, with an average cost of $477.93. (URA 812)

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Hyaluronic acid injections

See Viscosupplementation.

Hybresis

Hybresis is a drug delivery system that uses iontophoresis technology. There are no published studies specific to Hybresis. See Iontophoresis.

Ice packs

See Cold packs.

Imaging

See MRIs; Radiography; Ultrasound; & Computed tomography (CT).

Immobilization (treatment)

Not recommended as a primary treatment. Immobilization and rest appear to be overused as treatment. Early mobilization benefits include earlier return to work; decreased pain, swelling, and stiffness; and a greater preserved range of joint motion, with no increased complications. (Nash, 2004) (Liow, 2002) Early physical therapy, without immobilization, may be sufficient for some types of undisplaced fractures. It is unclear whether operative intervention, even for specific fracture types, will produce consistently better long-term outcomes. There was some evidence that 'immediate' physical therapy, without routine immobilization, compared with that delayed until after three weeks immobilization resulted in less pain and both faster and potentially better recovery in patients with undisplaced two-part fractures. Similarly, there was evidence that mobilization at one week instead of three weeks alleviated pain in the short term without compromising long-term outcome. (Handoll-Cochrane, 2003) (Handoll2-Cochrane, 2003)

Injections (corticosteroid)

Not recommended as a routine intervention for epicondylitis, based on recent research. In the past a single injection was suggested as a possibility for short-term pain relief in cases of severe pain from epicondylitis, but beneficial effects persist only for a short time, and the long-term outcome could be poor. (Boisaubert, 2004) The significant short-term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow. (Bisset, 2006) While there is some benefit in short-term relief of pain, patients requiring multiple corticosteriod injections to alleviate pain have a guarded prognosis for continued nonoperative management. Corticosteroid injection does not provide any long-term clinically significant improvement in the outcome of epicondylitis, and rehabilitation should be the first line of treatment in acute cases, but injections combined with work modification may have benefit. (Assendelft, 1996) (Bowen, 2001) (Reveille, 1997) (AHRQ, 2002) (Newcomer, 2001) (Smidt, 2002) (Stahl, 1997) (Crowther, 2002) (Smidt, 2005) A recent clinical trial of treatments for epicondylitis found that, after 12 months, the success rate for physical therapy (91%) was significantly higher than injection (69%), but only slightly higher than in the wait-and-see group (83%). (Korthals-de Bos, 2004) According to another study, botulinum toxin injection may improve pain over a three-month period in some patients with lateral epicondylitis, but injections may be associated with digit paresis and weakness of finger extension. (Wong, 2005) Steroid injection was associated with an increase in reported pain for the first 24 hours of treatment, but the therapeutic benefits compared with naproxen and placebo were evident 3 to 4 days after the start of treatment. (Lewis, 2005) On the basis of the results of this study, the study authors advocate steroid injection alone as the first line of treatment for patients presenting with tennis elbow demanding a quick return to daily activities. (Tonks, 2007)

Recent research: In this RCT, corticosteroid injection did not affect the apparently self-limited course of lateral elbow pain. One month after injection, DASH (Disabilities of the Arm, Shoulder, and Hand questionnaire) scores averaged 24 versus 27 points (dexamethasone vs placebo), pain 3.7 versus 4.3 cm, and grip strength 83% versus 87%. At 6 months, DASH scores averaged 18 versus 13 points, pain 2.4 versus 1.7 cm, and grip strength 98% versus 97%. In secondary analyses in a subset of patients, perceived disability associated with lateral elbow pain correlated with depression and ineffective coping skills. (Lindenhovius, 2008) In the short-term (< 6 weeks), corticosteroid injection helps relieve symptoms from lateral epicondylitis. After 6 weeks, however, physical therapy is superior to steroid injection for symptom relief (level of evidence, A). Lateral epicondylitis (tennis elbow) can be treated in the short-term (< 6 weeks) with corticosteroid injection, with better improvement vs nonsteroidal anti-inflammatory drugs. After 6 weeks, physical therapy is more efficacious in reducing symptoms vs corticosteroid injection. During initial physical rehabilitation, corticosteroid injections can help control pain from lateral epicondylitis. (Stephens, 2008) Long-term use of corticosteroid injections for tendinopathy may be harmful, according to the results of a systematic review of randomized controlled trials reported in The Lancet. There was moderate evidence of harmful effects of repeated corticosteroid injection on pain, but the optimal number of doses and interval between injections are not known. The authors urged patients and practitioners to consider results of corticosteroid treatment that might not be defined as adverse, including negative long-term outcomes and high recurrence rates. The evidence for specific exercise therapy is more encouraging than the evidence for corticosteroid injection, and exercise therapy is likely to promote protein synthesis via cell signalling. Specific exercise therapy might produce more cures at 6 and 12 months than one or more corticosteroid injections. (Coombes, 2010) An RCT comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis found that the iontophoresis patients had statistically significant improvement in grip strength, and they were also more likely to get back to work without restriction. However, by six-month follow-up, all groups had equivalent results for all measured outcomes. (Stefanou, 2012) This RCT found that patients treated with a single corticosteroid injection had a 14% greater chance of poor outcome and a 77% increased risk for reinjury at 1 year relative to placebo. Physical therapy did improve short-term pain and disability outcomes, although those benefits were lost when steroid injection was added to the treatment. Lateral epicondylitis is not an inflammatory condition, and steroid shots work best when inflammation is the problem, and even then they usually provide only temporary relief at best. Use of steroid injections to treat tennis elbow has been increasingly discouraged because of lack of long-term efficacy data and high recurrence rates. (Coombes, 2013) See also Iontophoresis; Hyaluronic acid injections; Viscosupplementation; Prolotherapy; Autologous blood injection; Platelet-rich plasma (PRP); & Botulinum toxin injection.

Injection of bursa

See Injections.

Iontophoresis

Recommended as a conservative option if there is evidence of objective functional improvement after trial use. Limited evidence suggests that iontophoresis treatment was well tolerated by most patients and was effective in reducing symptoms of epicondylitis at short-term follow-up, but little difference was noted long-term. (Nirschl, 2003) (Baskurt, 2003) (Runeson, 2002) (Demirtas, 1998) Some evidence suggests that iontophoresis and phonophoresis may show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis but more studies need to be conducted. (Trudel, 2004) Some group health insurers have concluded that use of iontophoresis for treatment of inflammatory musculoskeletal disorders is experimental and investigational because of insufficient evidence of its effectiveness. (Aetna, 2006) An RCT comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis found that the iontophoresis patients had statistically significant improvement in grip strength, and they were also more likely to get back to work without restriction. However, by six-month follow-up, all groups had equivalent results for all measured outcomes. (Stefanou, 2012) Iontophoresis is a method of transdermal local drug delivery using electrical current. A charged, ionic drug is placed on the skin using an electrode of the same charge, allowing direct current to drive the drug into the skin. Iontophoresis may take advantage of sweat ducts, sebaceous glands, hair follicles, and imperfections in the skin to achieve penetration. In the treatment of musculoskeletal disorders, iontophoresis is often offered in the physical medicine and rehabilitation setting.

Laser treatment (LLLT)

Recommended as an option for lateral epicondylitis using a narrowly defined LLLT regimen where lasers of 904 nm wavelength with low output (5–50 mW) are used to irradiate the tendon insertion at the lateral elbow using 2–6 points or an area of 5 cm2 and doses of 0.25–1.2 Joules per point/area. Not recommended using wavelengths of 820, 830 or 1064 nm, or higher doses or higher power, or using irradiation of trigger points or irradiation of acupuncture points. The available material suggests that LLLT is safe and effective, and that LLLT acts in a dose-dependent manner by biological mechanisms that modulate both tendon inflammation and tendon repair processes. With the recent discovery that long-term prognosis is significantly worse for corticosteroid injections than placebo in lateral epicondylitis, LLLT irradiation with 904 nm wavelength aimed at the tendon insertion at the lateral elbow is emerging as a safe and effective alternative to corticosteroid injections and NSAIDs. LLLT also seems to work well when added to exercise and stretching regimens. There is a need for future trials to compare adjunctive pain treatments such as LLLT with commonly used pharmacological agents. A recent meta-analysys concluded that low level level laser therapy (LLLT) administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in lateral elbow tendinopathy (LET), both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews that failed to assess treatment procedures, wavelengths and optimal doses. (Bjordal, 2008) Before this study, there was good evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of lateral epicondylitis. (Trudel, 2004) (AHRQ, 2002) (Basford, 2000) (Simunovic, 1998) Only limitied evidence was shown for treatment of lateral elbow tendinopathy. (Smidt, 2003) (Stasinopoulos, 2005) Some limited results suggested that polarized, polychromatic, non-coherent, low energy light (Bioptron) could reduce patients' symptoms with acute tennis elbow; future controlled studies are needed to establish its relative effectiveness. (Stasinopoulos, 2005)

Light therapy

See Laser treatment.

Magnets

Not recommended. Static magnetic fields are no more effective than placebo in treating elbow muscle soreness. (Reeser, 2005)

Manipulation

Recommended only on a short-term limited basis as indicated below. Insufficient evidence exists to evaluate many physical modalities, including manipulation, used to treat disorders of the elbow, often employed based on anecdotal or case reports alone. In general, if approved on a limited basis, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards pain reduction VAS greater than 4 change and returning to regular work is demonstrated. (Bisset, 2006) (Boisaubert, 2004) According to one retrospective review, most lateral epicondylitis patients had successful outcomes regardless of the inclusion of manual therapy interventions to the cervical spine. The Local Management + Manipulation group achieved the successful long-term outcome in significantly fewer visits. (Cleland, 2004) (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999) (Geldschlager, 2004) A recent small study concluded that manipulation of the wrist appeared to be more effective than ultrasound, friction massage, and muscle stretching and strengthening exercises for the management of lateral epicondylitis when there was a short-term follow-up. However, replication of these results is needed in a large-scale randomized clinical trial with a control group and a longer-term follow-up. (Struijs, 2003) This review determined, with good evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, and ionization with diclofenac all show positive short term effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. (Trudel, 2004) See also Manipulation under anesthesia (MUA), a different procedure.

ODG Chiropractic Guidelines – Elbow:
Up to 3 visits contingent on objective improvement documented (ie. VAS improvement greater than 4).

Further trial visits up to 3 more contingent on further objectification of long-term resolution of symptoms, plus active self-directed home therapy.

Manipulation under anesthesia (MUA)

Not recommended. No quality studies. In case series outcomes for stiff elbow may be no better than the natural history of the condition. (Duke, 1991)

Mason classification of fractures

Definition: The Mason classification of fractures is as follows: Type I - Nondisplaced; Type II - Marginal with displacement; Type III - Comminuted; & Type IV - With elbow dislocation.

Massage

Under study. Insufficient evidence exists to evaluate many physical modalities used to treat disorders of the elbow, often employed based on anecdotal or case reports alone. In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999) Deep transverse friction massage (DTFM) combined with other physical therapy modalities did not show consistent benefit over the control of pain, or improvement of grip strength and functional status. (Brosseau-Cochrane, 2002) For the long term in treating tennis elbow, one meta-analysis determined that physiotherapy (pulsed ultrasound, deep friction massage and exercise program) was the best option but was not significantly different from the "wait-and-see" approach. (Boisaubert, 2004)

Medications

For detailed information see the Pain Chapter of ODG Treatment. In this Elbow Chapter, these listings may also be relevant: Acetaminophen; Aspirin; Autologous blood injection; Botulinum toxin injection; Corticosteroid injections; Fatty acid supplements; Gravitational platelet gel suspension; Injections; Injection of bursa; Nonprescription medications; NSAIDs; Opioids; Oral NSAIDs; Platelet-rich plasma (PRP); Steroid injection therapy; Topical NSAIDs.

Microtenotomy

See Radiofrequency epicondylitis treatment (Topaz procedure).

Mobilization

See Massage & Manipulation.

MRI’s

Recommended as indicated below. Magnetic resonance imaging may provide important diagnostic information for evaluating the adult elbow in many different conditions, including: collateral ligament injury, epicondylitis, injury to the biceps and triceps tendons, abnormality of the ulnar, radial, or median nerve, and for masses about the elbow joint. There is a lack of studies showing the sensitivity and specificity of MR in many of these entities; most of the studies demonstrate MR findings in patients either known or highly likely to have a specific condition. Epicondylitis (lateral - "tennis elbow" or medial - in pitchers, golfers, and tennis players) is a common clinical diagnosis, and MRI is usually not necessary. Magnetic resonance may be useful for confirmation of the diagnosis in refractory cases and to exclude associated tendon and ligament tear. (ACR, 2001) See also ACR Appropriateness Criteria

Indications for imaging -- Magnetic resonance imaging (MRI):

- Chronic elbow pain, suspect intra-articular osteocartilaginous body; plain films nondiagnostic

- Chronic elbow pain, suspect occult injury; e.g., osteochondral injury; plain films - nondiagnostic

- Chronic elbow pain, suspect unstable osteochondral injury; plain films nondiagnostic

- Chronic elbow pain, suspect nerve entrapment or mass; plain films nondiagnostic

- Chronic elbow pain, suspect chronic epicondylitis; plain films nondiagnostic

- Chronic elbow pain, suspect collateral ligament tear; plain films nondiagnostic

- Chronic elbow pain, suspect biceps tendon tear and/or bursitis; plain films nondiagnostic

- Repeat MRI is not routinely recommended, and should be reserved for a significant change in symptoms and/or findings suggestive of significant pathology. (Mays, 2008)

Nonprescription medications

Recommended for early use only. Acetaminophen (safest), or NSAIDs (aspirin, ibuprofen). There is fair to good evidence that NSAIDs are effective for reducing pain in patients with acute musculoskeltal problems, and there is evidence that acetaminophen is comparable in efficacy to NSAIDs and with fewer side effects. (Piligian, 2000) (Green-Cochrane, 2002) (Reveille, 1997) See also NSAIDs.

NSAIDs

Recommended for short-term pain relief. Nonprescription medications (acetaminophen, NSAIDs, aspirin) will provide sufficient pain relief for most acute and subacute disorders of the elbow. (Piligian, 2000) (Green-Cochrane, 2002) (Reveille, 1997) See also Topical NSAIDs; & Nonprescription medications. For more information see the Pain Chapter, specifically NSAIDs (non-steroidal anti-inflammatory drugs) and NSAIDs, GI symptoms & cardiovascular risk.

Office visits

Recommended as determined to be medically necessary. Evaluation and management (E&M) outpatient visits to the offices of medical doctor(s) play a critical role in the proper diagnosis and return to function of an injured worker, and they should be encouraged. The need for a clinical office visit with a health care provider is individualized based upon a review of the patient concerns, signs and symptoms, clinical stability, and reasonable physician judgment. The determination is also based on what medications the patient is taking, since some medicines such as opiates, or medicines such as certain antibiotics, require close monitoring. As patient conditions are extremely varied, a set number of office visits per condition cannot be reasonably established. The determination of necessity for an office visit requires individualized case review and assessment, being ever mindful that the best patient outcomes are achieved with eventual patient independence from the health care system through self care as soon as clinically feasible. The ODG Codes for Automated Approval (CAA), designed to automate claims management decision-making, indicates the number of E&M office visits (codes 99201-99285) reflecting the typical number of E&M encounters for a diagnosis, but this is not intended to limit or cap the number of E&M encounters that are medically necessary for a particular patient. Office visits that exceed the number of office visits listed in the CAA may serve as a “flag” to payors for possible evaluation, however, payors should not automatically deny payment for these if preauthorization has not been obtained. Note: The high quality medical studies required for treatment guidelines such as ODG provides guidance about specific treatments and diagnostic procedures, but not about the recommended number of E&M office visits. Studies have and are being conducted as to the value of “virtual visits” compared with inpatient visits, however the value of patient/doctor interventions has not been questioned. (Dixon, 2008) (Wallace, 2004) Further, ODG does provide guidance for therapeutic office visits not included among the E&M codes, for example Chiropractic manipulation and Physical/Occupational therapy.

Open reduction internal fixation (ORIF)

Recommended as an option for fractures when radiographic evidence indicates a displaced fracture or comminuted fracture, or an open fracture with bone protrusion. Open reduction internal fixation (ORIF) is a method of surgically repairing a fractured bone, in which surgery is used to reduce or set the fracture fragments and then hardware (such as a rod, plate and/or screws) is then implanted to hold the reduction in place. (Lange, 2007)

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Opioids

Not recommended except for short use for severe cases, not to exceed 2 weeks. See the Pain Chapter for the results of relevant studies, under Opioids (with links to multiple topics on opioids).

Oral NSAIDs

See NSAIDs.

Orthotic devices

See Splinting.

Pad, elbow

See Splinting (padding).

Patient education

See Education.

Pharmaceuticals

See Medications.

Phonophoresis

Not recommended. The use of phonophoresis is considered experimental and investigational for any indications. Phonophoresis has been used to enhance the absorption of analgesics and anti-inflammatory agents. Controlled clinical trials, however, have failed to demonstrate that phonophoresis increases the rate or extent of absorption of these agents. (Aetna2, 2006) Insufficient evidence exists to evaluate many physical modalities used to treat disorders of the elbow, often employed based on anecdotal or case reports alone. In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999) Some evidence suggests that iontophoresis and phonophoresis may show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis but more studies need to be conducted. (Baskurt, 2003) (Trudel, 2004) Phonophoresis is the use of ultrasound to enhance the delivery of topically applied drugs.

Physical therapy

Recommended. Limited evidence. As with any treatment, if there is no improvement after 2-3 weeks the protocol may be modified or re-evaluated. See also specific physical therapy modalities by name. (Piligian, 2000) (Handoll-Cochrane, 2003) (Boisaubert, 2004) (Boyer, 1999) (Sevier, 1999) (Foley, 1993) (Struijs, 2004) (Smidt, 2005) (Smidt, 2003) (Lund, 2006) Women and patients who report nerve symptoms are more likely to experience a poorer short-term outcome after PT management of lateral epicondylitis. Work-related onsets, repetitive keyboarding jobs, and cervical joint signs have a prognostic influence on women. (Waugh, 2004) A recent clinical trial found that, after 12 months, the success rate for physical therapy (91%) was significantly higher than injection (69%), but only slightly higher than in the wait-and-see group (83%). (Korthals-de Bos, 2004) This RCT found that physical therapy for epicondylitis did improve short-term pain and disability outcomes, but those benefits were lost when steroid injection was added to the treatment. Physical therapy alone for tennis elbow provided benefit both to help the patient through the acute phase of the injury and to provide the patient with exercises/knowledge to prevent reinjury in the future. (Coombes, 2013)

ODG Physical Therapy Guidelines –

General: Up to 3 visits contingent on objective improvement documented (ie. VAS improvement of greater than 4). Further trial visits with fading frequency up to 6 contingent on further objectification of longterm resolution of symptoms, plus active self-directed home PT. Also see other general guidelines that apply to all conditions under Physical Therapy in the ODG Preface.
Sprains and strains of elbow and forearm (ICD9 841):

Medical treatment: 9 visits over 8 weeks

Post-surgical treatment/ligament repair: 24 visits over 16 weeks

Lateral epicondylitis/Tennis elbow (ICD9 726.32):

Medical treatment: 8 visits over 5 weeks

Post-surgical treatment: 12 visits over 12 weeks

Medial epicondylitis/Golfers' elbow (ICD9 726.31):

Medical treatment: 8 visits over 5 weeks

Post-surgical treatment: 12 visits over 12 weeks

Enthesopathy of elbow region (ICD9 726.3):

Medical treatment: 8 visits over 5 weeks

Post-surgical treatment: 12 visits over 12 weeks

Ulnar nerve entrapment/Cubital tunnel syndrome (ICD9 354.2):
Medical treatment: 14 visits over 6 weeks
Post-surgical treatment: 20 visits over 10 weeks

Olecranon bursitis (ICD9 726.33):
Medical treatment: 8 visits over 4 weeks

Dislocation of elbow (ICD9 832):

Stable dislocation: 6 visits over 2 weeks

Unstable dislocation, post-surgical treatment: 10 visits over 9 weeks

Fracture of radius/ulna (ICD9 813):

Post-surgical treatment: 16 visits over 8 weeks

Fracture of humerus (ICD9 812):

Medical treatment: 18 visits over 12 weeks

Post-surgical treatment: 24 visits over 14 weeks

Ill-defined fractures of upper limb (ICD9 818):

8 visits over 10 weeks

Arthropathy, unspecified (ICD9 716.9):

Post-surgical treatment, arthroplasty, elbow: 24 visits over 8 weeks

Rupture of biceps tendon (ICD9 727.62):

Post-surgical treatment: 24 visits over 16 weeks

Traumatic amputation of arm (ICD9 887):

Post-replantation surgery: 48 visits over 26 weeks

Platelet-rich plasma (PRP)

Recommend single injection as a second-line therapy for chronic lateral epicondylitis after first-line physical therapy such as eccentric loading, stretching and strengthening exercises, based on recent research below. This small pilot study found that 15 patients with chronic elbow tendinosis treated with buffered platelet-rich plasma (PRP) showed an 81% improvement in their visual analog pain scores after six months, and concluded that PRP should be considered before surgical intervention. Further evaluation of this novel treatment is warranted. (Mishra, 2006) This review concluded that there is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of lateral epicondylosis (LE). Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies. (Rabago, 2009) Using a Gravitational platelet separation system, whole blood can yield platelet-rich plasma. Specially prepared platelets taken from the patient are then re-injected into the tendon of the affected elbow. Platelet-rich plasma contains powerful growth factors that initiate healing in the tendon, but may also send signals to other cells in the body drawing them to the injured area to help in repair. Treatment with PRP is still considered investigational and further research is needed before it can be made available to the general population. According to the author, "The body has an extraordinary ability to heal itself. All we did was speed the process by taking blood from a different area, concentrating it, and putting it back into an area where there was relatively poor blood supply to help repair the damage." Early studies have shown PRP therapy may be useful in maxillofacial surgery, wound healing, microfracture repair, and in the treatment of plantar faciitis. PRP looks promising, but it is not yet ready for prime time. PRP has become popular among professional athletes because it promises to enhance performance, but there is no science behind it yet. PRP was better than corticosteroid injections in relieving pain and improving function in patients with chronic severe lateral epicondylitis, but the study concluded that PRP should be reserved for the most severe cases since 80% of tennis elbows will be cured spontaneously without doing anything within a year. (AAOS, 2010)

Recent research: This RCT showed that 49% of patients in the corticosteroid group while 73% of patients in the PRP group were successful. The corticosteroid group was better initially and then declined, whereas the PRP group progressively improved. The authors concluded that treatment of patients with chronic lateral epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection. (Peerbooms, 2010) These benefits persisted even after a follow-up of 2 years. (Gosens, 2011) This RCT found success with both autologous blood and PRP, but PRP was superior to autologous blood in the short term. (Thanasas, 2011) At 6 months the authors observed a 66% success rate in the platelet-rich plasma (PRP) injections group versus 72% in the autologous blood injections (ABI) group, but there was a higher rate of conversion to surgery in the ABI group (20%) versus the PRP group (10%). In patients who are resistant to first-line physical therapy such as eccentric loading, ABI or PRP injections are useful second-line therapies to improve clinical outcomes. In this study, up to seven out of 10 additional patients in this difficult to treat cohort benefit from these surgery-sparing interventions. (Creaney, 2011) (Bisset, 2011) According to this short-term RCT, neither steroids nor platelet-rich plasma injections are any better than injections of inactive salt water for treating tennis elbow. After one month, pain had dropped by almost 10 points on a 50-point scale among people who'd had steroid injections, compared to less than two points for the PRP and saline groups. Elbow function had also improved significantly more for people injected with steroids. However, at three months, any extra benefit due to steroids had disappeared and pain and functioning were similar across all three groups. The study did not follow patients for enough time to see the long-term effects of platelets. In other studies, PRP patients continue to improve, and the glucocorticoid patients revert back to normal, as steroids only provide short-term relief and may actually damage the tendon further with repeat injections. For people who have had tendon problems for weeks rather than months or years, watchful waiting might be the most appropriate treatment, since after a year, 80% of people with tennis elbow will be cured. (Krogh, 2013) See also Autologous blood injection.

Prolotherapy

Recommend single injection as an option for short-term pain relief in cases of severe pain from epicondylitis. Outcomes are no better than corticosteroid injection, which is weakly recommended, and exercise should be the first line of treatment in acute cases, but injections combined with work modification may have some short-term benefit. There has been limited evidence, although promising. In this small RCT, prolotherapy with dextrose and sodium morrhuate was well tolerated, effectively decreased elbow pain, and improved strength testing in subjects with refractory lateral epicondylosis compared to control group injections. (Scarpone, 2008) This review concluded that there is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of lateral epicondylosis (LE). Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies. (Rabago, 2009) In this RCT, both prolotherapy and corticosteroid therapy were generally well tolerated and appeared to provide equal benefit for the treatment of chronic lateral epicondylosis. (Carayannopoulos, 2011) By comparison with placebo, reductions in pain were reported after injections of prolotherapy for treatment of lateral epicondylalgia, but prolotherapy was not more effective than eccentric exercise. (Coombes, 2010)

Pulsed electromagnetic field therapy

Not recommended. There is good evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of epicondylitis. (Trudel, 2004) This RCT found that pulsed electromagnetic field therapy (PEMF) seems to reduce lateral epicondylitis pain better than sham PEMF, but not as well as corticosteroid and anesthetic agent injections. (Uzunca, 2007)

Radial head fracture surgery

Recommended for level III and IV fractures. Under study for level II, and not recommended for level I. Radial head fractures are common elbow fractures. The Mason classification is used to describe the fracture. For nondisplaced fractures (level I), a sling may be all that is necessary, and symptomatic treatment and splinting followed by early range of motion also appear to produce uniformly good results. A systematic review compared the results of conservative treatment with different surgical strategies for radial head fractures. For Mason type II fractures, residual pain was present in 42% of the conservatively treated patients compared to 32% of the surgically treated patients. Good/excellent results for Broberg score were 52 and 88%, respectively. For Mason type III and IV fractures, no conservatively treated patients were described. (Thompson, 1988) (Bano, 2006) (Struijs, 2007) Radial head fractures are common injuries, occurring in about 20 percent of all acute elbow injuries, usually caused by a fall breaking the smaller bone (radius) in the forearm. (AAOS, 2001) In acute trauma, a radial head fracture not suitable for internal fixation without (Mason grade III) and with (Mason grade IV) concomitant destabilizing injury, Essex-Lopresti injury, sequelae following radial head resection (e.g., elbow instability or wrist pain), failed reconstruction of the radial head, and tumor-associated radial head or neck resection, radial head arthroplasty is recommended as a treatment of non-reconstructable, comminuted fractures of the radial head in order to achieve elbow stability and to prevent secondary complications, such as valgus elbow instability and radius proximalization. (Müller, 2011)

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Radial shockwave therapy (RSWT)

Under study. Radial shockwave therapy (RSWT) differs from extracorporeal shockwave therapy (ESWT) in that it delivers low-energy shockwaves directly to the skin, not through the skin and directly to the injured tissues. A recent trial found that use of RSWT allowed a decrease of pain, and functional impairment, and an increase of the pain-free grip strength test, in patients with tennis elbow. (Spacca, 2005) More studies are needed. See also Extracorporeal shockwave therapy (ESWT).

Radiofrequency epicondylitis treatment (Topaz procedure)

Not recommended. Radiofrequency coblation devices (e.g., Topaz Microdebrider) are experimental and investigational for the treatment of musculoskeletal conditions because their effectiveness for these conditions has not been established. There was one small, short-term, non-randomized study; its findings need to be validated by future prospective randomized studies with large sample sizes and longer follow-up. In addition, evidence is needed about the effectiveness of this approach compared to established methods of management of these musculoskeletal conditions. (Aetna, 2008) (Tasto, 2005)

Radiography (x-rays)

Recommended as indicated below. Radiographs are required before other imaging studies and may be diagnostic for osteochondral fracture, osteochondritis dissecans, and osteocartilaginous intra-articular body. (ACR, 2001) Those patients with normal extension, flexion and supination do not require emergent elbow radiographs. (Lennon, 2007) See also ACR Appropriateness Criteria™.

Return to work

Recommended, with modification if necessary. Patients recovering from acute and subacute disorders of the elbow are encouraged to return to modified or full duty as soon as the condition permits. See ODG for expected disability durations. (Denniston-ODG) (Boyer, 1999) Some things to watch out for include: Poor prognosis at one year of follow-up for lateral epicondylitis was related to manual work and high baseline pain, while no relation was found between the type of medical treatment given/chosen and prognosis. Management of lateral epicondylitis requires a greater focus on interaction with the workplace regarding job modification to reduce physical demands during recovery. (Haahr, 2003)  Tennis elbow is associated with non-neutral postures of hands and arms, use of heavy hand held tools, and high physical strain measured as a combination of forceful work, non-neutral posture of hands and arms, and repetition. Furthermore, tennis elbow among women was associated with low social support at work. The results for precision demanding movements and for vibration were less consistent. (Haahr2, 2003) Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. For detecting elbow fracture, the elbow extension test had sensitivity of 96.8% and specificity of 48.5%. (Appelboam, 2008)

Shockwave therapy

See Extracorporeal shockwave therapy (ESWT) and Radial shockwave therapy (RSWT).

Simple decompression

See Surgery for cubital tunnel syndrome.

Soft tissue mobilization

Under study. Insufficient evidence exists to evaluate many physical modalities used to treat disorders of the elbow, often employed based on anecdotal or case reports alone. In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999)

Splinting (padding)

Recommended for cubital tunnel syndrome (ulnar nerve entrapment), including a splint or foam elbow pad worn at night (to limit movement and reduce irritation), and/or an elbow pad (to protect against chronic irritation from hard surfaces). (Apfel, 2006) (Hong, 1996) Under study for epicondylitis. No definitive conclusions can be drawn concerning effectiveness of standard braces or splints for lateral epicondylitis. (Borkholder, 2004) (Derebery, 2005) (Van De Streek, 2004) (Jensen, 2001) (Struijs, 2001) (Jansen, 1997) If used, bracing or splitting is recommended only as short-term initial treatment for lateral epicondylitis in combination with physical therapy. (Struijs, 2004) (Struijs, 2006) Some positive results have been seen with the development of a new dynamic extensor brace but more trials need to be conducted. Initial results show significant pain reduction, improved functionality of the arm, and improvement in pain-free grip strength. The beneficial effects of the dynamic extensor brace observed after 12 weeks were significantly different from the treatment group that received no brace. The beneficial effects were sustained for another 12 weeks. (Faes, 2006) (Faes2, 2006) Static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate, particularly after the original injury. Operative treatment of stiffness was avoided in most patients. (Doornberg, 2006) These results differ from studies testing standard bracing which showed little to no effect on pain. (Wuori, 1998) (AHRQ, 2002) (Gabel, 1999) See also Static progressive stretch therapy and Tennis elbow band.

Static progressive stretch (SPS) therapy

Recommended as indicated below. Static progressive stretch (SPS) therapy uses mechanical devices for joint stiffness and contracture to be worn across a stiff or contractured joint and provide incremented tension in order to increase range of motion. (Bonutti, 1994) (Stasinopoulos, 2005) (Doornberg, 2006) (BlueCross BlueShield, 2003)

Criteria for the use of static progressive stretch (SPS) therapy:

A mechanical device for joint stiffness or contracture may be considered appropriate for up to eight weeks when used for one of the following conditions:

1. Joint stiffness caused by immobilization

2. Established contractures when passive ROM is restricted

3. Healing soft tissue that can benefit from constant low-intensity tension

Steroid injection therapy

See Injections.

Stretching

Recommended. Lateral epicondylitis and other disorders of the elbow can be treated conservatively with activity modification and exercise, including gentle muscle stretching, range-of-motion exercises, flexibility and graduated strengthening. As with any treatment, if there is no improvement after 2-3 weeks the protocol may be modified or re-evaluated. (Field, 1998) (California, 1997) (Pienimaki, 1998) (Solveborn, 1997) See also Physical therapy, Exercise and Static progressive stretch therapy.

Supports, tennis elbow

See Tennis elbow band.

Surgery

See more specific procedure. The following are choices: Radial head fracture surgery; Surgery for cubital tunnel syndrome (ulnar nerve entrapment); Surgery for epicondylitis; Surgery for olecranon bursitis; Surgery for pronator syndrome; Surgery for radial head fracture; Surgery for radial tunnel syndrome (lesion of radial nerve); Total elbow replacement (TER); Open reduction internal fixation (ORIF); Humerus fracture surgery; Surgery for ruptured biceps tendon (at the elbow); & Triceps tendon repair.

Surgery for cubital tunnel syndrome (ulnar nerve entrapment)

Recommended as indicated below (simple decompression in most cases). Surgical transposition of the ulnar nerve is not recommended unless the ulnar nerve subluxes on ROM of the elbow. Surgery for ulnar neuropathy at the elbow is effective at least two-thirds of the time. The outcomes of simple decompression (SD) and anterior subcutaneous transposition (AST) are equivalent, except for the complication rate, which is 31% in AST. Because the intervention is simpler and associated with fewer complications, SD is generally advised. (Bartels, 2005) (Asamoto, 2005) (Lund, 2006) (Nabhan, 2007) Although clinically equally effective, simple decompression was associated with lower cost than anterior subcutaneous transposition for the treatment of ulnar neuropathy at the elbow. The main difference was in the costs related to sick leave, which is significantly shorter for simple decompression. (Bartels2, 2005) (Nabhan, 2005) Simple decompression may offer excellent intermediate and long-term relief of symptoms. Less complete relief of symptoms following ulnar nerve decompression may be related to unrecognized carpal tunnel syndrome or weight gain. (Nathan, 2005) Medial epicondylectomy for persons with cubital tunnel syndrome was superior to anterior transposition in relieving pain and in improving global outcome scores. Patients whose cubital tunnel syndrome is caused by an acute trauma have better outcomes after surgical treatment than patients with cubital tunnel syndrome from other causes. (AHRQ, 2002) Partial medial epicondylectomy seems to be safe and reliable for treatment of cubital compression neuropathy at the elbow. (Efstathopoulos, 2006) One study reviewed the results of two surgical methods for treating cubital tunnel syndrome. From 1994 to 2001, minimal medial epicondylectomy was performed on 22 elbows, and anterior subcutaneous transposition of the ulnar nerve was done on 34 elbows. In the group treated by medial epicondylectomy, 9 of the results (41%) were excellent, 10 (45%) were good, 2 (9%) were fair, and 1 result (5%) was poor. In the group treated by anterior subcutaneous transposition of ulnar nerve, 14 of the results (41%) were excellent, 13 (38%) were good, 6 (18%) were fair, and 1 result (3%) was poor. No significant difference was found between the 2 groups (P < .05). (Baek, 2005) (Greenwald, 2006) Age at surgery, duration of cubital tunnel syndrome, preoperative severity, and clinical symptom score and motor nerve conduction velocity in the early postoperative stage (one month after surgery) were found to be important prognostic factors of the syndrome. (Yamamoto, 2006)

Simple decompression vs anterior transposition: Transposition may only be required if the ulnar nerve subluxes on ROM of the elbow. Otherwise simple decompression is recommended. (Heithoff, 1999) (Posner, 1998) (Bartels, 2005) (Elhassan, 2007) Irrespective of the surgical method, roughly 90% of patients are satisfied with surgical treatment of the ulnar nerve entrapment. However, one specific group of patients (people with habitual ulnar luxation or subluxation of the ulnar nerve) experienced a distinctly better result when treated by anterior transposition than by simple decompression, so simple decompression of the ulnar nerve can be recommended in all patients without cubital (sub)luxation of the nerve, whereas people with a tendency of cubital (sub)luxation of the ulnar nerve should be treated by submuscular anterior transposition. (Bimmler, 1996) In this study, both simple decompression and anterior transposition resulted in improvement in over 80% of cases, but a higher percentage of full recovery was seen in the cases treated by simple decompression. (Chan, 1980) The results of simple decompression of the ulnar nerve are similar to transposition, so the former simpler method is recommended as the standard procedure. (Lugnegård, 1982) The advantages of simple decompression make it the procedure of choice for most cases of ulnar neuropathy. (Nathan, 1992) The simpler procedure of neurolysis in situ is the treatment of choice, but submuscular transposition remains appropriate in certain circumstances. (Biggs, 2006)

ODG Indications for Surgery -- Surgery for cubital tunnel syndrome: Initial conservative treatment, requiring ALL of the following:

- Exercise: Strengthening the elbow flexors/extensors isometrically and isotonically within 0-45 degrees

- Activity modification: Recommend decreasing activities of repetition that may exacerbate the patient's symptoms. Protect the ulnar nerve from prolonged elbow flexion during sleep, and protect the nerve during the day by avoiding direct pressure or trauma.

- Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) in an attempt to decrease inflammation around the nerve.

- Pad/splint: Use an elbow pad and/or night splinting for a 3-month trial period. Consider daytime immobilization for 3 weeks if symptoms do not improve with splinting. If the symptoms do improve, continue conservative treatment for at least 6 weeks beyond the resolution of symptoms to prevent recurrence.

Surgery for epicondylitis

Under study. Almost all patients respond to conservative measures and do not require surgical intervention. Treatment involves rest, ice, stretching, strengthening, and lower intensity to allow for maladaptive change. Any activity that hurts on extending or pronating the wrist should be avoided. With healing, strengthening exercises are recommended. Patients who are recalcitrant to six months of conservative therapy (including corticosteroid injections) may be candidates for surgery. There currently are no published controlled trials of surgery for lateral elbow pain. Without a control, it is impossible to draw conclusions about the value of surgery. Generally, surgical intervention may be considered when other treatment fails, but over 95% of patients with tennis elbow can be treated without surgery. (Buchbinder-Cochrane, 2002) (California, 1997) (Piligian, 2000) (Foley, 1993) (AHRQ, 2002) (Theis, 2004) (Jerosch, 2005) (Balk, 2005) (Sennoune, 2005) (Szabo, 2006) Disappointing results of surgery were found in litigants with epicondylitis. (Kay, 2003) (Balk, 2005) Surgery is not very common for this condition. In workers' compensation, surgery is performed in only about 5% cases. (WLDI, 2007) For the minority of people with lateral epicondylitis who do not respond to nonoperative treatment, surgical intervention is an option. The surgical techniques for treating lateral epicondylitis can be grouped into three main categories: open, percutaneous, and arthroscopic. Although there are advantages and disadvantages to each procedure, no technique appears superior by any measure. Therefore, until more randomized, controlled trials are done, it is reasonable to defer to individual surgeons regarding experience and ease of procedure. (Lo, 2007)

Surgery for olecranon bursitis

Not recommended. Conservative treatment remains the treatment of choice for olecranon bursitis. The risk of wound healing problems and recurrence is high after surgical resection. (Degreef, 2006) Usually, no surgical intervention is required in cases of olecranon bursitis; however, very severe chronic cases may require bursectomy. This demonstrated endoscopic bursal resection relieves pain symptoms in patients with olecranon bursitis. Fortunately, most cases of olecranon bursitis respond to nonsurgical treatment. If the fluid continues to return after multiple drainings or the bursa is constantly causing pain to the patient, surgery to remove the bursa is an option. The minor operation removes the bursa from the elbow and is left to regrow but at a normal size over a period of ten to fourteen days. It is usually done under general anaesthetic and has very minimal risks. (Ogilvie, 2000) Elbow bursitis, also called olecranon bursitis, is a common cause of swelling and inflammation around the elbow joint. It is usually treated easily by draining.

Surgery for pronator syndrome

Under study. Due to the relative rarity of pronator syndrome, few controlled studies exist to determine the most effective treatment techniques. Pronator syndrome is usually treated conservatively, with surgery to release pressure on the nerve an option for severe cases. Outcome following surgery is unpredictable, and at least one out of three patients have lingering symptoms despite technically satisfactory surgery. In some cases surgical release of the median nerve at the elbow level may provide an immediate as well as long-term return to normal strength. (Stal, 2004) (Lee, 2004)

Surgery for radial head fracture

See Radial head fracture surgery.

Surgery for radial tunnel syndrome (lesion of radial nerve)

Recommended as an option in simple cases after 3-6 months of conservative care plus positive electrodiagnostic studies and objective evidence of loss of function. Surgical decompression of radial tunnel syndrome (RTS), a relatively rare condition, remains controversial because the results are unpredictable. Surgical decompression may be beneficial for simple RTS, but may be less successful if there are coexisting additional nerve compression syndromes or lateral epicondylitis or if the patient is receiving workers’ compensation. (Lee, 2007)

Surgery for ruptured biceps tendon (at the elbow)

Recommended as indicated below. Surgery may be an appropriate treatment option for tears in the distal biceps tendons (biceps tendon tear at the elbow) for patients who need normal arm strength. Nonsurgical treatment is usually all that is needed for tears in the proximal biceps tendons (biceps tendon tear at the shoulder). (Mazzocca, 2008) (Chillemi, 2007) (Rantanen, 1999)

ODG Indications for Surgeryä -- Ruptured biceps tendon surgery:

Criteria for reinsertion of ruptured biceps tendon with diagnosis of distal rupture of the biceps tendon: All should be repaired within 2 to 3 weeks of injury or diagnosis. A diagnosis is made when the physician cannot palpate the insertion of the tendon at the patient's antecubital fossa. Surgery is not indicated if 3 or more months have elapsed. (Washington, 2002)

Tennis elbow band

Recommended for epicondylitis. Positive but limited evidence. (Van De Streek, 2004) (Thurston, 1998) (Solveborn, 1997) (Foley, 1993) (Van De Streek, 2004)

TENS (transcutaneous electrical neurostimulation)

See Transcutaneous electrical neurostimulation (TENS).

Tests for cubital tunnel syndrome (ulnar nerve entrapment)

Under study. One test for cubital tunnel syndrome, ulnar motor nerve conduction velocity at the elbow, is reported to have high specificity and low sensitivity. Insufficient data exists to allow firm evidence-based conclusions regarding the effectiveness of any tests for cubital tunnel syndrome, as the evidence base is small and heterogeneous. Diagnosis may be made by symptoms. The elbow is the most common site of compression of the ulnar nerve. Cubital tunnel syndrome is the second most common compressive neuropathy (after carpal tunnel syndrome). Cubital tunnel syndrome affects men 3-8 times as often as women. Affected patients often experience numbness and tingling along the little finger and the ulnar half of the ring finger. This discomfort often is accompanied by weakness of grip. An electromyography (EMG) is not essential when the diagnosis of cubital tunnel syndrome is obvious on clinical examination, as a false test result can be misleading. (AHRQ, 2002) (Lo, 2005) (Robertson, 2005) See also Surgery for cubital tunnel syndrome. The incidence of ulnar nerve entrapment at the elbow (overall 0.8%) is associated with one job related risk factor (holding a tool in position, repetitively, with an odds ratio of 4.1), plus obesity (4.3) and other upper-limb work-related musculoskeletal disorders, especially medial epicondylitis and other nerve entrapment disorders (cervicobrachial neuralgia and carpal and radial tunnel syndromes). (Descatha, 2004) Cubital tunnel syndrome (entrapment of the ulnar nerve at the elbow) is the second most common peripheral nerve entrapment syndrome in the human body, after carpal tunnel syndrome. Patients who are affected with cubital tunnel syndrome often experience numbness and tingling along the little finger and ulnar half of the ring finger, usually accompanied by weakness of grip. This frequently occurs when the patient rests upon or flexes the elbow. When appropriately diagnosed, this condition may be treated by both conservative and operative means. (Cutts, 2007)

Tests for epicondylitis

Under study. Insufficient data exists to allow firm evidence-based conclusions regarding the effectiveness of any tests for epicondylitis, as the evidence base is small and heterogeneous. (AHRQ, 2002) Typical symptoms of lateral epicondylitis (“tennis elbow”) include pain in the lateral aspect of the elbow with pain or burning radiating to the forearm (and occasionally proximal radiation). With medial epicondylitis (“golfers elbow”) the pain is on the inside of the elbow (versis outside of the elbow for tennis elbow). See also Surgery for epicondylitis.

Tests for pronator syndrome

Under study. Pronator syndrome (median nerve entrapment at the elbow) is a rare condition, but it is more common among women than men. Differential diagnosis is based largely on the symptoms, patterns of paresthesia, and specific patterns of muscle weakness. Pronator syndrome may resemble carpal tunnel syndrome, but is much less common than carpal tunnel syndrome. Unfortunately, there is no reliable nerve test to confirm the diagnosis except in cases having nerve damage. Pronator syndrome may be an explanation for persistent or recurrent symptoms following surgery for carpal tunnel syndrome, and may be part of a double crush condition. (Stal, 2004) (Lee, 2004) See also Surgery for pronator syndrome.

Topaz procedure

See Radiofrequency epicondylitis treatment (Topaz procedure).

Topical NSAIDs

Recommended for short-term pain relief. There is evidence that topical NSAIDs are significantly more effective than placebo with respect to pain and participant satisfaction in the short term, and this finding is robust against the possible bias introduced by the inclusion of unblinded trials and publication bias. The adverse effects reported were minor. (Green-Cochrane, 2002) One double-blinded randomized controlled trial and one double blinded randomized crossover trial, of a total of 47 patients, compared topical diclofenac to placebo. The study reported that the group treated with the NSAID may have had some statistically significant benefit from the treatment. One randomized controlled trial of 40 patients compared topical diclofenac to topical salicylate, and reported that diclofenac was more effective for treating epicondylitis. Topical NSAIDs were reported to occasionally cause mild skin rashes. (AHRQ, 2002) (Boisaubert, 2004) See also NSAIDs.

Total elbow replacement (TER)

Recommended for the treatment of an acute distal humeral fracture, when strict inclusion criteria are observed. (Muller, 2005) (Landor, 2006) (Krishnan, 2007)

Indications for surgery -- Total elbow replacement (TER):

Non-soft-tissue-attached fragments, poor-quality bone, where stable osteosynthesis is not attainable. Severely comminuted intraarticular closed type C fractures according to the AO classification with multiple small bone/cartilage fragments. In case of degenerative joint diseases and/or previous surgery in rheumatoid patients also type A and B fractures. High compliance, low demand, and old patient > 65 years.

Contraindications: Type II or III Gustilo-Anderson open fractures (primary irrigation and debridement). Preexisting infection, open wounds. Younger, high-demand or noncompliant patient. Paralysis of the biceps muscle.

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Transcutaneous electrical neurostimulation (TENS)

Not recommended. Transcutaneous electrical neurostimulation (TENS) units have no scientifically proven efficacy in the treatment of acute hand, wrist, or forearm symptoms, but are commonly used in physical therapy. Insufficient evidence exists to evaluate many physical modalities used to treat disorders of the elbow, often employed based on anecdotal or case reports alone. In general, it would not be advisable to use these modalities beyond 2-3 visits if signs of objective progress towards functional restoration are not demonstrated. (California, 1997) (Piligian, 2000) (Boyer, 1999) (Sevier, 1999)

Transposition of ulnar nerve

See Surgery for cubital tunnel syndrome.

Triceps tendon repair

Recommend surgical repair for complete ruptures. Biceps and triceps tendon ruptures are uncommon injuries. MRI can help differentiate an incomplete tear and define any degeneration of the tendon. Surgical anatomical repair is typically performed in acute complete ruptures whereas nonoperative treatment can be used for partial ruptures, as well as for patients unfit for surgery. Although various fixation methods have been applied, the current evidence does not support the superiority of one method over the other. A well-planned postop rehab program is essential for a good final outcome. (Kokkalis, 2013) Biceps or triceps ruptures are rare but can cause a significant disability. Surgical repair has become the preferred method of treatment for the complete rupture, but also for partial tears only if patients have a delayed presentation. (Bain, 2010) While distal triceps rupture is an uncommon injury, it is most often associated with anabolic steroid use, weight lifting, and laceration. Other local and systemic risk factors include local steroid injection, olecranon bursitis, and hyperparathyroidism. Distal triceps rupture is usually caused by a fall on an outstretched hand or a direct blow. Eccentric loading of a contracting triceps has been implicated, particularly in professional athletes. Initial diagnosis may be difficult because a palpable defect is not always present. Pain and swelling may limit the ability to evaluate strength and elbow range of motion. Although plain radiographs are helpful in ruling out other elbow pathology, MRI is used to confirm the diagnosis, classify the injury, and guide management. Incomplete tears with active elbow extension against resistance are managed nonsurgically. Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength. Good to excellent results have been reported with surgical repair, and very good results have been achieved even for chronic tears. (Yeh, 2010)

Ulnar motor nerve conduction velocity test

Under study. This test for cubital tunnel syndrome is fairly common. Three studies report high specificity/low sensitivity, but quantitative conclusions cannot be drawn at this time. (AHRQ, 2002) See also Tests for cubital tunnel syndrome.

Ultrasound, diagnostic

Recommended as indicated below. Ultrasound (US) has been shown to be helpful for diagnosis of complete and partial tears of the distal biceps tendon, providing an alternative to MRI. (ACR, 2001) (Wiesler, 2006) See also ACR Appropriateness Criteria™. Ultrasound of the common extensor tendon had high sensitivity but low specificity in the detection of symptomatic lateral epicondylitis. (Levin, 2005) Limited evidence shows that diagnostic sonography may not be effective in predicting response to conservative therapy for tennis elbow. (Struijs, 2005)

Indications for imaging -- Ultrasound:

- Chronic elbow pain, suspect nerve entrapment or mass; plain films nondiagnostic (an alternative to MRI if expertise available)

- Chronic elbow pain, suspect biceps tendon tear and/or bursitis; plain films nondiagnostic (an alternative to MRI if expertise available)

Ultrasound, therapeutic

Recommended as a conservative option if there is evidence of objective functional improvement after trial use. Three trials compare ultrasound treatment to controls for epicondylitis. All three report a trend towards better outcomes with ultrasound. However, this difference reached statistical significance in only one. (AHRQ, 2002) (Klaiman, 1998) In another study, low-intensity ultrasound therapy was no more effective for a large treatment effect than placebo for chronic lateral epicondylitis. (D’Vaz, 2006) A meta analysis to evaluate the available evidence of the effectiveness of physical therapy for lateral epicondylitis of the elbow, concluded that the pooled estimate of the treatment effects of two studies on ultrasound compared to placebo ultrasound, showed statistically significant and clinically relevant differences in favour of ultrasound. Despite the large number of studies, there is still insufficient evidence for most physiotherapy interventions for lateral epicondylitis due to contradicting results, insufficient power, and the low number of studies per intervention. Only for ultrasound, weak evidence for efficacy was found. (Smidt, 2003) This review determined, with good evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. (Trudel, 2004) See also Phonophoresis (the use of ultrasound to enhance the delivery of topically applied drugs), which is Not recommended.

Ultrasound fracture healing (bone-growth stimulators)

See Bone growth stimulators, ultrasound.

Viscosupplement-ation

Not recommended. The only published trial concluded that, because the use of viscosupplementation for the treatment of post-traumatic osteoarthritis of the elbow provides only slight, short-term pain relief and a very limited decrease in activity impairment, viscosupplementation is not suitable for this indication. After 6 months, no beneficial effects were noticed in any of the injected elbows. Other parameters were not influenced by treatment with viscosupplementation at any time. (van Brakel, 2006)

Work

Recommended as indicated below. In the design of computer workstations, screen below eye height is a significant predictor for elbow symptoms. (Juul-Kristensen, 2004) One study concluded that the predictive factors for persistent elbow tendonitis included older age, higher hand repetition level for their job(s), more deviation from a neutral wrist position during the work activity, and lower perceived decision authority on the job. Workers at highest risk for persistent elbow tendonitis should be placed at jobs with lower repetition levels and that use more neutral wrist postures. (Werner, 2005) Mouse and keyboard time seem to predict elbow and wrist/hand pain. (Lassen, 2004) Women and patients who report nerve symptoms are more likely to experience a poorer short-term outcome after PT management of lateral epicondylitis. Work-related onsets, repetitive keyboarding jobs, and cervical joint signs have a prognostic influence on women. (Waugh, 2004) Medial epicondylitis is clearly associated with forceful work (Descatha, 2003) Disappointing results of therapy were found in litigants with epicondylitis. (Kay, 2003) The incidence of cubital tunnel syndrome (overall 0.8%) is associated with one job related risk factor (holding a tool in position, repetitively, with an odds ratio of 4.1), plus obesity (4.3) and other upper-limb work-related musculoskeletal disorders, especially medial epicondylitis and other nerve entrapment disorders (cervicobrachial neuralgia and carpal and radial tunnel syndromes). (Descatha, 2004) There is a lack of high quality evidence to inform workplace management of lateral epicondylitis. (Dick, 2010)

ODG Capabilities & Activity Modifications for Restricted Work:
Modified work: Repetitive motion activities not more than 4 times/hr; single upper extremity work if injured arm is non-dominant arm; lifting and carrying up to 3 lbs not more than 4 times/hr; pulling and pushing up to 5 lbs 3 times/hr; gripping using light tools (pens, scissors, etc) with 5-minute break at least every 20 min; avoid direct pressure on the elbow area; limit repetitive keying up to 15 keystrokes/min not more than 2 hrs/day; driving car up to 2 hrs/day; no full extension activities; possible immobilization by long arm splint or cast, tennis elbow splint, or wrist splint; no climbing ladders.

Regular manual work: Repetitive motion activities not more than 8 times/hr; use of injured dominant arm for moderate work; lifting and carrying up to 20 lbs not more than 15 times/hr; pulling and pushing up to 40 lbs 15 times/hr; gripping using moderate tools (pliers, screwdrivers, etc) full time; driving car or light truck up to 6 hrs/day or heavy truck up to 4 hrs/day; full extension activities up to 12 times/hr with up to 10 lbs of weight; possible immobilization by sling, wrist splint, or tennis elbow splint; climbing ladders up to 50 rungs/hr.

Work conditioning, work hardening

Recommended as an option, depending on the availability of quality programs, and should be specific for the job individual is going to return to. (Schonstein-Cochrane, 2003) Work Conditioning should restore the client’s physical capacity and function. Work Hardening should be work simulation and not just therapeutic exercise, plus there should also be psychological support. Work Hardening is an interdisciplinary, individualized, job specific program of activity with the goal of return to work. Work Hardening programs use real or simulated work tasks and progressively graded conditioning exercises that are based on the individual’s measured tolerances. (CARF, 2006) (Washington, 2006) There is limited, but high quality, evidence that multi-disciplinary rehabilitation for non-specific musculoskeletal arm pain was beneficial for those workers absent from work for at least four weeks. (Dick, 2010) For more information and references, see the Low Back Chapter. The Low Back WH & WC Criteria are copied below.

Criteria for admission to a Work Hardening (WH) Program:

(1) Prescription: The program has been recommended by a physician or nurse case manager, and a prescription has been provided.

(2) Screening Documentation: Approval of the program should include evidence of a screening evaluation. This multidisciplinary examination should include the following components: (a) History including demographic information, date and description of injury, history of previous injury, diagnosis/diagnoses, work status before the injury, work status after the injury, history of treatment for the injury (including medications), history of previous injury, current employability, future employability, and time off work; (b) Review of systems including other non work-related medical conditions; (c) Documentation of musculoskeletal, cardiovascular, vocational, motivational, behavioral, and cognitive status by a physician, chiropractor, or physical and/or occupational therapist (and/or assistants); (d) Diagnostic interview with a mental health provider; (e) Determination of safety issues and accommodation at the place of work injury. Screening should include adequate testing to determine if the patient has attitudinal and/or behavioral issues that are appropriately addressed in a multidisciplinary work hardening program. The testing should also be intensive enough to provide evidence that there are no psychosocial or significant pain behaviors that should be addressed in other types of programs, or will likely prevent successful participation and return-to-employment after completion of a work hardening program. Development of the patient’s program should reflect this assessment.

(3) Job demands: A work-related musculoskeletal deficit has been identified with the addition of evidence of physical, functional, behavioral, and/or vocational deficits that preclude ability to safely achieve current job demands. These job demands are generally reported in the medium or higher demand level (i.e., not clerical/sedentary work). There should generally be evidence of a valid mismatch between documented, specific essential job tasks and the patient’s ability to perform these required tasks (as limited by the work injury and associated deficits).

(4) Functional capacity evaluations (FCEs): A valid FCE should be performed, administered and interpreted by a licensed medical professional. The results should indicate consistency with maximal effort, and demonstrate capacities below an employer verified physical demands analysis (PDA). Inconsistencies and/or indication that the patient has performed below maximal effort should be addressed prior to treatment in these programs.

(5) Previous PT: There is evidence of treatment with an adequate trial of active physical rehabilitation with improvement followed by plateau, with evidence of no likely benefit from continuation of this previous treatment. Passive physical medicine modalities are not indicated for use in any of these approaches.

(6) Rule out surgery: The patient is not a candidate for whom surgery, injections, or other treatments would clearly be warranted to improve function (including further diagnostic evaluation in anticipation of surgery).

(7) Healing: Physical and medical recovery sufficient to allow for progressive reactivation and participation for a minimum of 4 hours a day for three to five days a week.

(8) Other contraindications: There is no evidence of other medical, behavioral, or other comorbid conditions (including those that are non work-related) that prohibits participation in the program or contradicts successful return-to-work upon program completion.

(9) RTW plan: A specific defined return-to-work goal or job plan has been established, communicated and documented. The ideal situation is that there is a plan agreed to by the employer and employee. The work goal to which the employee should return must have demands that exceed the claimant’s current validated abilities.

(10) Drug problems: There should be documentation that the claimant’s medication regimen will not prohibit them from returning to work (either at their previous job or new employment). If this is the case, other treatment options may be required, for example a program focused on detoxification.

(11) Program documentation: The assessment and resultant treatment should be documented and be available to the employer, insurer, and other providers. There should documentation of the proposed benefit from the program (including functional, vocational, and psychological improvements) and the plans to undertake this improvement. The assessment should indicate that the program providers are familiar with the expectations of the planned job, including skills necessary. Evidence of this may include site visitation, videotapes or functional job descriptions.

(12) Further mental health evaluation: Based on the initial screening, further evaluation by a mental health professional may be recommended. The results of this evaluation may suggest that treatment options other than these approaches may be required, and all screening evaluation information should be documented prior to further treatment planning.

(13) Supervision: Supervision is recommended under a physician, chiropractor, occupational therapist, or physical therapist with the appropriate education, training and experience. This clinician should provide on-site supervision of daily activities, and participate in the initial and final evaluations. They should design the treatment plan and be in charge of changes required. They are also in charge of direction of the staff.

(14) Trial: Treatment is not supported for longer than 1-2 weeks without evidence of patient compliance and demonstrated significant gains as documented by subjective and objective improvement in functional abilities. Outcomes should be presented that reflect the goals proposed upon entry, including those specifically addressing deficits identified in the screening procedure. A summary of the patient’s physical and functional activities performed in the program should be included as an assessment of progress.

(15) Concurrently working: The patient who has been released to work with specific restrictions may participate in the program while concurrently working in a restricted capacity, but the total number of daily hours should not exceed 8 per day while in treatment.

(16) Conferences: There should be evidence of routine staff conferencing regarding progress and plans for discharge. Daily treatment activity and response should be documented.

(17) Voc rehab: Vocational consultation should be available if this is indicated as a significant barrier. This would be required if the patient has no job to return to.

(18) Post-injury cap: The worker must be no more than 2 years past date of injury. Workers that have not returned to work by two-years post injury generally do not improve from intensive work hardening programs. If the worker is greater than one-year post injury a comprehensive multidisciplinary program may be warranted if there is clinical suggestion of psychological barrier to recovery (but these more complex programs may also be justified as early as 8-12 weeks, see Chronic pain programs).

(19) Program timelines: These approaches are highly variable in intensity, frequency and duration. APTA, AOTA and utilization guidelines for individual jurisdictions may be inconsistent. In general, the recommendations for use of such programs will fall within the following ranges: These approaches are necessarily intensive with highly variable treatment days ranging from 4-8 hours with treatment ranging from 3-5 visits per week. The entirety of this treatment should not exceed 20 full-day visits over 4 weeks, or no more than 160 hours (allowing for part-day sessions if required by part-time work, etc., over a longer number of weeks). A reassessment after 1-2 weeks should be made to determine whether completion of the chosen approach is appropriate, or whether treatment of greater intensity is required.

(20) Discharge documentation: At the time of discharge the referral source and other predetermined entities should be notified. This may include the employer and the insurer. There should be evidence documented of the clinical and functional status, recommendations for return to work, and recommendations for follow-up services. Patient attendance and progress should be documented including the reason(s) for termination including successful program completion or failure. This would include noncompliance, declining further services, or limited potential to benefit. There should also be documentation if the patient is unable to participate due to underlying medical conditions including substance dependence.

(21) Repetition: Upon completion of a rehabilitation program (e.g., work conditioning, work hardening, outpatient medical rehabilitation, or chronic pain/functional restoration program) neither re-enrollment in nor repetition of the same or similar rehabilitation program is medically warranted for the same condition or injury.

ODG Work Conditioning (WC) Physical Therapy Guidelines

WC amounts to an additional series of intensive physical therapy (PT) visits required beyond a normal course of PT, primarily for exercise training/supervision (and would be contraindicated if there are already significant psychosocial, drug or attitudinal barriers to recovery not addressed by these programs). See also Physical therapy for general PT guidelines. WC visits will typically be more intensive than regular PT visits, lasting 2 or 3 times as long. And, as with all physical therapy programs, Work Conditioning participation does not preclude concurrently being at work.

Timelines: 10 visits over 4 weeks, equivalent to up to 30 hours.

Workstation modifications

See Work.

X-rays

See Radiography.

 

 

 

 

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REFERENCE SUMMARIES

 

AAOS. Radial Head Fractures. The American Academy of Orthopaedic Surgeons. March 2001.

 

Radial head fractures are common injuries, occurring in about 20 percent of all acute elbow injuries.

Fracture types and treatments. Radial head fractures are classified according to the degree of displacement (movement from the normal position), with the four types below:

(1) Type I fractures are generally small, like cracks, and the bone pieces remain fitted together. The fracture may not be visible on initial X-rays, but can usually be seen if the X-ray is taken three weeks after the injury. Nonsurgical treatment involves using a splint or sling for a few days, followed by early motion. If too much motion is attempted too quickly, the bones may shift and become displaced.

(2) Type II fractures are slightly displaced and involve a larger piece of bone. If displacement is minimal, splinting for one to two weeks, followed by range of motion exercises, is usually successful. Small fragments may be surgically removed. If the fragment is large and can be fitted back to the bone, the orthopaedic surgeon will first attempt to fix it with pins or screws. If this is not possible, however, the surgeon will remove the broken pieces or the radial head. For older, less active individuals, the surgeon may simply remove the broken piece, or perhaps the entire radial head. The surgeon will also correct any other soft-tissue injury, such as a torn ligament.

(3) Type III fractures have more than three broken pieces of bone, which cannot be fitted back together for healing. Usually, there is also significant damage to the joint and ligaments. Surgery is always required to remove the broken bits of bone, including the radial head, and repair the soft-tissue damage. Early movement to stretch and bend the elbow is necessary to avoid stiffness. A prosthesis can be used to prevent deformity if elbow instability is severe.

 

Rating: 11b

 

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Aetna Clinical Policy Bulletins. Phonophoresis. May 2, 2006

 

Policy

Aetna considers the use of phonophoresis experimental and investigational for any indications.

Background

Phonophoresis has been suggested by early studies to enhance the absorption of analgesics and anti-inflammatory agents. More recent, better-controlled studies have consistently failed to demonstrate that phonophoresis increases the rate of absorption or the extent of absorption over placebo. In a randomized study (n = 60) comparing the effectiveness of ibuprofen phonophoresis with conventional ultrasound therapy in patients with knee osteoarthritis, Kozanoglu et al (2003) found that ibuprofen phonophoresis was not superior to conventional ultrasound.

 

Rating: 7b

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Aetna Clinical Policy Bulletins. Iontophoresis. May 2006.

 

Aetna considers other uses of iontophoresis (e.g., administration of NSAIDS or corticosteroids for treatment of inflammatory musculoskeletal disorders) experimental and investigational because of insufficient evidence of its effectiveness.

Background

There is insufficient evidence that iontophoresis of corticosteroids is effective in treating musculoskeletal disorders.

 

Rating: 7b

 

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Aetna. Clinical Policy Bulletin: Coblation Non-thermal Volumetric Tissue Reduction. Number: 0475. 10/07/2008.

 

Aetna considers Coblation devices (e.g., Topaz Microdebrider) experimental and investigational for the treatment of musculoskeletal conditions because its effectiveness for these conditions has not been established. Coblation devices such as the Topaz Microdebrider (ArthroCare, Sunnyvale, CA) are being studied for their use in treating musculoskeletal conditions.

Tasto JP, Cummings J, Medlock V, et al. Microtenotomy using a radiofrequency probe to treat lateral epicondylitis. This was a small. short-term, non-randomized study; its findings need to be validated by future prospective randomized studies with large sample sizes and longer follow-up. In addition, evidence is needed about the effectiveness of this approach compared to established methods of management of these musculoskeletal conditions.

 

Rating: 7b

 

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AHRQ Evidence Report/Technology Assessment: Number 62. Diagnosis and Treatment of Worker-Related Musculoskeletal Disorders of the Upper Extremity. October 2002.

 

Four disorders are the focus of this report; carpal tunnel syndrome, cubital tunnel syndrome, epicondylitis, and de Quervain's disease.

Cubital Tunnel Syndrome: One test for cubital tunnel syndrome, ulnar motor nerve conduction velocity at the elbow, was commonly mentioned by reviewers. Three studies reported high specificity and low sensitivity for this test. Due to the small number of studies, however, one cannot draw quantitative conclusions about the effectiveness of the test. There are insufficient data to permit firm evidence-based conclusions about the effectiveness of this or any other tests for cubital tunnel syndrome. One randomized controlled trial of 52 patients found that medial epicondylectomy was superior to anterior transposition in relieving pain and in improving global outcome scores. The results of this study are suggestive, but one cannot arrive at a strong conclusion from the results of only one trial. There is insufficient evidence to determine the relative effectiveness of other surgical treatments. Therefore, currently available evidence tentatively suggests that there is a correlation between having less severe symptoms and having a higher global outcome score after surgical treatment for cubital tunnel syndrome. Two studies that used multiple regression to examine relationships between patient characteristics and treatment outcomes found that patients whose cubital tunnel syndrome is caused by an acute trauma have better outcomes after surgical treatment than patients with cubital tunnel syndrome from other causes.

Epicondylitis: Nineteen studies of patients who received surgery for epicondylitis were identified. Due to a lack of reported data, few trends or characteristics of patients who received surgery could be identified. Seven double-blinded randomized controlled trials compared laser therapy to sham laser therapy as treatment for epicondylitis. A meta-analysis of the results of the four studies that reported “success of treatment” did not reveal a statistically significant difference in outcome between laser and sham-treated patients. Only one study examined work status of patients after laser treatment. This study was also small, and it failed to find a statistically significant effect of laser treatment on work status. The results of all seven small randomized double-blinded controlled trials are consistent with the results of our meta-analysis, and suggest that if there is an effect of laser therapy on epicondylitis, it is not large. Two randomized controlled trials of 82 patients in total compared ultrasound treatment to phonophoresis of hydrocortisone as a therapy for epicondylitis. Neither study found a statistically significant difference between treatment groups for any of the outcomes. Three randomized controlled trials of 220 patients in total compared ultrasound treatment to sham ultrasound treatment or no treatment as a therapy for epicondylitis. All three of the studies reported a trend towards better outcomes in the groups treated with ultrasound. However, this difference reached statistical significance in only one of the studies. Although low statistical power may explain the negative results of the two “nonsignificant” studies, further research is required to demonstrate this. Simply wearing an elbow brace is reported by two crossover studies to have no effect on pain. Because these two studies were of less than optimal design, further studies are necessary before a conclusion may be reached. Two randomized controlled trials of a total of 134 patients evaluated the effect of acupuncture on epicondylitis. Both studies reported patients treated with acupuncture had better global outcomes and greater pain relief than patients treated with sham acupuncture at relatively short (2 weeks) followup times. Although only two studies evaluated this treatment, both were well-designed. It is possible to tentatively conclude that acupuncture is an effective palliative treatment for epicondylitis. One randomized controlled trial of 63 patients reported that patients treated with acupuncture had better outcomes than patients treated with corticosteroid injections. However, the results of this study may have been affected by patient selection bias because it enrolled only patients previously found to be unresponsive to injections of corticosteroids.

 

Rating: 6a

 

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Almquist EE, Necking L, Bach AW. Epicondylar resection with anconeus muscle transfer for chronic lateral epicondylitis. J Hand Surg [Am] 1998 Jul;23(4):723-31.

 

Department of Orthopaedics, University of Washington, Seattle Hand Surgery Group, P.C., USA.

 

This study indicates that this is an effective primary operative treatment for lateral epicondylitis when conservative treatment has failed. It also is effective in patients who continue to have persistent pain and inability to perform normal activities after previous lateral epicondylar release or resection.

 

PMID: 9708389

 

Rating: 3b

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Altay T, Gunal I, Ozturk H. Local injection treatment for lateral epicondylitis. Clin Orthop 2002 May;(398):127-30.

 

Departments of Orthopedics, Social Security and Dokuz Eylul University Hospitals, Izmir, Turkey.

 

This study concluded, “the peppering technique seems to be a reliable method of treatment.

 

PMID: 11964641

 

Rating: 2b, 120 patients

 

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Amako M, Nemoto K, Kawaguchi M, Kato N, Arino H, Fujikawa K. Comparison between partial and minimal medial epicondylectomy combined with decompression for the treatment of cubital tunnel syndrome. J Hand Surg [Am] 2000 Nov;25(6):1043-50.

 

Department of Orthopedic Surgery, National Defense Medical College Tokorozawa, Saitama, Japan.

 

We therefore conclude that minimal medial epicondylectomy combined with ulnar nerve decompression is an effective treatment for cubital tunnel syndrome and that a larger excision of the medial epicondyle should be avoided.

 

PMID: 11119661

 

Rating: 3c

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American Association of Electrodiagnostic Medicine. Practice parameter: Electrodiagnostic studies in ulnar neuropathy at the elbow. Neurology, 1999 Mar; 10.

 

(1) Editor's Note: The following is a summary statement of the American Association of Electrodiagnostic Medicine's (AAEM) Practice Parameter for Electrodiagnostic Studies in Ulnar Neuropathy at the Elbow. This summary statement of the practice parameter was developed jointly by the Quality Assurance Committee of the AAEM and the Quality Standards Subcommittee of the American Academy of Neurology and was endorsed by the AAN and AAPM&R. It is reproduced here with the permission of the AAEM.

Introduction.

Ulnar neuropathy at the elbow (UNE) is a common peripheral mononeuropathy, second only to carpal tunnel syndrome in incidence. The electrodiagnostic evaluation of UNE is frequently complex and challenging to even the most experienced electrodiagnostic medicine consultant. This document defines the standards, guidelines, and options for electrodiagnostic studies of UNE based on a critical review of the literature.

 

Rating: 7b

 

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American College of Radiology (ACR), Expert Panel on Musculoskeletal Imaging. Chronic elbow pain. Reston (VA): American College of Radiology (ACR); 2011. 5 p. (ACR appropriateness criteria). [29 references]

 

Summary

Osteochondral Lesion or Intra-articular Osteocartilaginous Body

Radiographs are required before other imaging studies and may be diagnostic for osteochondral fracture, osteochondritis dissecans, and osteocartilaginous intra-articular body (IAB)..

Tendon, Ligament, Muscle, Nerve, or Other Soft-Tissue Abnormality

Magnetic resonance imaging may provide important diagnostic information for evaluating the adult elbow in many different conditions, including: collateral ligament injury, epicondylitis, injury to the biceps and triceps tendons, abnormality of the ulnar, radial, or median nerve, and for masses about the elbow joint. There is a lack of studies showing the sensitivity and specificity of MR in many of these entities; most of the studies demonstrate MR findings in patients either known or highly likely to have a specific condition. Ultrasound (US) has been shown to be helpful for diagnosis of complete and partial tears of the distal biceps tendon, providing an alternative to MRI.

Epicondylitis (lateral – "tennis elbow" or medial – in pitchers, golfers, and tennis players) is a common clinical diagnosis, and MRI is usually not necessary. Magnetic resonance may be useful for confirmation of the diagnosis in refractory cases and to exclude associated tendon and ligament tear.

ACR Appropriateness Criteria™ -- Clinical Condition: Chronic Elbow Pain

Appropriateness Criteria Scale: 1 2 3 4 5 6 7 8 9 (1=Least appropriate 9=Most appropriate)

Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging

Variant 1: Suspect intra-articular osteocartilaginous body; plain films nondiagnostic.

Radiologic Procedure -- Rating

CT:      With or without contrast -- 8 (If double contrast is used, dose of less than 0.5 cc of contrast should be used)

Without intra-articular contrast-- 2

Arthrogram, positive contrast -- 2

Arthrogram, air only -- 2

MRI: With or without intra-articular contrast -- 6 (May show donor site and additional pathology)

Tomography -- 2

Variant 2: Suspect occult injury; e.g., osteochondral injury; plain films nondiagnostic.

MRI:    No intra-articular contrast -- 9

Intra-articular contrast -- 2

CT:      With or without contrast -- 2

Tomography -- 2

Variant 3: Suspect unstable osteochondral injury; plain films nondiagnostic.

MRI:    With or without intra-articular contrast -- 8

CT:      With or without contrast -- 2

Arthrogram, positive contrast -- 2

Arthrogram, air only -- 2

Arthrogram, double contrast -- 2

Tomography -- 2

Variant 4: Suspect nerve entrapment or mass; plain films nondiagnostic.

MRI -- 9

Ultrasound -- 5 (An alternative to MRI if expertise is available)

No imaging indicated -- 2

CT -- 2

Radionuclide bone scan -- 2

Variant 5: Suspect chronic epicondylitis; plain films nondiagnostic.

MRI:    No intra-articular contrast -- 9

Intra-articular contrast -- 2

Variant 6: Suspect collateral ligament tear; plain films nondiagnostic.

MRI -- 9

CT -- 2

Variant 7: Suspect biceps tendon tear and/or bursitis; plain films nondiagnostic.

MRI:    No intra-articular contrast -- 9

Ultrasound -- 5 (An alternative to MRI if expertise available)

 

Rating: 7b

 

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Apfel E, Sigafoos GT. Comparison of Range-of-Motion Constraints Provided by Splints Used in the Treatment of Cubital Tunnel Syndrome-A Pilot Study. J Hand Ther. 2006 Oct-Dec;19(4):384-92.

 

Department of Rehabilitation Medicine, Division of Occupational and Hand Therapy, VA Healthcare System, San Diego, California, U.S.A.

 

Nocturnal splinting of the elbow is commonly used to treat cubital tunnel syndrome (CBTS). Rationales are based on several studies, which suggest that proper nocturnal positioning of the elbow during sleep contributes to decreased cubital tunnel symptoms.

 

PMID: 17056398

 

Rating: 5c

 

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American Association of Orthopaedic Surgeons (AAOS) 2010 Annual Meeting: Platelet-Rich Plasma Shows Promise but Results Vary Widely. Abstracts 043 and 054, presented March 10, 2010; Abstracts 685 and 714, presented March 12, 2010

 

In 4 studies highlighted at the AAOS 2010 Annual Meeting, platelet-rich plasma (PRP) either worked like a charm or failed totally. PRP looks promising, but it is not ready for prime time. The biologic, currently being used off-label to treat conditions such as tennis elbow, jumper's knee, and other sports-related conditions, "signals the beginning of the biotreatments trend in orthopaedic medicine," Rocco Monto, MD, an orthopaedist in private practice in Nantucket and Martha's Vineyard, Massachusetts, said at a press briefing. "Many believe PRP is the first effective biologic treatment, which is why people are talking about it, debating it, and studying it so much." Dr. Monto presented the results of a prospective cohort study in which 30 patients with chronic refractory Achilles tendonosis were successfully treated with PRP. According to Dr. Monto, PRP should be reserved for patients with refractory Achilles tendonosis. "The worst of the worst should be getting PRP. I think it's ready for certain things, like chronic Achilles tendonosis and tennis elbow." In another study, Taco Gosens, MD, from St. Elizabeth Hospital in Tilburg, the Netherlands, reported that PRP was significantly better than corticosteroid injections, "the current gold standard," in relieving pain and improving function in patients with chronic severe lateral epicondylitis, more commonly known as tennis elbow. "In tennis elbow, we have proven that PRP is better than corticosteroid injection, which is what most orthopaedic surgeons are doing nowadays." Dr. Gosens agreed with Dr. Monto that PRP should be reserved for the most severe cases. "We know that 80% of tennis elbows will be cured spontaneously without doing anything within a year, so I am not treating patients with platelet-rich plasma if they are not severe and chronic. But for chronic, severe tennis elbows, this is a proven therapy, and it is better than the gold standard." Elizaveta Kon, MD, from Rizzoli Orthopaedic Institute in Bologna, Italy, presented preliminary results from a study of PRP injections in patients with early arthritis. She compared the effectiveness of PRP with that of low-molecular-weight hyaluronic acid and high-molecular-weight hyaluronic acid injections in 150 patients (50 patients for each treatment)."It think PRP is promising for less severe, very early arthritis," she told Medscape Orthopaedics. "I don't think it is promising for very severe osteoarthritis in old patients. But it is very promising in younger people, under 50 years of age." In a fourth study, a blinded, prospective, randomized trial of PRP vs placebo in patients undergoing surgery to repair a torn rotator cuff, there was no difference in pain relief or in function between the 2, said Stephen C. Weber, MD, from Sacramento Knee and Sports Medicine in California. "There are high rates of anatomic failure after arthroscopic rotator cuff repair, and we wanted to see if we could do better with PRP injections," Dr. Weber told Medscape Orthopaedics. "Our study was a level 1 study and would be regarded as the best level of evidence for a product. It is the kind of study that would be used in approving a drug," Dr. Weber said. "There was no difference in anything we could measure at any time during recovery from rotator cuff surgery. The only thing that was significantly different was the time it took to do the repair; it was longer if you put PRP in the joint." The fact that there were no differences in residual defects on MRI was another disappointment, he said. "We really need good level 1 evidence to show that PRP is effective. Right now, I would say it is promising, but it's not ready for prime time." Dr. Weber added that having desperate patients is no reason for a routine recommendation of an unproven technology. "We need level 1 studies to recommend this product. These studies are always difficult to do. Mine certainly was. But level 1 studies should be the responsibility of the manufacturer. If they are going to sell the stuff, the impetus is on them to prove the product works before it is marketed." Providing an independent perspective on PRP, Clifford Colwell, MD, medical director of the Shiley Center for Orthopaedic Research and Education at the Scripps Clinic in San Diego, California, said PRP has become popular among professional athletes because it promises to enhance performance. "I took care of the San Diego Padres for 25 years. Professional athletes are extremely performance oriented. They have a very short career and they make a lot of money for a very short period, so if they can't play, they lose their opportunity. They will believe anybody who comes along and tells them a product will optimize their performance. They will take it, whether it is good or bad for their health.”

"This is what this plasma business is about right now, there are very few data. Most of the people who are taking PRP are athletes. There is no science behind it yet."

 

Dr. Monto reports being a speaker for Exact Tech. Dr. Gosens reports that his study was sponsored by Biomet. Dr. Kon, Dr. Weber, and Dr. Colwell have disclosed no relevant financial relationships.

 

Source: Medscape Medical News

 

Rating: 10a

 

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Appelboam A, Reuben AD, Benger JR, Beech F, Dutson J, Haig S, Higginson I, Klein JA, Le Roux S, Saranga SS, Taylor R, Vickery J, Powell RJ, Lloyd G. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ. 2008 Dec 9;337:a2428. doi: 10.1136/bmj.a2428.

 

Emergency Department, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW.

 

PARTICIPANTS: 2127 adults and children presenting to the emergency department with acute elbow injury. CONCLUSION: Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present.

 

PMID: 19066257

 

Rating: 3a

 

Elbow injuries are common in primary and secondary care, accounting for 2-3% of emergency department attendances," write A. Appelboam, from the Emergency Department, Royal Devon and Exeter Foundation NHS Trust in Exeter, United Kingdom, and colleagues. "Only a minority of patients with such injuries have a fracture, but although clinical decision rules for other limb injuries are well recognised, no guidelines have been established to indicate which patients with an elbow injury require radiography. An effective clinical decision rule to exclude fracture in acute elbow injury would prevent unnecessary radiography, and could reduce expenditure." For detecting elbow fracture, the elbow extension test had sensitivity of 96.8% (95% confidence interval [CI], 95.0 - 98.2) and specificity of 48.5% (95% CI, 45.6 - 51.4). Negative predictive value for fracture of full elbow extension was 98.4% (95% CI, 96.3 - 99.5) in adults and 95.8% (95% CI, 92.6 - 97.8) in children, and negative likelihood ratios were 0.03 (95% CI, 0.01 - 0.08) and 0.11 (95% CI, 0.06 - 0.19), respectively. However, the study authors caution that patients who do not undergo radiography should return for reevaluation if symptoms have not resolved within 7 to 10 days. Limitations of this study include possible failure of the follow-up protocol to identify all patients with a fracture undetected by the test, lack of validation of the recall criteria, failure to evaluate interobserver agreement, and no mechanism to record or analyze equivocal results. "Ultimately, application of this test will rely on physicians' judgment, informed by the risk and consequences of false negatives, and by the availability of a gold standard diagnostic test (radiography) and follow-up," the study authors conclude. "Most false negative results are likely to be minor or occult fractures that require no change in treatment."

 

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Arle JE, Zager EL. Surgical treatment of common entrapment neuropathies in the upper limbs. Muscle Nerve 2000 Aug;23(8):1160-74.

 

(2) Department of Neurosurgery, The Lahey Clinic, Burlington, MA, USA.

 

Entrapment neuropathies of the upper extremity are common, debilitating conditions. Most patients with these neuropathies are readily diagnosed on purely clinical grounds and may be effectively managed with nonoperative measures. However, the broad differential diagnosis often necessitates electrodiagnostic testing and radiographic imaging to clarify the situation.

 

PMID: 10918251

 

Rating: 5b

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Artico M, Pastore FS, Nucci F, Giuffre R. 290 surgical procedures for ulnar nerve entrapment at the elbow: physiopathology, clinical experience and results. Acta Neurochir (Wien) 2000;142(3):303-8.

 

(2) Department of Neurological Sciences, University of Rome La Sapienza, Italy.

 

We present our 8-years surgical experience with 290 cases of ulnar nerve entrapment at the elbow analysing the salient clinical features and the results of the surgical treatment in the light of the relevant literature available on this topic.

 

PMID: 10819261

 

Rating: 3b

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Asami A, Morisawa K, Tsuruta T. Functional outcome of anterior transposition of the vascularized ulnar nerve for cubital tunnel syndrome. J Hand Surg [Br] 1998 Oct;23(5):613-6.

 

(2) Department of Orthopaedic Surgery, Saga Medical School, Japan. asamia@post.saga-med.ac.jp

 

Anterior transposition of the ulnar nerve is a widely used treatment for cubital tunnel syndrome, but neurolysis performed at the time of surgery may impair the blood supply to the ulnar nerve. The postoperative nerve conduction velocity and the clinical results were better in the group in which the extrinsic vessels were presented.

 

PMID: 9821606

 

Rating: 3c

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Asamoto S, Boker DK, Jodicke A. Surgical treatment for ulnar nerve entrapment at the elbow. Neurol Med Chir (Tokyo). 2005 May;45(5):240-4; discussion 244-5.

 

Department of Neurosurgery, Justus-Liebig University of Giessen. spine-ns@sb.dcns.ne.jp

 

Simple ulnar nerve decompression or anterior transposition of the ulnar nerve (subcutaneous or intramuscular) was performed with or without the operating microscope. Nine patients were lost to follow up. The outcome was excellent or good in 63 of 72 cases, no change in eight cases, and poor in one case. The outcomes of procedures performed with the operating microscope tended to be superior.

 

PMID: 15914963

 

Rating: 3c

 

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Assendelft WJ, Hay EM, Adshead R, Bouter LM, Corticosteroid injections for lateral epicondylitis: a systematic overview, Br J Gen Pract. 1996 Apr;46(405):209-16.

 

AIM: The aim of the study was to assess the effectiveness of corticosteroid injections in the treatment of lateral epicondylitis (tennis elbow) by systematic review of the available randomized clinical trials. RESULTS: Twelve randomized clinical trials were identified. The studies of better methodological quality indicated more favourable results than those of lesser methodological quality. CONCLUSION: Corticosteroid injections appear to be relatively safe and seem to be effective in the short term (2-6 weeks). Although the treatment seems to be suitable for application in general practice, further trials in this setting are needed. As yet, questions regarding the optimal timing, dosage, injection technique and injection volume remain unanswered.

 

PMID: 8703521

 

Rating: 1b

 

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Baek GH, Kwon BC, Chung MS. Comparative study between minimal medial epicondylectomy and anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome. J Shoulder Elbow Surg. 2006 Sep-Oct;15(5):609-13.

 

Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea.

 

In the group treated by medial epicondylectomy, 9 of the results (41%) were excellent, 10 (45%) were good, 2 (9%) were fair, and 1 result (5%) was poor. In the group treated by anterior subcutaneous transposition of ulnar nerve, 14 of the results (41%) were excellent, 13 (38%) were good, 6 (18%) were fair, and 1 result (3%) was poor. No significant difference was found between the 2 groups (P < .05). Both methods can be used for the treatment of cubital tunnel syndrome with a high rate of satisfaction.

 

PMID: 16979058

 

Rating: 3c

 

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Bain GI, Durrant AW. Sports-related injuries of the biceps and triceps. Clin Sports Med. 2010 Oct;29(4):555-76. doi: 10.1016/j.csm.2010.07.002.

 

PMID: 20883897

 

Rating: 5b

 

 

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Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg 2000 Nov-Dec;9(6):475-82.

 

(1) Hughston Clinic, PC, 6262 Veterans Parkway, Columbus, GA 31909, USA.

 

This study of 40 patients concluded, “Arthroscopic tennis elbow release is a reliable treatment that allows patients an expedited return to work and may result in greater postsurgical grip strength.

 

PMID: 11155299

 

Rating: 4b

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Balk ML, Hagberg WC, Buterbaugh GA, Imbriglia JE. Outcome of surgery for lateral epicondylitis (tennis elbow): effect of worker's compensation. Am J Orthop. 2005 Mar;34(3):122-6; discussion 126.

 

Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

 

We retrospectively compared the results of extensor origin release for lateral epicondylitis (tennis elbow) against worker's compensation (WC) status. All patients (N = 57) underwent extensor origin release between October 1989 and June 1998. For the 33 patients (37 elbows) who received WC, mean follow-up was 55 months; for the 25 patients (26 elbows) who did not receive WC, mean follow-up was 45 months. Pain relief, symptom recurrence, satisfaction with procedure outcome, and ability to return to work (same or similar job) were evaluated. A majority of patients in both groups returned to work, but a significantly higher percentage of patients in the WC group changed jobs because of persistent symptoms.

 

PMID: 15828514

 

Rating: 4b

 

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Bano KY, Kahlon RS. Radial head fractures--advanced techniques in surgical management and rehabilitation. J Hand Ther. 2006 Apr-Jun;19(2):114-35.

 

Hand & Upper Extremity Center, PRO Physical Therapy, Newark, Delaware, USA. kbano25@hotmail.com

 

Radial head fractures are the most common fractures in the elbow, and the treatment of nondisplaced fractures is often straightforward. This article summarizes current advanced techniques in the surgical management and rehabilitation of radial head fractures. Comprehensive protocols for decision making and treatment are introduced for both simple and complex radial head fractures.

 

PMID: 16713860

 

Rating: 5b

 

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Barden J, Edwards J, Moore A, McQuay H. Single dose oral paracetamol (acetaminophen) for postoperative pain. Cochrane Database Syst Rev. 2004;(1):CD004602.

 

Pain Research Unit, University of Oxford, Churchill Hospital, Old Road, Oxford, UK, OX3 7LJ.

 

RESULTS: Forty-seven reports that enrolled 4186 patients (2561 patients were treated with a single oral dose of paracetamol and 1625 with placebo) met the inclusion criteria and were included in the analyses. The NNTs for at least 50% pain relief over four to six hours following a single dose of paracetamol were as follows: 325 mg NNT 3.8 (2.2 to 13.3); 500 mg NNT 3.5 (2.7 to 4.8); 600/650 mg NNT 4.6 (3.9 to 5.5); 975/1000 mg NNT 3.8 (3.4 to 4.4); and 1500 mg NNT 3.7 (2.3 to 9.5). Drug-related study withdrawals were rarely reported. Studies reported a variable incidence of adverse effects that were generally mild and transient. REVIEWER'S CONCLUSIONS: Single doses of paracetamol are effective analgesics for acute postoperative pain and give rise to few adverse effects.

 

PMID: 14974073

 

Rating: 1a

 

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Bartels RH. History of the surgical treatment of ulnar nerve compression at the elbow. Neurosurgery 2001 Aug;49(2):391-9; discussion 399-400.

 

Department of Neurosurgery, University Medical Center Nijmegen St. Radboud, The Netherlands. r.bartels@czzonch.azn.nl

 

This article is the first in the literature to provide information about and photographs of nearly all of the people who were important in the development of the surgical treatment of compression of the ulnar nerve at the elbow.

 

PMID: 11504115

 

Rating: 1b

 

 

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Bartels RH, Termeer EH, van der Wilt GJ, van Rossum LG, Meulstee J, Verhagen WI, Grotenhuis JA. Simple decompression or anterior subcutaneous transposition for ulnar neuropathy at the elbow: a cost-minimization analysis--Part 2. Neurosurgery. 2005 Mar;56(3):531-6; discussion 531-6.

 

Department of Neurosurgery, University Medical Center St. Radboud, Nijmegen, The Netherlands. r.bartels@nch.umcn.nl

 

OBJECTIVE: Clinically, both surgical options seem to be equally effective. RESULTS: The total costs per group and per patient were statistically significantly less for those treated with simple decompression. The total median costs per patient were 1124 Euros for simple decompression and 2730 Euros for anterior subcutaneous transposition. The main difference was in the costs related to sick leave, which is significantly shorter for simple decompression. CONCLUSION: Although clinically equally effective, simple decompression was associated with lower cost than anterior subcutaneous transposition for the treatment of ulnar neuropathy at the elbow.

 

PMID: 15730579

 

Rating: 2b

 

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Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery. 2005 Mar;56(3):522-30; discussion 522-30.

 

Department of Neurosurgery, University Medical Center St. Radboud, Nijmegen, The Netherlands. r.bartels@nch.umcn.nl

 

METHODS: One hundred fifty-two patients met the inclusion criteria and were randomized into two surgical groups: 75 were assigned to SD, and 77 were assigned to AST. Participants were followed for 1 year after surgery. The main outcome measure was clinical outcome 1 year after surgery. RESULTS: An excellent or good result was obtained in 49 of 75 participants who underwent SD and in 54 of 77 participants undergoing AST. CONCLUSION: Surgery for ulnar neuropathy at the elbow is effective. The outcomes of SD and AST are equivalent, except for the complication rate. Because the intervention is simpler and associated with fewer complications, SD is advised, even in the presence of (sub)luxation.

 

PMID: 15730578

 

Rating: 2a

 

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Basford JR, Sheffield CG, Cieslak KR. Laser therapy: a randomized, controlled trial of the effects of low intensity Nd:YAG laser irradiation on lateral epicondylitis. Arch Phys Med Rehabil 2000 Nov;81(11):1504-10.

 

(1) Department of Physical Medicine and Rehabilitation, Mayo Clinic and Foundation, Rochester, MN 55902, USA. basford.jeffrey@mayo.edu

 

This study of 52 patients concluded, “Treatment with low intensity 1.06-microm laser irradiation within the parameters of this study was a safe but ineffective treatment of lateral epicondylitis.

 

PMID: 11083356

 

Rating: 2b

 

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Baskurt F, Ozcan A, Algun C, Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis, Clin Rehabil. 2003 Feb;17(1):96-100.

 

Dokuz Eylul University School of Physical Therapy, Izmir, Turkey.

 

SUBJECTS: This study was carried out with 61 patients who had lateral epicondylitis. CONCLUSION: The results suggest that iontophoresis and phonophoresis of naproxen are equally effective electrotherapy methods in the treatment of lateral epicondylitis.

 

PMID: 12617384

 

Rating: 2c

 

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Behar SM, Chertow GM. Olecranon bursitis caused by infection with Candida lusitaniae. J Rheumatol 1998 Mar;25(3):598-600.

 

(3) Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA. smbehar@bics.bwh.harvard.edu

 

Infection, especially with unusual microbial pathogens, should be considered in cases of chronic bursitis in patients taking immunosuppressive medicine, even if the classic signs of septic bursitis are absent.

 

PMID: 9517788

 

Rating: 11c

 

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Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery. 2006 Feb;58(2):296-304; discussion 296-304.

 

METHODS: Forty-four surgical candidates were recruited prospectively and were randomized into the neurolysis (n = 23) or transposition (n = 21) arm of the study. CONCLUSION The authors therefore suggest the simpler procedure of neurolysis in situ as the treatment of choice. Submuscular transposition remains appropriate in certain circumstances.

 

PMID: 16462483

 

Rating: 2b

 

 

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Bimmler D, Meyer VE. Surgical treatment of the ulnar nerve entrapment neuropathy: submuscular anterior transposition or simple decompression of the ulnar nerve? Long-term results in 79 cases. Ann Chir Main Memb Super. 1996;15(3):148-57.

 

We studied the outcome in 79 patients whose ulnar nerve had been operated on for the first time. Irrespective of the surgical method, roughly 90% of the patients considered their postoperative condition to be improved. However, one specific group of patients (people with habitual ulnar luxation or subluxation of the ulnar nerve) experienced a distinctly better result when treated by anterior transposition than by simple decompression. Our results show that simple decompression of the ulnar nerve can be recommended in all patients without cubital (sub)luxation of the nerve, whereas people with a tendency of cubital (sub)luxation of the ulnar nerve should be treated by submuscular anterior transposition.

 

PMID: 8791977

 

Rating: 3b

 

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Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005 Jul;39(7):411-22; discussion 411-22.

 

Division of Physiotherapy, University of Queensland, St Lucia, QLD 4072, Australia.

 

Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow.

 

PMID: 15976161

 

Rating: 1b

 

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Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Sep 29.

 

School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, QLD, Australia 4072.

 

CONCLUSION: Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks, providing a reasonable alternative to injections in the mid to long term. The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow.

 

PMID: 17012266

 

Rating: 3b

 

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Bisset L, Coombes B, Vicenzino B. Tennis elbow. Clin Evid (Online). 2011 Jun 27;2011. pii: 1117.

 

RESULTS: We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria.

 

PMID: 21708051

 

Rating: 1b

 

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Bjordal JM, Lopes-Martins RA, Joensen J, Couppe C, Ljunggren AE, Stergioulas A, Johnson MI. A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskelet Disord. 2008 May 29;9:75.

 

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

 

RESULTS: 18 randomised placebo-controlled trials (RCTs) were identified with 13 RCTs (730 patients) meeting the criteria for meta-analysis. CONCLUSION: LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses.

 

PMID: 18510742

 

Rating: 1a

 

Background: Lateral elbow tendinopathy (LET) or "tennis elbow" is a common disorder with a prevalence of at least 1.7%, and occuring most often between the third and sixth decades of life. Physical strain may play a part in the development of LET, as the dominant arm is significantly more often affected than the non-dominant arm. The condition is largely self-limiting, and symptoms seem to resolve between 6 and 24 months in most patients. A number of interventions have been suggested for LET. Steroid injections, non-steroidal anti-inflammatory drugs or a regimen of physiotherapy with various modalities, seem to be the most commonly applied treatments. However, treatment effect sizes seem to be rather small, and recommendations have varied over the years. In several systematic reviews over the last decade, glucocorticoid steroid injections have been deemed effective, at least in the short-term. But in later well-designed trials evidence is found that intermediate and long-term effects of steroid injections groups yield consistently and significantly poorer outcomes than placebo injection groups, and physiotherapy or wait-and-see groups. Nevertheless, steroid injections have been considered as the most thoroughly investigated intervention, with 13 randomized controlled trials comparing steroid injections to either placebo/local anaesthetic or another type of intervention. Non-steroidal anti-inflammatory drugs (NSAIDs) have been found to achieve smaller short-term effect sizes than steroid injections, and topical application seems to be the best medication administration route. Although the sparse evidence makes it difficult to assess the separate effect of active exercises or stretching, four studies have found that either exercises alone, or in conjunction with a physiotherapy package, are more effective than placebo ultrasound therapy or wait-and-see controls. Among the physical interventions, ultrasound therapy has been considered to offer a small benefit over placebo from two small trials, but a well-designed and more recent trial did not find significant effects of ultrasound therapy in LET. A good example of this is the negative conclusion of the LET review for extracorporeal shockwave therapy (ESWT) by Buchbinder et al., where a later review with in-depth assessments of treatment intervention protocols, found that a subgroup of trials with proper treatment procedures and adequate timing of outcomes gave a positive result. Low level laser therapy (LLLT) has been available for nearly three decades, and scattered positive results have been countered by numerous negative trial results. Several systematic reviews have found no significant effects from LLLT, in musculoskeletal disorders in general, and in LET in particular.

Discussion: Our review suggests that LLLT trials reporting negative results are more likely to be published than trials with positive results. This may reflect a predominance of RCTs designed using drug-research methodology paradigms without due consideration given to adequacy of the technique used in delivering LLLT, leading to under dosing and negative outcome bias. In addition, it has been that documented drug sponsorship of research activities may influence guideline panels, journal editors and referees leading to negative views on non-drug treatments such as LLLT as reflected in editorials in pain journals and national medical journals. Despite these concerns, we believe that the positive overall results of this review need to interpreted with some caution. They arise from a subgroup of 7 out of the 13 included trials. These 7 trials had a narrowly defined LLLT regimen where lasers of 904 nm wavelength with low output (5–50 mW) were used to irradiate the tendon insertion at the lateral elbow using 2–6 points or an area of 5 cm2 and doses of 0.25–1.2 Joules per point/area. The positive results for this subgroup of trials were consistent across outcomes of pain and function, and significance persisted for at least 3–8 weeks after the end of treatment, in spite of several factors which may have deflated effect sizes. Based on the above findings, LLLT should be considered as an alternative therapy to commonly used pharmacological agents in LET management.

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Black BT, Barron OA, Townsend PF, Glickel SZ, Eaton RG. Stabilized subcutaneous ulnar nerve transposition with immediate range of motion. Long-term follow-up. J Bone Joint Surg Am 2000 Nov;82-A(11):1544-51.

 

(1) C.V. Starr Hand Surgery Center and St. Luke's-Roosevelt Hospital, New York, NY 10025, USA.

 

This technique of stabilized subcutaneous anterior transposition of the ulnar nerve yielded predictably good results for a wide spectrum of patients. Patients returned to their occupation sooner when the elbow had been mobilized immediately.

 

PMID: 11097442

 

Rating: 3b

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Blue Cross and Blue Shield Association's Technology Evaluation Center (TEC), Extracorporeal shock wave treatment for chronic tendinitis of the elbow (lateral epicondylitis), Technol Eval Cent Asses Program Exec Summ. 2005 Feb;19(16):1-3.

 

This Assessment evaluates whether extracorporeal shock wave treatment (ESWT) improves health outcomes for patients with lateral epicondylitis that is unresponsive to conservative treatment.

1. The technology must have final approval from the appropriate governmental regulatory bodies.

There are currently 3 ESWT devices approved by the U.S. Food and Drug Administration (FDA) via the premarket application (PMA) approval process. The OssaTron® device (HealthTronics, Marietta, GA), an electrohydraulic delivery system, was initially approved by the FDA on October 12, 2000, for patients with chronic proximal plantar fasciitis that has failed to respond to conservative management (defined as lasting 6 months or more). The OssaTron® was subsequently approved via a supplemental PMA on March 14, 2003, for the treatment of chronic lateral epicondylitis that has failed to respond to conservative treatment (defined as lateral epicondylitis that has persisted for 6 months or more with a history of unsuccessful conservative treatment). The Dornier Epos™ Ultra (Dornier Medical Systems, Inc.; Kennesaw, GA), an electromagnetic delivery system, was approved on January 15, 2002, for the treatment of chronic plantar fasciitis for patients with symptoms of plantar fasciitis for 6 months or more and a history of unsuccessful conservative therapy. The SONOCUR® Basic (Siemens Medical Solutions, USA; Iselin, NJ) also uses an electromagnetic delivery system and was approved for chronic lateral epicondylitis (defined as lasting 6 months or more and with a history of unsuccessful conservative treatments) on July 19, 2002.

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.

Six trials evaluated ESWT for tendinitis of the elbow. Overall, the available data does not provide strong and consistent evidence that ESWT improves outcomes of chronic lateral epicondylitis. Thus, the second TEC criterion is not met. Therefore, based on the above, extracorporeal shock wave treatment for chronic lateral epicondylitis does not meet the TEC criteria.

 

PMID: 15714699

 

Rating: 1b

 

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BlueCross BlueShield. Medicine Section - Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions. Policy No: 90. Effective Date: 05/04/2004

 

Policy/Criteria: ESWT is considered investigational for all indications, including but not limited to plantar fasciitis, lateral epicondylitis, tendinopathies including calcific tendinitis of the shoulder, stress fracture, delayed union, nonunion, and avascular necrosis of the femoral head. In summary, it is not possible to draw conclusions concerning the effect of ESWT on tendinitis of the elbow from the conflicting data reported in the three studies above. This data parallels that for plantar fasciitis in that it is not known whether the different results are due to methodological bias or to differences in the population and intervention.

 

Rating: 7b

 

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BlueCross BlueShield, Durable Medical Equipment Section - Mechanical Devices for Joint Stiffness and Contracture. Policy No: 9. Revised/Effective Date: 12/02/2003

 

Description

Joint stiffness or contracture may occur following illness, trauma, and/or surgery. Mechanical devices for joint stiffness and contracture are prefabricated or custom fabricated to be worn across a stiff or contractured joint and provide incremented tension in order to increase range of motion. Treatment usually consists of progressive sessions used alone or in conjunction with physical therapy. Several types of joint contracture devices are available: a dynamic splint is spring-loaded and designed to apply constant low-intensity stretch force; other devices allow for patient controlled stretch-relaxation for a progressive stretch of the affected joint.

Scientific Background

Active and passive range of motion exercises, as well as progressive splinting, are established interventions for the treatment of a stiff or contractured joints..

 

References

1.      Clinics in Sports Medicine; Volume 19, Number 3, July 2000: W. B. Saunders Company

2.      McClure PW, Blackburn LG, Dusold C. The use of splints in the treatment of joint stiffness: Biologic rationale and an algorithm for making clinical decisions. Phys Ther 1994;74:1101-1107

3.      Bonutti PM, Windau JE, Ables BA et al. Static progressive stretch to reestablish elbow range of motion. Clin Orthop 1994;303:128-134

4.      Crosby, CA, Wehbe MA. Early protected motion after extensor tendon repair. J Hand Surg [AM] 1999;24(5):1061-70

5.      Maddy LS, Meyerdierks EM. Dynamic extension assist splinting of acute central slip lacerations. J Hand Ther 1997;10(3):206-12

6.      Donatelli R, Oltz MW et al. Using static progressive stretch and stress relaxation in the treatment of genohumeral joint capsulitis. Orthopaedic Research Society Annual Meeting, March 2000

7.      Chester DL, Beale S, Beveridge L et al. A prospective, controlled, randomized trial comparing early active extension with passive extension using a dynamic splint in the rehabilitation of repaired extensor tendons. J Hand Surg [Br] 2002;27(3):283-8

8.      Harvey L, Herbert R, Crosbie J. Does stretching induce lasting increases in joint ROM? A systematic review. Physiother Res Int 2002;7(1):1-13

 

Rating: 7b

 

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Boddeker I, Haake M. Extracorporeal shockwave therapy in treatment of epicondylitis humeri radialis. A current overview. Orthopade 2000 May;29(5):463-9.

 

(3) Institut fur Medizinische Biometrie und Epidemiologie, Philipps-Universitat Marburg.

 

A systematic literature search was conducted which yielded 20 relevant papers that described trials on the efficacy of ESWT in the treatment of radiohumeral epicondylitis. These were rated according to biometrical criteria for the conduct of therapeutic trials. None of the rated trials fulfilled all of the criteria, and it is concluded that the efficacy of ESWT in the treatment of epidondylitis can presently be neither confirmed nor excluded.

 

PMID: 10875141

 

Rating: 1b

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Boisaubert B, Brousse C, Zaoui A, Montigny JP. Nonsurgical treatment of tennis elbow. Ann Readapt Med Phys. 2004 Aug;47(6):346-55.

 

Service de medecine physique et de readaptation, hopital Foch, 92150 Suresnes, France. b.boisaubert@hopital-foch.org

 

Corticosteroid injection is the best treatment option for the short term. However, beneficial effects persisted only for a short time, and the long-term outcome could be poor. For the long term, physiotherapy (pulsed ultrasound, deep friction massage and exercise programme) was the best option but was not significantly different from the "wait-and-see" approach. Some support is offered for the use of topical nonsteroid anti-inflammatory drugs, at least for the short term. There is insufficient evidence to support or refute the use of acupuncture, extracorporeal shock wave therapy, manipulation, orthoses, low-energy laser, glycosaminoglycan polysulfate injection, botulinum toxin injection, or topical nitric oxide application.

 

PMID: 15297125

 

Rating: 1b

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Bonutti PM, Windau JE, Ables BA, Miller BG. Static progressive stretch to reestablish elbow range of motion. Clin Orthop Relat Res. 1994 Jun;(303):128-34.

 

Department of Orthopaedic Surgery, University of Arkansas, Little Rock.

 

Static progressive stretch (SPS) is a technique using the biomechanical principle of stress relaxation to restore range of motion (ROM) in joint contractures. The increase in motion for the 20 patients in the study averaged 31 degrees (69%).

 

PMID: 8194222

 

Rating: 3c

 

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Borkholder CD, Hill VA, Fess EE. The efficacy of splinting for lateral epicondylitis: a systematic review. J Hand Ther. 2004 Apr-Jun;17(2):181-99.

 

Department of Occupational Therapy, School of Health & Rehabilitation Sciences, Indiana University, Indianapolis, Indiana USA.

 

To determine the efficacy of using splinting as a treatment for lateral epicondylitis (LE), a systematic review of the literature was conducted on Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, PEDro, and Cochrane databases using pertinent key words and phrases. These articles were copied and further triaged according to predefined criteria, resulting in 22 articles that were numbered randomly and blinded. This review identified one Sackett level 1b study and ten Sackett level 2b studies that offer early positive, but not conclusive, support for the effectiveness of splinting lateral epicondylitis. None of the reviewed studies received a perfect quality score, and the wide range of quality scores attests to the fact that considerable improvement of future studies is essential.

 

PMID: 15162105

 

Rating: 1c

 

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Bouter LM. Insufficient scientific evidence for efficacy of widely used electrotherapy, laser therapy, and ultrasound treatment in physiotherapy. Ned Tijdschr Geneeskd. 2000 Mar 11;144(11):502-5.

 

Instituut voor Extramuraal Geneeskundig Onderzoek, Faculteit der Geneeskunde Vrije Universiteit, Amsterdam. lm.bouter.emgo@med.vu.nl

 

The Dutch Health Council recently published a report on the efficacy of electrotherapy, laser therapy and ultrasound treatment for musculoskeletal disorders. The assessment was based on three systematic reviews, including 169 randomized clinical trials, and focused on a best-evidence synthesis. Virtually no conclusive clinically relevant effects of the three forms of physical therapy were found. Possible exceptions are electrotherapy for osteoarthrosis of the hip or knee, laser therapy for pain treatment and rheumatoid arthritis, and ultrasound treatment for epicondylitis lateralis. But even for these putative indications, further research is clearly needed before implementation in practice is justifiable. It is strongly recommended that the current widespread use of electrotherapy, laser therapy and ultrasound treatment should be reduced, preferably by self-regulation within the profession itself.

 

PMID: 10735134

 

Rating: 5b

 

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Bowen RE, Dorey FJ, Shapiro MS. Efficacy of nonoperative treatment for lateral epicondylitis. Am J Orthop 2001 Aug;30(8):642-6.

 

(1) Department of Orthopaedic Surgery, University of California, Los Angeles, USA.

 

Patients requiring multiple cortisone injections to alleviate acute pain have a guarded prognosis for continued nonoperative management.

 

PMID: 11520020

 

Rating: 3b

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Boyer MI, Hastings H 2nd. Lateral tennis elbow: "Is there any science out there?" J Shoulder Elbow Surg 1999 Sep-Oct;8(5):481-91

 

(2) Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO, USA.

 

The term epicondylitis suggests an inflammatory cause; however, in all but 1 publication examining pathologic specimens of patients operated on for this condition, no evidence of acute or chronic inflammation is found. In this review article we will examine the "myths" of tennis elbow: the name, the salient features on history and physical examination, the diagnostic modalities, the pathology of the "lesion," the anatomy of the lateral elbow and extensor origin and why it has led to such confusion in differential diagnosis, the nonoperative and operative treatment of tennis elbow, and finally the various studies that have been carried out on elbow biomechanics as it relates to the pathoetiology of true "tennis elbow." It is our hope that the reader will emerge with a clearer picture of the pathoetiology of the condition and the scientific rationale (or lack thereof) of the various operative and nonoperative treatment modalities.

 

PMID: 10543604

 

Rating: 5b

 

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Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell P, Wells G, Deep transverse friction massage for treating tendonitis, Cochrane Database Syst Rev. 2002;(4):CD003528

 

School of Rehabilitation Sciences, University of Ottawa, 451 Smyth, Room 3060, Ottawa, ON, Canada, K1H8M5. LBROSSEA@UOTTAWA.CA

 

BACKGROUND: Deep transverse friction massage (DTFM) is one of several physiotherapy interventions suggested for the management of tendinitis pain. OBJECTIVES: To assess the efficacy of DTFM for treating tendinitis. SELECTION CRITERIA: All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing therapeutic ultrasound with control or another active intervention in patients with all types of tendinitis, such as iliotibial band friction syndrome and extensor carpi radialis tendinitis (i.e. tennis elbow or lateral epicondylitis or lateralis epicondylitis humeri), were selected. REVIEWER'S CONCLUSIONS: DTFM combined with other physiotherapy modalities did not show consistent benefit over the control of pain, or improvement of grip strength and functional status for patients with ITBFS or for patients with ECRT. These conclusions are limited by the small sample size of the included RCTs.

 

PMID: 12519601

 

Rating: 1b

 

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Buchbinder R, Green S, White M, Barnsley L, Smidt N, Assendelft WJJ. Shock wave therapy for lateral elbow pain (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.

 

Objectives: To determine the effectiveness and safety of ESWT in the treatment of adults with lateral elbow pain. 

Reviewers' conclusions: The two trials included in this review yielded conflicting results. Further trials

are needed to clarify the value of ESWT for lateral elbow pain.

 

PMID: 16235324

 

Rating: 1b

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Buchbinder R, Green S, Bell S, Barnsley L, Smidt N, Assendelft WJJ. Surgery for lateral elbow pain (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.

 

Objectives: To determine the effectiveness of surgical interventions in the treatment of adults with lateral elbow pain. 

Reviewers' conclusions: At this time there are no published controlled trials of surgery for lateral elbow pain. Without a control group, it is not possible to draw any conclusions about the value of this modality of treatment.

 

PMID: 11869670

 

Rating: 1b

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Buchbinder R, Green S, Youd J, Assendelft W, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. 2005 Oct 19;4:CD003524.

 

OBJECTIVES: To determine the effectiveness and safety of extracorporeal shock wave therapy (ESWT) for lateral elbow pain. SELECTION CRITERIA: We included nine trials that randomised 1006 participants to ESWT or placebo and one trial that randomised 93 participants to ESWT or steroid injection. MAIN RESULTS: Eleven of the 13 pooled analyses found no significant benefit of ESWT over placebo. For example, the weighted mean difference for improvement in pain (on a 100-point scale) from baseline to 4-6 weeks from a pooled analysis of three trials (446 participants) was -9.42 (95% CI -20.70 to 1.86) and the weighted mean difference for improvement in pain (on a 100-point scale) provoked by resisted wrist extension (Thomsen test) from baseline to 12 weeks from a pooled analysis of three trials (455 participants) was -9.04 (95% CI -19.37 to 1.28). Steroid injection was more effective than ESWT at 3 months after the end of treatment assessed by a reduction of pain of 50% from baseline (21/25 (84%) versus 29/48 (60%), p<0.05). AUTHORS' CONCLUSIONS: Based upon systematic review of nine placebo-controlled trials involving 1006 participants, there is "Platinum" level evidence that shock wave therapy provides little or no benefit in terms of pain and function in lateral elbow pain. There is "Silver" level evidence based upon one trial involving 93 participants that steroid injection may be more effective than ESWT.

 

PMID: 16235324

 

Rating: 1b

 

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Buchbinder R, Green SE, Youd JM, Assendelft WJ, Barnsley L, Smidt N. Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain. J Rheumatol. 2006 Jul;33(7):1351-63.

 

Monash Department of Clinical Epidemiology, Cabrini Hospital, Melbourne, Australia. rachelle.buchbinder@med.monash.edu.au

 

OBJECTIVE: To determine the efficacy and safety of extracorporeal shock wave therapy (ESWT) for lateral elbow pain. RESULTS: Nine placebo-controlled trials (1006 participants) and one trial of ESWT versus steroid injection (93 participants) were included. CONCLUSION: Based upon systematic review of 9 placebo-controlled trials, there is "platinum" level evidence that ESWT provides little or no benefit in terms of pain and function in lateral elbow pain. There is "silver" level evidence based upon one trial that steroid injection may be more effective than ESWT.

 

PMID: 16821270

 

Rating: 1b

 

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California Industrial Medical Council, Treatment Guidelines, Elbow Problems, May 15, 1997

 

Rating: 7c

 

 

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Caputo AE, Watson HK. Subcutaneous anterior transposition of the ulnar nerve for failed decompression of cubital tunnel syndrome. J Hand Surg [Am] 2000 May;25(3):544-51.

 

Connecticut Combined Hand Service at Hartford Hospital, University of Connecticut, Hartford 06106, USA.

 

The current literature universally suggests that submuscular anterior transposition is the standard operative treatment for recurrent cubital tunnel syndrome. Subcutaneous anterior transposition of the ulnar nerve proved to be an effective treatment for recurrent cubital tunnel syndrome.

 

PMID: 10811760

 

Rating: 4c

 

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Carayannopoulos A, Borg-Stein J, Sokolof J, Meleger A, Rosenberg D. Prolotherapy versus corticosteroid injections for the treatment of lateral epicondylosis: a randomized controlled trial. PM R. 2011 Aug;3(8):706-15.

 

PARTICIPANTS: Twenty-four subjects with clinically determined chronic (ie, lasting 3 months or longer) lateral epicondylosis were recruited. CONCLUSIONS: Both prolotherapy and corticosteroid therapy were generally well tolerated and appeared to provide benefit of long duration.

 

PMID: 21871414

 

Rating: 2c

 

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Casier PJ, Balle J. Lesion of the radial profundus nerve after injection of a steroid. Ugeskr Laeger 2001 Jun 11;163(24):3364-5.

 

Sonderborg Sygehus, neurologisk afdeling.

 

PMID: 11434126

 

Rating: 11c

 

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Chan RC, Paine KW, Varughese G. Ulnar neuropathy at the elbow: comparison of simple decompression and anterior transposition. Neurosurgery. 1980 Dec;7(6):545-50.

 

The authors report 235 cases of ulnar neuropathy at the elbow. Both simple decompression and anterior transposition result in improvement in 82% of the cases; however, a higher percentage of full recovery was seen in the cases treated by simple decompression.

 

PMID: 7207750

 

Rating: 3b

 

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Chen FS, Rokito AS, Jobe FW. Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg 2001 Mar-Apr;9(2):99-113.

 

Department of Orthopaedic Surgery, Suite 322, University of Southern California School of Medicine, 1510 San Pablo, Los Angeles, CA 90033, USA.

 

Although acute injuries of the medial elbow can occur, the majority are overuse injuries as a result of the repetitive forces imparted to the elbow by throwing. Advances in nonoperative and operative treatment regimens specific to each injury pattern have resulted in the restoration of elbow function and the successful return of most injured overhead athletes to competitive activities.

 

PMID: 11281634

 

Rating: 5b 

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Chillemi C, Marinelli M, De Cupis V. Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertion--clinical and radiological evaluation after 2 years. Arch Orthop Trauma Surg. 2007 Oct;127(8):705-8. Epub 2007 Apr 28.

 

Istituto Chirurgico Ortopedico Traumatologico, Via del Lido, 110, 04100 Latina, Italy. c_chillemi@libero.it

 

Our findings confirm the view that anatomic repair of distal biceps tendon rupture provides consistently good results and early anatomic reconstruction can restore strength and endurance for the elbow.

 

PMID: 17468875

 

Rating: 3c

 

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Choudhery V. The role of diagnostic needle aspiration in olecranon bursitis. J Accid Emerg Med 1999 Jul;16(4):282-3.

 

PMID: 10417940

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Chung B, Wiley JP, Extracorporeal shockwave therapy: a review, Sports Med. 2002;32(13):851-65.

 

Sport Medicine Centre, University of Calgary, Calgary, Alberta, Canada.

 

The exact mechanism by which ESWT relieves tendon-associated pain is not known; however, there is an increasing body of literature that suggests that it can be an effective therapy for patients who have had repeated nonsurgical treatment failures. The highest strength of evidence is shown in randomised controlled trials, of which there are a small number. Reported results for tendinopathies of the shoulder, elbow and heel have shown consistent positive results in favour of ESWT over placebo ESWT in individuals who have failed conservative therapy. There is still much debate over several issues surrounding ESWT that have not been adequately addressed by the literature: high- versus low-energy ESWT, shockwave dosage and number of sessions required for a therapeutic effect. Further research is needed to ascertain the most beneficial protocol for patient care.

 

PMID: 12392445

 

Rating: 5b

 

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Chung B, Wiley JP. Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial. Am J Sports Med. 2004 Oct-Nov;32(7):1660-7.

 

University of Calgary Sport Medicine Centre, Faculty of Kinesiology, Calgary, Alberta, Canada.

 

 METHODS: Sixty subjects who had previously untreated lateral epicondylitis for less than 1 year and more than 3 weeks were included in this study. Subjects were randomly allocated to receive 1 session per week for 3 weeks of either sham or active extra-corporeal shock wave therapy. RESULTS: Success rates in the sham and active therapy groups were 31% and 39%, respectively. No significant difference was detected between groups (chi(2)(1)= 0.3880, P = .533). CONCLUSIONS: Despite improvement in pain scores and pain-free maximum grip strength within groups, there does not appear to be a meaningful difference between treating lateral epicondylitis with extracorporeal shock wave therapy combined with forearm-stretching program and treating with forearm-stretching program alone, with respect to resolving pain within an 8-week period of commencing treatment.

 

PMID: 15494330

 

Rating: 2b

 

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Cleland JA, Whitman JM, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis. J Orthop Sports Phys Ther. 2004 Nov;34(11):713-22; discussion 722-4.

 

Department of Physical Therapy, Franklin Pierce College, Concord, NH 03301, USA. clelandj@fpc.edu

 

METHODS AND MEASURES: Of the 213 charts reviewed, 112 satisfied inclusion-exclusion criteria and were divided into 2 groups: those who received treatment solely directed at the elbow (local management [LM]), or those who received treatment directed at the elbow and cervical manual therapy (LM+C). CONCLUSIONS: The results of this retrospective review suggest that most patients had successful outcomes regardless of the inclusion of manual therapy interventions to the cervical spine. The LM+C group achieved the successful long-term outcome in significantly fewer visits.

 

PMID: 15609491

 

Rating: 3b

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Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol. 2006 Jun;35(6):371-7. Epub 2006 Mar 22.

 

Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, H47 4Lp, UK, david.connell@rnoh.nhs.uk.

 

OBJECTIVE: To assess the efficacy of autologous blood injection under sonographic guidance for the treatment of lateral epicondylitis. RESULTS: Neovascularity also significantly decreased from a median (inter-quartile range) of 6 (4-7) at baseline to 1 (0-3) at 6 months post-procedure (p<0.001), although sonographic abnormality remained in many asymptomatic patients. CONCLUSIONS: Autologous blood injection is a primary technique for the treatment of lateral epicondylitis.

 

PMID: 16552606

 

Rating: 4c

 

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Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet, 22 October 2010. doi:10.1016/S0140-6736(10)61160-9.

 

Findings: 3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. Interpretation: Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia.

 

Rating: 1b

 

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Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010 Nov 20;376(9754):1751-67.

 

FINDINGS: 3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia.

 

PMID: 20970844

 

Rating: 1b

 

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Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013 Feb 6;309(5):461-9. doi: 10.1001/jama.2013.129.

 

Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.

 

PMID: 23385272

 

Rating: 2b

 

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Creaney L, Wallace A, Curtis M, Connell D. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med. 2011 Sep;45(12):966-71.

 

METHODS: Elbow tendinopathy patients who had failed conservative physical therapy were divided into two patient groups: PRP injection (N=80) and autologous blood injection (ABI) (N=70). RESULTS: At 6 months the authors observed a 66% success rate in the PRP group versus 72% in the ABI group, p=NS. There was a higher rate of conversion to surgery in the ABI group (20%) versus the PRP group (10%). CONCLUSION: In patients who are resistant to first-line physical therapy such as eccentric loading, ABI or PRP injections are useful second-line therapies to improve clinical outcomes. In this study, up to seven out of 10 additional patients in this difficult to treat cohort benefit from a surgery-sparing intervention.

 

PMID: 21406450

 

Rating: 2a

 

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Crowther MA, Bannister GC, Huma H, Rooker GD, A prospective, randomised study to compare extracorporeal shock-wave therapy and injection of steroid for the treatment of tennis elbow, J Bone Joint Surg Br. 2002 Jul;84(5):678-9.

 

Department of Orthopaedic Surgery, Southmead Hospital, Bristol, Westbury-on-Trym, UK.

 

After six weeks there was a significant difference between the groups with the mean pain score for the injection group falling from 66 to 21 compared with a decrease from 61 to 35 in the shock-wave group (p = 0.05). After three months, 84% of patients in group 1 were considered to have had successful treatment compared with 60% in group 2. In the medium term local injection of steroid is more successful and 100 times less expensive than ESWT in the treatment of tennis elbow.

 

PMID: 12188483

 

Rating: 2c

 

 

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Cutts S. Cubital tunnel syndrome. Postgrad Med J. 2007 Jan;83(975):28-31.

 

stevenfrcs@hotmail.com

 

Cubital tunnel syndrome is the second most common peripheral nerve entrapment syndrome in the human body. It is the cause of considerable pain and disability for patients. When appropriately diagnosed, this condition may be treated by both conservative and operative means. In this review, the current thinking on this important and common condition is discussed

 

PMID: 17267675

 

Rating: 5b

 

 

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Degreef I, De Smet L. Complications following resection of the olecranon bursa. Acta Orthop Belg. 2006 Aug;72(4):400-3.

 

Department of Orthopaedic Surgery, University Hospital Pellenberg, Belgium. ilse.degreef@uz.kuleuven.ac.be

 

We retrospectively reviewed 37 cases of resection of the olecranon bursa and noted wound healing problems in 10 (27%) and recurrence in 8 (22%).

 

PMID: 17009818

 

Rating: 4b

 

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Demirtas RN, Oner C. The treatment of lateral epicondylitis by iontophoresis of sodium salicylate and sodium diclofenac. Clin Rehabil 1998 Feb;12(1):23-9.

 

(2) Department of Physical Medicine and Rehabilitation, Medical Faculty, Osmangazi University, Eskisehir, Turkey.

 

The results suggest some benefits from the process of iontophoresis and the use of infrared in the treatment of lateral epicondylitis and indicate that iontophoresis of sodium diclofenac is more effective than that of sodium salicylate.

 

PMID: 9549022

 

Rating: 2b

 

 

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Denniston, Kennedy, et al., Official Disability Guidelines, 11th edition, “RTW Raw Data (Calendar-days by decile, with 7-day waiting period)”, December 2006.

 

METHODOLOGY:

Section of ODG showing "RTW Raw Data" displays the CDC data by decile for only those cases with over 7 lost workdays. The 7-day cutoff is chosen so the data would be comparable to the most common reporting systems used for short-term disability, and to the workers’ compensation systems in many states, which have a 7-day waiting period. Showing calendar days off by percentile allows meaningful benchmarking of disability claims experience data, to identify opportunities for improvement. The 50% number is the median and the 90% number can be used to identify “outliers”.

 

FINDINGS:                                                                 50%                 90%

354.2   Ulnar nerve entrapment                         21 days            116 days

            (Cubital tunnel syndrome)

354.3   Radial nerve entrapment                                    28 days            119 days

            (Radial tunnel syndrome)

726.3   Epicondylitis/olecranon bursitis              27 days            44 days

813      Fracture of radius and ulna                                17 days            42 days

832      Dislocation of elbow                                         16 days            42 days

841      Sprains & strains of elbow                                22 days            42 days

 

CONCLUSIONS:

            These durations should be compatible with claims systems, to identify overall norms and to identify “outliers”.

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Denniston, Kennedy, et al., Official Disability Guidelines (ODG), 11th edition, “Return-To-Work Best Practice Guidelines”, December 2006.

[Use link above to start up ODG, or scroll Treatment Protocol for full duration info]

 

FINDINGS:                                                                 modified           w/o modified

354.2   Cubital tunnel syndrome, w/o surgery                0 days              14 days

354.2   Cubital tunnel syndrome, w/surgery                   14 days            21-49 days

354.3   Radial tunnel syndrome                         0-14 days         42 days

726.31 Medial epicondylitis w/o surgery                       0 days              7-42 days

726.32 Lateral epicondylitis w/o surgery                       0 days              7-42 days

726.32 Lateral epicondylitis w/surgery (rare)                 6-21 days         21-42 days

726.33 Olecranon bursitis w/out surgery                       0 days              4-35 days

813      Fracture, stable                                     2 days              14 days

813      Fracture, reduction/manipulation                        14 days            28-42 days

832      Dislocation                                                       0-7 days           10-42 days

841      Sprains & strains                                              4-7 days           21-42 days

 

Following is an example of a complete ODG Best Practice Guideline for

726.32 Lateral epicondylitis (see ODG 2003 for complete duration information and Activity Modifications early return-to-work and modified duty):

 

Return-To-Work "Best Practice" Guidelines

Without surgery, modified work: 0 day

Without surgery, regular manual work: 7 days

Without surgery, heavy manual work: 42 days

Without surgery, heavy manual vibrating work, if cause of disability: indefinite

With surgery (rare), modified work, non-dominant arm: 6 days

With surgery (rare), modified work, dominant arm: 21 days

With surgery (rare), regular work, non-dominant arm: 28 days

With surgery (rare), regular work, dominant arm: 42 days

Acupuncture (3-6 treatments): 7-21 days

 

 

 

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Derebery VJ, Devenport JN, Giang GM, Fogarty WT. The effects of splinting on outcomes for epicondylitis. Arch Phys Med Rehabil. 2005 Jun;86(6):1081-8.

 

Concentra Inc., 5080 Spectrum Drive, Suite 400, West Tower, Addison, TX 75001, USA.

 

OBJECTIVE: To evaluate the effects of splinting on outcomes for injured workers with epicondylitis. PARTICIPANTS: All injured workers (N=4614) receiving primary care for lateral or medical epicondylitis (International Classification of Diseases, 9th Revision, codes 726.31 or 726.32). CONCLUSIONS: Splinting patients with epicondylitis may not optimize outcomes, including rates of limited duty, treatment duration, and medical costs.

 

PMID: 15954044

 

Rating: 3a

 

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Descatha A, Leclerc A, Chastang JF, Roquelaure Y; The Study Group on Repetitive Work, Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors, J Occup Environ Med. 2003 Sep;45(9):993-1001

 

Hopital National de Saint-Maurice, France.

 

A total of 1757 workers were examined by an occupational health physician in 1993-1994. Five hundred ninety-eight of them were reexamined 3 years later. Prevalence was between 4% and 5%, with an annual incidence estimate at 1.5%. Forceful work was a risk factor (odds ratio [OR], 1.95; confidence interval [CI] = 1.15-3.32), but not exposure to repetitive work (OR, 1.11; CI = 0.59-2.10). The prognosis for medial epicondylitis in this population was good with a 3-year recovery rate at 81%.

 

PMID: 14506342

 

Rating: 4b

 

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Descatha A, Leclerc A, Chastang JF, Roquelaure Y; Study Group on Repetitive Work. Incidence of ulnar nerve entrapment at the elbow in repetitive work. Scand J Work Environ Health. 2004 Jun;30(3):234-40.

 

Institut National de la Sante et de la Recherche Medicale (National Institute for Health and Medical Research), U88-IFR 69, Saint-Maurice, France.

 

METHODS: In 1993-1994 and 3 years later, 598 workers whose jobs involved repetitive work underwent an examination by their occupational health physicians and completed a self-administered questionnaire. RESULTS: The annual incidence was estimated at 0.8% per person-year, on the basis of 15 new cases during the 3-year period. Holding a tool in position was the only predictive biomechanical factor [odds ratio (OR) 4.1, 95% confidence interval (95% CI) 1.4-12.0]. Obesity increased the risk of ulnar nerve entrapment at the elbow (OR 4.3, 95% CI 1.2-16.2), as did the presence of medial epicondylitis, carpal tunnel syndrome, radial tunnel syndrome, and cervicobrachial neuralgia. CONCLUSIONS: Despite the limitations of the study, the results suggest that the incidence of ulnar nerve entrapment at the elbow is associated with one biomechanical risk factor (holding a tool in position, repetitively), overweight, and other upper-limb work-related musculoskeletal disorders, especially medial epicondylitis and other nerve entrapment disorders (cervicobrachial neuralgia and carpal and radial tunnel syndromes).

 

PMID: 15250652

 

Rating: 3a

 

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Dick FD, Graveling RA, Munro W, Walker-Bone K; on behalf of the Guideline Development Group. Workplace management of upper limb disorders: a systematic review. Occup Med (Lond). 2010 Dec 2. [Epub ahead of print]

 

RESULTS: 1532 abstracts were identified, 28 papers critically appraised and four papers met the minimum quality standard. There was limited evidence that computer keyboards with altered force displacement characteristics or altered geometry were effective in reducing carpal tunnel syndrome symptoms. There was limited, but high quality, evidence that multi-disciplinary rehabilitation for non-specific musculoskeletal arm pain was beneficial for those workers absent from work for at least four weeks. In adults with tenosynovitis there was limited evidence that modified computer keyboards were effective in reducing symptoms. There was a lack of high quality evidence to inform workplace management of lateral epicondylitis.

 

PMID: 21127200

 

Rating: 1b

 

 

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Doornberg JN, Ring D, Jupiter JB. Static Progressive Splinting for Posttraumatic Elbow Stiffness. J Orthop Trauma. 2006 Jul;20(6):400-404.

 

University of Amsterdam, Orthotrauma Research Center Amsterdam, Academic Medical Center Amsterdam daggerHarvard Medical School, Orthopaedic Hand and Upper Extermity Service, Massachusetts General Hospital.

 

PATIENTS AND INTERVENTION: Over a 3-year period, 29 consecutive patients with elbow stiffness after trauma (flexion contracture greater than 30 degrees or flexion less than 130 degrees) were treated with static progressive elbow splinting when a standard exercise program was no longer achieving gains in motion. CONCLUSIONS: Static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate, particularly after the original injury. Operative treatment of stiffness was avoided in most patients.

 

PMID: 16825965

 

Rating: 3b

 

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Duke JB, Tessler RH, Dell PC. Manipulation of the stiff elbow with patient under anesthesia. J Hand Surg Am. 1991 Jan;16(1):19-24.

 

Department of Orthopaedics, University of Florida, Gainesville 32610.

 

Eleven patients had elbow manipulation under general anesthesia to improve a dysfunctional range of motion. Six (55%) patients improved their motion, three (27%) patients had no significant change, and two (18%) patients lost motion.

 

PMID: 1995685

 

Rating: 4c

 

Only 6 out 11 improved, which may be no better than the natural history of stiff elbow.

 

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D'Vaz AP, Ostor AJ, Speed CA, Jenner JR, Bradley M, Prevost AT, Hazleman BL. Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial. Rheumatology (Oxford). 2006 May;45(5):566-70.

 

Rheumatology Research Unit, Addenbrooke's Hospital, Cambridge University NHS Trust, Cambridge, UK.

 

OBJECTIVES: Pulsed low-intensity ultrasound therapy (LIUS) has been found to be beneficial in accelerating fracture healing and has produced positive results in animal tendon repair. In the light of this we undertook a randomized, double-blind, placebo controlled trial to assess the effectiveness of LIUS vs placebo therapy daily for 12 weeks in patients with chronic lateral epicondylitis (LE). CONCLUSION: In this study LIUS was no more effective for a large treatment effect than placebo for recalcitrant LE. This is in keeping with other interventional studies for the condition.

 

PMID: 16303817

 

Rating: 2c

 

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Edwards SG, Calandruccio JH, Autologous blood injections for refractory lateral epicondylitis, J Hand Surg [Am]. 2003 Mar;28(2):272-8.

 

Department of Orthopaedic Surgery, University of Tennessee, Memphis/Campbell Clinic, USA.

 

PURPOSE: Most nonsurgical treatments for lateral epicondylitis have focused on suppressing an inflammatory process that does not actually exist in conditions of tendinosis. METHOD: Twenty-eight patients with lateral epicondylitis were injected with 2 mL of autologous blood under the extensor carpi radialis brevis. CONCLUSIONS: After autologous blood injection therapy 22 patients (79%) in whom nonsurgical modalities had failed were relieved completely of pain even during strenuous activity. This study offers encouraging results of an alternative minimally invasive treatment that addresses the pathophysiology of lateral epicondylitis that has failed traditional nonsurgical modalities.

 

PMID: 12671860

 

Rating: 3b

 

 

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Efstathopoulos DG, Themistocleous GS, Papagelopoulos PJ, Chloros GD, Gerostathopoulos NE, Soucacos PN. Outcome of partial medial epicondylectomy for cubital tunnel syndrome. Clin Orthop Relat Res. 2006 Mar;444:134-9.

 

Department of Hand Surgery, KAT Hospital, Kifissia, Greece.

 

Partial medial epicondylectomy seems to be safe and reliable for treatment of cubital compression neuropathy at the elbow. Level of Evidence: Therapeutic study, Level IV (case series).

 

PMID: 16446591

 

Rating: 3c

 

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Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg. 2007 Nov;15(11):672-81.

 

Surgical release may be done alone or with nerve transposition at the elbow.

 

PMID: 17989418

 

Rating: 5b

 

 

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Espandar R, Heidari P, Rasouli MR, Saadat S, Farzan M, Rostami M, Yazdanian S, Mortazavi J. Use of anatomic measurement to guide injection of botulinum toxin for the management of chronic lateral epicondylitis: a randomized controlled trial. CMAJ. 2010 Apr 26. [Epub ahead of print]

 

METHODS: In this randomized placebo-controlled trial, 48 patients with chronic refractory lateral epicondylitis were randomly assigned to receive a single injection of either botulinum toxin (60 units) or placebo (normal saline). INTERPRETATION: The use of precise anatomic measurement to guide injection of botulinum toxin significantly reduced pain at rest in patients with chronic refractory lateral epicondylitis. However, the transient extensor lag makes this method inappropriate for patients whose job requires finger extension.

 

PMID: 20421357

 

Rating: 2b

 

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Faes M, van den Akker B, de Lint JA, Kooloos JG, Hopman MT. Dynamic extensor brace for lateral epicondylitis. Clin Orthop Relat Res. 2006 Jan;442:149-57.

 

Department of Physiology, University Medical Centre Nijmegen, The Netherlands.

 

Based on the failure of current therapies, a new dynamic extensor brace has been developed. Brace treatment resulted in significant pain reduction, improved functionality of the arm, and improvement in pain-free grip strength. The beneficial effects of the dynamic extensor brace observed after 12 weeks were significantly different from the treatment group that received no brace.

 

PMID: 16394754

 

Rating: 2c

 

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Faes M, van Elk N, de Lint JA, Degens H, Kooloos JG, Hopman MT. A dynamic extensor brace reduces electromyographic activity of wrist extensor muscles in patients with lateral epicondylalgia. J Orthop Sports Phys Ther. 2006 Mar;36(3):170-8.

 

Department of Physiology, University Medical Centre, Nijmegen, The Netherlands.

 

The results of this study indicate that the dynamic extensor brace as well as the external extension force significantly reduced the EMG signal of the wrist extensor muscles during gripping in patients with lateral epicondylalgia. Based on these results, the dynamic extensor brace could be a promising new intervention for lateral epicondylalgia.

 

PMID: 16596893

 

Rating: 2c

 

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Field LD, Savoie FH. Common elbow injuries in sport. Sports Med 1998 Sep;26(3):193-205.

 

Department of Orthopaedic Surgery, University of Mississippi School of Medicine, Jackson, USA.

 

Lateral epicondylitis can almost always be treated nonoperatively with activity modification and specific exercises. If the athlete fails to respond to nonoperative treatment after 6 months to 1 year, they are candidates for surgical intervention.

 

PMID: 9549022

 

Rating: 5b

 

 

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Filippi R, Charalampaki P, Reisch R, Koch D, Grunert P. Recurrent cubital tunnel syndrome. Etiology and treatment. Minim Invasive Neurosurg 2001 Dec;44(4):197-201.

 

Departement of Neurosurgery, University Mainz, Germany.

 

In summary, reoperation after primary surgery of cubital tunnel syndrome gave satisfactory results in 18 of 22 cases. Subsequent transfer of the ulnar nerve back into the sulcus promises to be useful in cases in which subcutaneous transposition had not been successful.

 

PMID: 11830777

 

Rating: 3c

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Fink M, Wolkenstein E, Karst M, Gehrke A. Acupuncture in chronic epicondylitis: a randomized controlled trial. Rheumatology (Oxford) 2002 Feb;41(2):205-9.

 

Department of Physical Medicine and Rehabilitation, Hannover Medical School, Hannover, Germany.

 

OBJECTIVE: To evaluate the clinical efficacy of acupuncture in the treatment of chronic lateral epicondylitis. CONCLUSION: In the treatment of chronic epicondylopathia lateralis humeri, acupuncture in which real acupuncture points were selected and stimulated was superior to non-specific acupuncture with respect to reduction in pain and improvement in the functioning of the arm. These changes are particularly marked at early follow-up.

 

PMID: 11886971

 

Rating: 2c

 

 

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Foley AE. Tennis elbow. Am Fam Physician 1993 Aug;48(2):281-8.

 

Wright State University School of Medicine, Dayton, Ohio.

 

Patient education, use of a tennis-elbow band and physical therapy play key roles in the management of acute symptoms and in the prevention of recurrence. Surgical intervention is required only when other treatment fails.

 

PMID: 8342481

 

Rating: 5c

 

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Gabel GT. Acute and chronic tendinopathies at the elbow. Curr Opin Rheumatol 1999 Mar;11(2):138-43.

 

(2) Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.

 

Chronic elbow tendinitis (medial or lateral epicondylitis and triceps tendinitis) are common disorders that, overall, have a good prognosis but, even with optimum management, require a minimum of 3 to 6 months to resolve. Patient education, activity modification, splinting, and corticosteroid injections each serve a role in symptom resolution; surgery is required in less than 10% of cases and has a similarly long period (3 to 6 months) of recovery.

 

PMID: 10319218

 

Rating: 5b

 

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Geldschlager S. Osteopathic versus orthopedic treatments for chronic epicondylopathia humeri radialis: a randomized controlled trial. Forsch Komplementarmed Klass Naturheilkd. 2004 Apr;11(2):93-7

 

Praxis fur Osteopathie/Naturheilkunde, Munchen, Germany.

 

MATERIAL AND METHODS: 53 patients were randomly distributed among examination and control group. They were treated for 8 weeks. The osteopathic treatment was done exclusively manually, with parietal, visceral, and craniosacral techniques, individually chosen for each patient. The orthopedic treatment was performed with chiropractic techniques, antiphlogistics, and mostly with injections of cortison. RESULTS: Subjective pain sensation reduced from 50% to 33% (p < 0.01) in the intervention group and from 48% to 32% (p = 0.03) in the orthopedic group. CONCLUSIONS: In this study it was possible to successfully treat the chronic Epicondylopathia humeri radialis with an osteopathic approach. A significant difference to an orthopedic treatment could not be proved.

 

PMID: 15138373

 

Rating: 2c

 

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Gobel F, Musgrave DS, Vardakas DG, Vogt MT, Sotereanos DG. Minimal medial epicondylectomy and decompression for cubital tunnel syndrome. Clin Orthop 2001 Dec;(393):228-36.

 

University of Pittsburgh, Department of Orthopaedic Surgery, PA 15213, USA.

 

This study concluded, “The results show that minimal medial epicondylectomy and in situ decompression of the ulnar nerve is a safe and effective method to treat patients with cubital tunnel syndrome.

 

PMID: 11764352

 

Rating: 2b, 66 elbows

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Goldwirth M, Krasin E, Goodwin DR. Talcum powder in revision surgery for olecranon bursitis. Good outcome in 11 patients. Acta Orthop Scand 1999 Jun;70(3):286-7.

 

Department of Orthopaedic Surgery A, Tel Aviv Sourasky Medical Centre, Israel.

 

We adapted the use of talcum powder in chest surgery to create a reactive pleuritis for treating recurrent olecranon bursitis. The 11 patients who underwent this procedure all had favorable outcomes.

 

PMID: 11764352

 

Rating: 4c

 

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Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011 Jun;39(6):1200-8. doi: 10.1177/0363546510397173.

 

Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years.

 

PMID: 21422467

 

Rating: 2a

 

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Grana W. Medial epicondylitis and cubital tunnel syndrome in the throwing athlete. Clin Sports Med 2001 Jul;20(3):541-8.

 

Department of Orthopaedic Surgery, University of Arizona Health Sciences Center, Tucson, Arizona, USA.

 

Nonetheless, medial stress injuries occur in the throwing athlete, and can cause inflammation of the adjacent anterior capsule flexor pronator mass, the ulnar collateral ligament, and the ulnar nerve. This review highlights these problems, their anatomy, diagnosis, and management.

 

PMID: 11494840

 

Rating: 5b

 

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Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W.  Acupuncture for lateral elbow pain (Cochrane Review). Cochrane Database Syst Rev 2002;(1):CD003527.

 

Australasian Cochrane Centre, Monash University, Australasian Cochrane Centre, Locked Bag 29, CLAYTON, VICTORIA, AUSTRALIA, 3168.

 

There is insufficent evidence to either support or refute the use of acupuncture (either needle or laser) in the treatment of lateral elbow pain. This review has demonstrated needle acupuncture to be of short term benefit with respect to pain, but this finding is based on the results of 2 small trials, the results of which were not able to be combined in meta-analysis. No benefit lasting more than 24 hours following treatment has been demonstrated. No trial assessed or commented on potential adverse effect. Further trials, utilising appropriate methods and adequate sample sizes, are needed before conclusions can be drawn regarding the effect of acupuncture on tennis elbow.

 

PMID: 11869671

 

 

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Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.

 

There is some support for the use of topical NSAIDs to relieve lateral elbow pain at least in the short term. There remains insufficient evidence to recommend or discourage the use of oral NSAID, although it appears injection may be more effective than oral NSAID in the short term. A direct comparison between topical and oral NSAID has not been made and so no conclusions can be drawn regarding the best method of administration.

 

PMID: 12076503

 

Rating: 1b

 

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Greenwald D, Moffitt M, Cooper B. Effective surgical treatment of cubital tunnel syndrome based on provocative clinical testing without electrodiagnostics. Plast Reconstr Surg. 2006 Apr 15;117(5):87e-91e.

 

James A. Haley Veterans' Hospital, Tampa, Fla., USA. docdan@tampabay.rr.com

 

 This study demonstrates the effectiveness of surgical therapy in patients with lesions identified by clinical examination without electrodiagnostic testing.

 

PMID: 16641701

 

Rating: 2b, 24 patients

 

 

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Haahr JP, Andersen JH, Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice, Rheumatology (Oxford). 2003 Oct;42(10):1216-25. Epub 2003 Jun 16.

 

Department of Occupational Medicine, Herning Hospital, Denmark. hecjph@ringamt.dk

 

METHODS: A randomized controlled trial was performed in a cohort of 266 consecutive new cases of lateral epicondylitis diagnosed in general practice. RESULTS: After 1 yr, 83% of cases showed improvement in the condition, but the intervention was found to have had no advantage. CONCLUSIONS: Poor prognosis at 1 yr of follow-up for lateral epicondylitis was related to manual work and high baseline pain, whilst no relation was found between the type of medical treatment given/chosen and prognosis. This may have implications for the future management of lateral epicondylitis in terms of a greater focus on interaction with the workplace regarding job modification to reduce physical demands during recovery.

 

PMID: 12810936

 

Rating: 2b

 

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Haahr JP, Andersen JH, Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study, Occup Environ Med. 2003 May;60(5):322-9.

 

Department of Occupational Medicine, Herning Hospital, DK-7400 Herning, Denmark. hecjph@ringamt.dk

 

METHODS: Case-referent study of 267 new cases of tennis elbow and 388 referents from the background population enrolled from general practices in Ringkjoebing County, Denmark. CONCLUSION: Results indicate that being a new case of tennis elbow is associated with non-neutral postures of hands and arms, use of heavy hand held tools, and high physical strain measured as a combination of forceful work, non-neutral posture of hands and arms, and repetition. Furthermore, tennis elbow among women was associated with low social support at work. The results for precision demanding movements and for vibration were less consistent.

 

PMID: 12709516

 

Rating: 4b

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Haake M, Konig IR, Decker T, Riedel C, Buch M, Muller HH; Extracorporeal Shock Wave Therapy Clinical Trial Group, Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial, J Bone Joint Surg Am. 2002 Nov;84-A(11):1982-91.

 

Klinik fur Orthopadie und Rheumatologie, Philipps-Universitat-Marburg, Baldingerstrasse 1, D-35033 Marburg, Germany. haake2@mailer.uni-marburg.de

 

METHODS: Treatment allocation was blinded for patients and for observers. The planned number of 272 patients was included in the study. RESULTS: The primary end point could be assessed for 90.8% of the patients. The success rate was 25.8% in the group treated with extracorporeal shock wave therapy and 25.4% in the placebo group, a difference of 0.4% with a 95% confidence interval of -10.5% to 11.3%. Similarly, there was no relevant difference between groups with regard to the secondary end points. Improvement was observed in two-thirds of the patients from both groups twelve months after the intervention. Few side effects were reported. CONCLUSIONS: Extracorporeal shock wave therapy as applied in the present study was ineffective in the treatment of lateral epicondylitis. The previously reported success of this therapy appears to be attributable to inappropriate study designs. Different application protocols might improve clinical outcome. We recommend that extracorporeal shock wave therapy be applied only in high-quality clinical trials until it is proved to be effective.

 

PMID: 12429759

 

Rating: 2a

 

 

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Haake M, Boddeker IR, Decker T, Buch M, Vogel M, Labek G, Maier M, Loew M, Maier-Boerries O, Fischer J, Betthauser A, Rehack HC, Kanovsky W, Muller I, Gerdesmeyer L, Rompe JD, Side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of tennis elbow, Arch Orthop Trauma Surg. 2002 May;122(4):222-8. Epub 2002 Jan 12.

 

Klinik fur Orthopadie, Philipps-Universitat Marburg, Baldingerstr. 1, 35033 Marburg, Germany. haake2@mailer.uni-marburg.de

 

Apart from a few observational reports, there are no studies on the side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of insertion tendopathies. ESWT for LE with an energy flux density of ED(+) 0.04 to 0.22 mJ/mm(2) is a treatment method which has very few side-effects. The possibility of migraine being triggered by ESWT and the risk of a syncope should be taken into account in the future.

 

PMID: 12029512

 

Rating: 2a

 

 

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Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ 1999 Oct 9;319(7215):964-8.

 

Staffordshire Rheumatology Centre, The Haywood, Burslem, Stoke on Trent ST6 7AG. Pra19@keele.ac.uk

 

Early local corticosteroid injection is effective for lateral epicondylitis. Outcome at one year was good in all groups, and effective early treatment does not seem to influence this.

 

PMID: 10514160

 

Rating: 2b

 

 

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Hayton MJ, Santini AJ, Hughes PJ, Frostick SP, Trail IA, Stanley JK. Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study. J Bone Joint Surg Am. 2005 Mar;87(3):503-7.

 

Wrightington Hospital, Hall Lane, Appley Bridge, Wigan WN6 9EP, United Kingdom. mjhayton@aol.com

 

BACKGROUND: A recent report has suggested that local injection of botulinum toxin type A is an effective method of treatment for chronic tennis elbow. The toxin is thought to provide temporary paralysis of the painful common extensor origin, thereby allowing a healing response to occur. METHODS: Forty patients with a history of chronic tennis elbow for which all conservative treatment measures, including steroid injection, had failed were randomized into two groups. RESULTS: Three months following the injections, there was no significant difference between the two groups with regard to grip strength, pain, or quality of life. CONCLUSIONS: With the numbers studied, we failed to find a significant difference between the two groups; thus, we have no evidence of a benefit from botulinum toxin injection in the treatment of chronic tennis elbow.

 

PMID: 15741614

 

Rating: 2b

 

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Heithoff SJ. Partial versus minimal medial epicondylectomy. J Hand Surg [Am] 2001 Jul;26(4):786.

 

PMID: 11466659

 

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Heithoff SJ. Cubital tunnel syndrome does not require transposition of the ulnar nerve. J Hand Surg [Am] 1999 Sep;24(5):898-905.

 

Department of Orthopedic Surgery, College of Osteopathic Medicine, Michigan State University, East Lansing, USA.

 

PMID: 11466659

 

 

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Helbig K, Herbert C, Schostok T, Brown M, Thiele R. Correlations between the duration of pain and the success of shock wave therapy. Clin Orthop 2001 Jun;(387):68-71.

 

This study concluded, “Patients who had experienced symptoms in the contralateral heel or elbow for a shorter period were less likely to have a positive result from shock wave therapy than those patients who had received treatments for more chronic symptoms.

 

PMID: 11400896

 

Rating: 4c

 

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Ho C. Extracorporeal shock wave treatment for chronic lateral epicondylitis (tennis elbow). Issues Emerg Health Technol. 2007 Jan;(96 (part 2)):1-4.

 

(1) Electrohydraulic, electromagnetic, or piezoelectric devices are used to translate energy into acoustic waves during extracorporeal shock wave treatment (ESWT) for chronic lateral epicondylitis (CLE) of the elbow (elbow tendonitis or tennis elbow). These waves may help to accelerate the healing process via an unknown mechanism. (2) Results from randomized controlled trials have been conflicting. (3) Limited evidence shows that ESWT is cheaper than arthroscopic surgery, open surgery, and other conservative therapies, such as steroid infiltrations and physiotherapy, that continue for more than six weeks. (4) The lack of convincing evidence regarding its effectiveness does not support the use of ESWT for CLE.

 

PMID: 17302021

 

Rating: 1b

 

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Hoens AM. Low intensity Nd:YAG laser irradiation for lateral epicondylitis. Clin J Sport Med 2002 Jan;12(1):55.

 

University of British Columbia, Vancouver, BC, Canada.

 

PMID: 11871356

 

 

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Hong CZ, Long HA, Kanakamedala RV, Chang YM, Yates L. Splinting and local steroid injection for the treatment of ulnar neuropathy at the elbow: clinical and electrophysiological evaluation. Arch Phys Med Rehabil 1996 Jun;77(6):573-7.

 

Department of Physical Medicine and Rehabilitation, University of California, Irvine, USA.

 

This study with 10 patients concluded, “Splint application alone is adequate to improve the symptoms and ulnar nerve conduction across the elbow. The addition of a steroid injection did not provide further benefit in the treatment of cubital tunnel syndrome.”

 

PMID: 8831474

 

Rating: 2c

 

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Hotchkiss RN. Epicondylitis--lateral and medial. A problem-oriented approach. Hand Clin 2000 Aug;16(3):505-8.

 

(2) Alberto Vilar Center for Research of the Hand and Upper Extremity, New York, New York, USA.

 

Epicondylitis will remain a problematic condition until we better understand the nature of the degenerative condition. Nonoperative management still is the most common treatment, but those patients who are disabled when this fails can expect improvement after surgery.

 

PMID: 10955223

 

Rating: 5c

 

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Howard KJ, Mayer TG, Gatchel RJ. Comparison of chronic occupational upper extremity versus lumbar disorders for differential disability-related outcomes and predictor variables. J Occup Environ Med. 2012 Aug;54(8):1002-9.

 

FRP is equally effective for patients with chronic upper extremity or lumbar spine disorders, regardless of the injury type, site in the upper extremity, or the disparity in injury-specific and psychosocial factors identified before treatment.

 

PMID: 22842915

 

Rating: 3b

 

The study consisted of a consecutive cohort of 2484 patients presenting with either a chronic disabling occupational lumbar disorder or a chronic disabling occupational upper extremity disorder diagnosis, who were admitted to a regional functional restoration program between 1997 and 2007. The upper extremity group included both musculoskeletal (n = 520) and neurocompressive (n = 291) diagnoses. The lumbar group (n = 1673) included those with only a lumbar diagnosis. The upper extremity disorders patients presented with an upper extremity injury, affecting multiple areas (n = 194), the shoulder (n = 299), elbow (n = 56), or wrist or hand (n = 262).

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Jansen CW, Olson SL, Hasson SM. The effect of use of a wrist orthosis during functional activities on surface electromyography of the wrist extensors in normal subjects. J Hand Ther 1997 Oct-Dec;10(4):283-9.

 

(1) University of Texas Medical Branch, Department of Physical Therapy, Galveston 77555-1028, USA. cjansen@utmb.edu

 

It was concluded that application of a wrist orthosis reduces electrical activity of the wrist extensors less than anticipated and only during lifting.

 

PMID: 9399177

 

Rating: 4c

 

 

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Jensen B, Bliddal H, Danneskiold-Samsoe B. Comparison of two different treatments of lateral humeral epicondylitis--"tennis elbow". A randomized controlled trial. Ugeskr Laeger 2001 Mar 5;163(10):1427-31.

 

H:S Frederiksberg Hospital, Parker Instituttet, reumatologisk klinik.

 

We conclude that injections were as effective as splinting in LE. Splinting is recommended in the early stages of the disorder because of its lack of adverse effects. In the long view diagnostics regarding LE have to be refined in order to differentiate patients who are expected to benefit from different treatments.

 

PMID: 11257751

 

Rating: 2c

 

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Jerosch J, Schunck J. Arthroscopic treatment of lateral epicondylitis: Indication, technique and early results. Knee Surg Sports Traumatol Arthrosc. 2005 Aug 3.

 

Klinik fur Orthopadie und Orthopadische Chirurgie, Johanna-Etienne-Krankenhaus, Am Hasenberg 46, 41462, Neuss, Germany, j.jerosch@jek-neuss.de.

 

The purpose of this study is to present the results of the arthroscopic treatment of lateral epicondylitis. Twenty patients with lateral epicondylitis (mean age 42 years) were treated arthroscopically. In conclusion, the arthroscopic release in patients with radial epicondylitis is a reproducible method with a marked postoperative increase in function within a short rehabilitation period.

 

PMID: 16078089

 

Rating: 4c

 

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Junk S, Bilinski PJ, Przelaskowski P, Grygiel M, Garbaczonek M. Evaluation of late results for surgical treatment of chronic lateral epicondylitis. Med Pr 2001;52(1):23-5.

 

(1) Katedry i Kliniki Ortopedii Akademii Medycznej w Bydgoszczy.

 

Two third of the patients were satisfied with the surgery outcome This moderately good general outcome was probably due to the prolonged time passed since the onset of symptoms and repeated local steroid injections. The majority of manual workers returned to their work.

 

PMID: 11424744

 

Rating: 2c

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Juul-Kristensen B, Sogaard K, Stroyer J, Jensen C. Computer users' risk factors for developing shoulder, elbow and back symptoms. Scand J Work Environ Health. 2004 Oct;30(5):390-8.

 

National Institute of Occupational Health, Copenhagen, Denmark. bjk@ami.dk

 

METHODS: A questionnaire on ergonomics, work pauses, work techniques, and psychosocial and work factors was delivered to 5033 office workers at baseline in early 1999 (response rate 69%) and to 3361 respondents at the time of the follow-up in late 2000 (response rate 77%). RESULTS: In the follow-up, 10%, 18%, and 23% had symptoms more often in the elbow, shoulder, and low back, respectively, and 14%, 20%, and 22% had more intense symptoms. Women were more likely to be afflicted than men in all regions. In the full-fit multivariate logistic regression analysis, little influence on the timing of a rest pause and being disturbed by glare or reflection were significant predictors of shoulder symptoms, screen below eye height was a significant predictor for elbow symptoms, and previous symptoms was a significant predictor for symptoms in all regions. CONCLUSIONS: Influence on work pauses, reduction of glare or reflection, and screen height are important factors in the design of future computer workstations.

 

PMID: 15529802

 

Rating: 5a

 

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Kaempffe FA, Farbach J. A modified surgical procedure for cubital tunnel syndrome: partial medial epicondylectomy. J Hand Surg [Am] 1998 May;23(3):492-9.

 

(1) Finger Lakes Hand Surgery, PLLC, Sodus, NY 14551, USA.

 

The results suggest that the procedure is an acceptable alternative for treatment of cubital tunnel syndrome.

 

PMID: 9620190

 

Rating: 3b

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Kaufman RL. Conservative chiropractic care of lateral epicondylitis. J Manipulative Physiol Ther 2000 Nov-Dec;23(9):619-22.

 

(3) Glendale Chiropractic Clinic, Glendale, CA 91205, USA.

 

CLINICAL FEATURES: A 45-year-old woman had difficulty in supinating her left elbow because of pain from activities at work. Standard tests demonstrated and reproduced pain at the lateral epicondyle with resisted extension of the wrist and fingers. CONCLUSION: Resolution of pain and limited elbow motion was demonstrated after Mills' manipulation.

 

PMID: 11145803

 

Rating: 11c

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Kay NR. Litigants' epicondylitis. J Hand Surg [Br]. 2003 Oct;28(5):460-4.

 

Claremont Hospital, Sandygate Road, Sheffield, UK.

 

The speculated pathological causes of tennis elbow and the part work might play in its causation are briefly reviewed. One hundred and eight consecutive patients with tennis elbow who were also litigants (seeking compensation) were reviewed and the result of treatment and specifically surgery, analysed. Disappointing results of surgery were found in litigants and recommendations are made as to the management of litigants epicondylitis.

 

PMID: 12954257

 

Rating: 4b

 

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Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam F, Panahi A. Autologous blood versus corticosteroid local injection in the short-term treatment of lateral elbow tendinopathy: a randomized clinical trial of efficacy. Am J Phys Med Rehabil. 2010 Aug;89(8):660-7. doi: 10.1097/PHM.0b013e3181ddcb31.

 

Autologous blood was more effective in short term than the corticosteroid injection.

 

PMID: 20463564

 

Rating: 2b

 

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Kehlet H, Werner MU. Role of paracetamol (acetaminophen) in the acute pain management. Drugs. 2003;63 Spec No 2:15-22.

 

Departement de Chirurgie Digestive 435 et Centre Anti-douleur, Departement d'Anesthesie, Hopital Universitaire de Hvidovre, Hvidovre, Danemark. henrik.kehlet@hh.hosp.dk

 

In conclusion, paracetamol has a favourable efficacy-tolerability profile and is therefore recommended as a basic, first-line analgesic in acute pain states and as a valuable component in multimodal analgesia.

 

PMID: 14758787

 

Rating: 5a

 

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Khan KM; Cook JL; Kannus P; Maffulli N; Bonar SF, Time to abandon the "tendinitis" myth, BMJ - 16-Mar-2002; 324(7338): 626-7

 

Time to abandon the "tendinitis" myth. Painful, overuse tendon conditions have a non-inflammatory pathology. It is time for medical educators to accept the irrefutable evidence that the term tendonitis must be abandoned to highlight a new perspective on tendon disorders.

 

PMID: 11895810  

 

Rating: 5b

 

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Kleinman WB. Cubital tunnel syndrome: anterior transposition as a logical approach to complete nerve decompression. J Hand Surg [Am] 1999 Sep;24(5):886-97.

 

(2) Indiana Hand Center, Indianapolis, USA.

 

Anterior transposition of the ulnar nerve at the elbow for cubital tunnel syndrome will eliminate natural as well as pathological traction and compression forces; the procedure relieves the nerve of potential microcirculation compromise. Risks of mobilizing the nerve for transposition, however, include iatrogenic ischemia from segmental separation of the nerve from its mesentery-like extrinsic blood supply. Intrinsic interstitial "step-ladder" vessels within the substance of the ulnar nerve allow it to be separated from its extrinsic circulation safely, making anterior transposition a logical and reasonable choice for cubital tunnel syndrome requiring operative intervention.

 

PMID: 10509265

 

Rating: 5b

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Knebel PT, Avery DW, Gebhardt TL, Koppenhaver SL, Allison SC, Bryan JM, Kelly A. Effects of the forearm support band on wrist extensor muscle fatigue. J Orthop Sports Phys Ther 1999 Nov;29(11):677-85.

 

(1) US Army, Ft Riley, Kan., USA. pauli_101@hotmail.com

 

STUDY DESIGN: A crossover experimental design with repeated measures. OBJECTIVE: To determine whether the forearm support band alters wrist extensor muscle fatigue. BACKGROUND: Fatigue of the wrist extensor muscles is thought to be a contributing factor in the development of lateral epicondylitis. The forearm support band is purported to reduce or prevent symptoms of lateral epicondylitis but the mechanism of action is unknown. METHODS AND MEASURES: However, there was a significant reduction in peak grip isometric force and peak wrist extension isometric force values for the with-forearm support band condition (grip force 28%, wrist extension force 26%) compared to the without-forearm support band condition (grip force 18%, wrist extension force 15%). CONCLUSIONS: Wearing the forearm support band increased the rate of fatigue in unimpaired individuals. Our findings do not support the premise that wearing the forearm support band reduces muscle fatigue in the wrist extensors.

 

PMID: 10575645

 

Rating: 4b

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Ko JY, Chen HS, Chen LM. Treatment of lateral epicondylitis of the elbow with shock waves. Clin Orthop 2001 Jun;(387):60-7.

 

(1) Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Kaohsiung, Taiwan.

 

This study concluded, “Shock wave therapy may offer a new and safer nonoperative treatment for patients with lateral epidoncylitis of the elbow.

 

PMID: 11400895

 

Rating: 2b, 56 elbows

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Klaiman MD, Shrader JA, Danoff JV, Hicks JE, Pesce WJ, Ferland J. Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions. Med Sci Sports Exerc 1998 Sep;30(9):1349-55.

 

(2) Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD, USA. mark_klaiman@nih.gov

 

This study concluded, “ultrasound results in decreased pain and increased pressure tolerance in these selected soft tissue injuries. The addition of phonophoresis with fluocinonide does not augment the benefits of ultrasound used alone.”

 

PMID: 9741602

 

Rating: 2b, 49 cases

 

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Kokkalis ZT, Ballas EG, Mavrogenis AF, Soucacos PN. Distal biceps and triceps ruptures. Injury. 2013 Jan 23. pii: S0020-1383(13)00015-6. doi: 10.1016/j.injury.2013.01.003.

 

PMID: 23352149

 

Rating: 5b

 

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Korthals-de Bos IB, Smidt N, van Tulder MW, Rutten-van Molken MP, Ader HJ, van der Windt DA, Assendelft WJ, Bouter LM. Cost effectiveness of interventions for lateral epicondylitis: results from a randomised controlled trial in primary care. Pharmacoeconomics. 2004;22(3):185-95.

 

Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands. ibc.Korthals-de_Bos.EMGO@med.vu.nl

 

PATIENTS AND INTERVENTIONS: Patients with pain at the lateral side of the elbow were randomised to one of three interventions: a wait-and-see policy, corticosteroid injections or physiotherapy. MAIN OUTCOME MEASURES AND 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%). CONCLUSIONS: The results of this economic evaluation provided no reason to update or amend the Dutch guidelines for GPs, which recommend a wait-and-see policy for patients with lateral epicondylitis.

 

PMID: 14871165

 

Rating: 2c

 

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Krischek O, Hopf C, Nafe B, Rompe JD. Shock-wave therapy for tennis and golfer's elbow--1 year follow-up. Arch Orthop Trauma Surg 1999;119(1-2):62-6.

 

(2) Orthopaedic University Hospital Mainz, Germany.

 

Only six patients were satisfied with the treatment. The average relief of pain was 32%. These data were significantly worse than for identically treated patients with chronic tennis elbow. Thus, the question arises as to whether extracorporal shock-wave therapy is indicated in medial epicondylitis.

 

PMID: 10076947

 

Rating: 2b

 

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Krishnan SG, Harkins DC, Pennington SD, Harrison DK, Burkhead WZ. Arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in patients aged under fifty years. J Shoulder Elbow Surg. 2007 Jan 23; [Epub ahead of print].

 

From the Shoulder and Elbow Service, W. B. Carrell Memorial Clinic, Dallas, TX.

 

Open ulnohumeral arthroplasty has been demonstrated to produce satisfactory pain relief and ROM gains. We report the results of an all-arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in younger patients. Eleven consecutive patients aged under 50 years with radiographically documented degenerative elbow arthritis underwent an all-arthroscopic ulnohumeral arthroplasty as described by Savoie et al. All-arthroscopic ulnohumeral arthroplasty provides significant short-term pain relief, as well as restoration of elbow ROM and function, in patients aged under 50 years with degenerative arthritis of the elbow.

 

PMID: 17254810

 

Rating: 4c

 

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Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013 Mar;41(3):625-35. doi: 10.1177/0363546512472975.

 

Neither injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at the primary end point at 3 months. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month in contrast to the other therapies. Injection of glucocorticoid in LE reduces both color Doppler activity and tendon thickness compared with PRP and saline.

 

PMID: 23328738

 

Rating: 2b

 

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Kuklo TR, Taylor KF, Murphy KP, Islinger RB, Heekin RD, Baker CL Jr. Arthroscopic release for lateral epicondylitis: a cadaveric model. Arthroscopy 1999 Apr;15(3):259-64.

 

Orthopaedic Surgery Service, Walter Reed Army Medical Center, Washington, DC 20307, USA.

 

Arthroscopic release of the extensor carpi radialis brevis tendon appears to be a safe, reliable, and reproducible procedure for refractory lateral epicondylitis. Cadaveric dissection confirms these findings.

 

PMID: 10231102

 

Rating: 2c

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Labelle H, Guibert R. Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization. The University of Montreal Orthopaedic Research Group. Arch Fam Med 1997 May-Jun;6(3):257-62.

(2) Division of Orthopaedics, Hopital Sainte-Justine, Universite de Montreal.

 

Taking into account the limited improvement noted over rest and cast immobilization and the number of associated adverse events, it is difficult to recommend the use of diclofenac in the treatment of lateral epicondylitis at the dosage used in this study.

 

PMID: 9161352

 

Rating: 2b

 

 

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Landor I, Vavrik P, Jahoda D, Guttler K, Sosna A. Total elbow replacement with the Souter-Strathclyde prosthesis in rheumatoid arthritis: LONG-TERM FOLLOW-UP. J Bone Joint Surg Br. 2006 Nov;88(11):1460-3.

 

First Orthopaedic Clinic, First Medical Faculty, Charles University, V Uvalu 84, 150 05 Prague 5, Czech Republic.

 

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. Failure of the ulnar component was found to be the main problem in relation to the loosening.

 

PMID: 17075090

 

Rating: 3c

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Lankester BJ, Giddins GE. Ulnar nerve decompression in the cubital canal using local anaesthesia. J Hand Surg [Br] 2001 Feb;26(1):65-6.

 

(1) Department of Orthopaedics and Trauma, Royal United Hospital, Bath, UK.

 

We conclude that decompression of the ulnar nerve under local anaesthetic is a reliable procedure, which is well tolerated by the majority of patients. Copyright 2001 The British Society for Surgery of the Hand.

 

PMID: 11162021

 

Rating: 3c

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Lascar T, Laulan J. Cubital tunnel syndrome: a retrospective review of 53 anterior subcutaneous transpositions. J Hand Surg [Br] 2000 Oct;25(5):453-6.

 

(1) Hand Surgery Unit, Tours, France.

 

Subcutaneous transposition is a reliable and effective surgical option. The result is less satisfactory if a thoracic outlet syndrome is also present. Copyright 2000 The British Society for Surgery of the Hand.

 

PMID: 10991811

 

Rating: 4c

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Lassen CF, Mikkelsen S, Kryger AI, Brandt LP, Overgaard E, Thomsen JF, Vilstrup I, Andersen JH. Elbow and wrist/hand symptoms among 6,943 computer operators: A 1-year follow-up study (the NUDATA study). Am J Ind Med. 2004 Nov;46(5):521-33.

 

Department of Occupational Medicine, The Copenhagen County Hospital in Glostrup, Glostrup, Denmark.

 

BACKGROUND: The aim of this study was to examine relations between computer work aspects and elbow and wrist/hand pain conditions and disorders. METHODS: In a 1-year follow-up study among 6,943 technical assistants and machine technicians self-reported active mouse and keyboard time, ergonomic exposures and associations with elbow and wrist/hand pain were determined. CONCLUSIONS: Detailed examination of self-reported exposures showed that mouse and keyboard time predicted elbow and wrist/hand pain from low exposure levels without a threshold effect, but mouse and keyboard time were not predictors of clinical conditions. Am. J. Ind. Med. 46:521-533, 2004. (c) 2004 Wiley-Liss, Inc.

 

PMID: 15490472

 

Rating: 5a

 

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Lee MJ, LaStayo PC. Pronator syndrome and other nerve compressions that mimic carpal tunnel syndrome. J Orthop Sports Phys Ther. 2004 Oct;34(10):601-9.

 

Physical Therapist, Sonoran Shoulder, Elbow & Hand Rehabilitation, PC, Tucson, AZ 85704, USA. mikeleept@hotmail.com

 

While rare in comparison to carpal tunnel syndrome, pronator syndrome and anterior interosseous nerve syndrome are proximal median nerve compressions that may be suspected if a patient with carpal tunnel syndrome fails to respond to conservative or surgical intervention. Differential diagnosis is based largely on the symptoms, patterns of paresthesia, and specific patterns of muscle weakness. Due to the relative rarity of pronator syndrome and anterior interosseous nerve syndrome, few controlled studies exist to determine the most effective treatment techniques.

 

PMID: 15552706

 

Rating: 5b

 

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Lee JT, Azari K, Jones NF. Long term results of radial tunnel release - the effect of co-existing tennis elbow, multiple compression syndromes and workers' compensation. J Plast Reconstr Aesthet Surg. 2007 Sep 12; [Epub ahead of print]

 

Department of Plastic and Reconstructive Surgery, Mackay Memorial Hospital, Mackay Junior College of Nursing, No. 92, Section 2, Chunsan North Road, Taipei 104, Taiwan.

 

Thirty-three extremities in 31 patients underwent decompression for radial tunnel syndrome between 1994 and 2003, of which 27 extremities in 25 patients were available for long term follow up after an average of 57 months (range 16 to 106 months). The outcome was better in patients with simple RTS (86% good results) compared with patients with additional nerve compression syndromes (57% good results), or patients with coexisting lateral epicondylitis (70% vs 43% good results), or patients who were receiving workers' compensation (73% vs 58% good results).

 

PMID: 17855177

 

Rating: 4b

 

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LeFevre, Denniston, et al. OSHA Durations Report, A Special Report from 1999 BLS OSHA Form 200, Work Loss Data Institute, April 2002.

 

Table 6 illustrates the national OSHA reported occupational illness and injury duration data for 1999 broken down by body part as defined and coded by OSHA.

 

Representative proportion of lost work days for elbow(s) (code 312):   245,619

Representative proportion of total lost work days:                                             10,214,820

 

Elbow(s) as percent of total:                  2.4%

 

 

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Lennon RI, Riyat MS, Hilliam R, Anathkrishnan G, Alderson G. Can a normal range of elbow movement predict a normal elbow x ray? Emerg Med J. 2007 Feb;24(2):86-8.

 

Derby Hospitals, NHS Foundation Trust, London Road, Derby DE1 2QY, UK. iain.lennon@nhs.net

 

RESULTS: 407 patients were entered into the study, of whom 331 received a radiograph of the elbow. CONCLUSION: A two-tier clinical rule for management of elbow injury is proposed: (1) Those patients aged < or = 16 years with a ROM equal to the unaffected side may be safely discharged; (2) Those patients with normal extension, flexion and supination do not require emergent elbow radiographs.

 

PMID: 17251609

 

Rating: 3a

 

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Leone J, Bhandari M, Thoma A. Anterior intramuscular transposition with ulnar nerve decompression at the elbow. Clin Orthop 2001 Jun;(387):132-9.

 

(2) Department of Surgery, St Joseph's Hospital, Canada.

 

This study concluded, “The results showed early clinical improvement of 77% of patients (mean followup, 3.34 months). With repeated assessments later, the same group of patients had clinical improvement of 62% (mean followup, 30.9 months

 

Rating: 4c, 34 patients

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Levin D, Nazarian LN, Miller TT, O'Kane PL, Feld RI, Parker L, McShane JM. Lateral epicondylitis of the elbow: US findings. Radiology. 2005 Oct;237(1):230-4. Epub 2005 Aug 18.

 

Department of Radiology, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107, USA.

 

MATERIALS AND METHODS: US of the common extensor tendon was performed in 20 elbows in 10 asymptomatic volunteers (six men, four women; age range, 22-38 years; mean age, 29.6 years) and 37 elbows in 22 patients with symptoms of lateral epicondylitis (10 men, 12 women; age range, 30-59 years; mean age, 46 years). RESULTS: Sensitivities of US in the detection of symptomatic lateral epicondylitis ranged from 72% to 88% and specificities from 36% to 48.5%.CONCLUSION: US of the common extensor tendon had high sensitivity but low specificity in the detection of symptomatic lateral epicondylitis. 

 

PMID: 16118152

 

Rating: 4c

 

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Lewis M, Hay EM, Paterson SM, Croft P. Local steroid injections for tennis elbow: does the pain get worse before it gets better?: Results from a randomized controlled trial. Clin J Pain. 2005 Jul-Aug;21(4):330-4.

 

Primary Care Sciences Research Centre, Keele University, Staffordshire, United Kingdom. a.m.lewis@cphc.keele.ac.uk

 

METHODS: A total of 164 patients aged 18 to 70 years presenting with a new episode of tennis elbow were recruited and invited to keep a daily record of their pain intensity and medication use over the first 5 days of randomized treatment using a "diary." RESULTS: On day 1, pain scores were higher in the injection group compared with the naproxen group and placebo group, and the injection group was also taking more painkillers. By day 4, the converse was true, pain scores were significantly lower in the injection group than the other 2 groups, and patients given an injection were less likely to be taking painkillers than those in the placebo group. DISCUSSION: Steroid injection was associated with an increase in reported pain for the first 24 hours of treatment, but the therapeutic benefits compared with naproxen and placebo were evident 3 to 4 days after the start of treatment.

 

PMID: 15951651

 

Rating: 2a

 

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Lindenhovius A, Henket M, Gilligan BP, Lozano-Calderon S, Jupiter JB, Ring D. Injection of dexamethasone versus placebo for lateral elbow pain: a prospective, double-blind, randomized clinical trial. J Hand Surg [Am]. 2008 Jul-Aug;33(6):909-19.

 

Harvard Medical School, Boston, MA, USA.

 

METHODS: Sixty-four patients were randomly assigned to dexamethasone (n = 31) or placebo (n = 33) injection. RESULTS: One month after injection, DASH scores averaged 24 versus 27 points (dexamethasone vs placebo), pain 3.7 versus 4.3 cm, and grip strength 83% versus 87%. At 6 months, DASH scores averaged 18 versus 13 points, pain 2.4 versus 1.7 cm, and grip strength 98% versus 97%. CESD and PCS scores correlated with disability as measured by the DASH questionnaire. CONCLUSIONS: Corticosteroid injection did not affect the apparently self-limited course of lateral elbow pain. In secondary analyses in a subset of patients, perceived disability associated with lateral elbow pain correlated with depression and ineffective coping skills. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

 

PMID: 18656765

 

Rating: 2b

 

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Lo YL, Leoh TH, Xu LQ, Nurjannah S, Dan YF. Short-segment nerve conduction studies in the localization of ulnar neuropathy of the elbow: use of flexor carpi ulnaris recordings. Muscle Nerve. 2005 May;31(5):633-6.

 

Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Outram Road, 169608, Singapore. gnrlyl@sgh.com.sg

 

Short-segment nerve conduction studies were performed in 17 limbs with clinical features suggestive of ulnar neuropathy at the elbow. Recording from flexor carpi ulnaris yielded 93% sensitivity, compared with 71.4% when recording from abductor digiti minimi.

 

PMID: 15645413

 

Rating: 4c

 

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Lo MY, Safran MR. Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res. 2007 Oct;463:98-106.

 

Department of Orthopaedic Surgery, Division of Sports Medicine, University of California-San Francisco, San Francisco, CA, USA.

 

For the minority of people with lateral epicondylitis who do not respond to nonoperative treatment, surgical intervention is an option, but confusion exists because of the plethora of options. The surgical techniques for treating lateral epicondylitis can be grouped into three main categories: open, percutaneous, and arthroscopic. Although there are advantages and disadvantages to each procedure, no technique appears superior by any measure. Therefore, until more randomized, controlled trials are done, it is reasonable to defer to individual surgeons regarding experience and ease of procedure.

 

PMID: 17632419

 

Rating: 1c

 

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Lowe JB 3rd, Novak CB, Mackinnon SE. Current approach to cubital tunnel syndrome. Neurosurg Clin N Am 2001 Apr;12(2):267-84.

 

(3) Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.

 

The choice for surgical treatment of cubital tunnel syndrome is no clearer today than when it was reviewed 10 years ago. There continue to be no significant prospective randomized trials to adequately compare the different surgical techniques. Even if such a trial were performed, most hand surgeons would probably continue to be skeptical. In the end, each surgeon must rely on his or her own personal experience or judgment. Based on the authors' experience in the treatment of cubital tunnel syndrome, they are confident that anterior transmuscular transposition of the ulnar nerve obtains the best results when the preoperative algorithm is properly applied and early postoperative physical therapy is instituted.

 

 

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Lugnegård H, Juhlin L, Nilsson BY. Ulnar neuropathy at the elbow treated with decompression. A clinical and electrophysiological investigation. Scand J Plast Reconstr Surg. 1982;16(2):195-200.

 

Forty-four patients with ulnar neuropathy confined to the elbow region were operated with simple decompression. Since the results of simple decompression of the ulnar nerve were similar to those obtained in a previous study of transposition, the former method is recommended as the standard procedure.

 

PMID: 7156904

 

Rating: 4b

 

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Lund AT, Amadio PC. Treatment of cubital tunnel syndrome: perspectives for the therapist. J Hand Ther. 2006 Apr-Jun;19(2):170-8.

 

Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.

 

The treatment of cubital tunnel syndrome provides therapists the opportunity to use a wide variety of their skills. Whether managed surgically or nonoperatively, differential diagnosis, manual therapy, application of therapeutic modalities, splinting, pain management, and facilitating return to work are often all included in a comprehensive treatment plan for return to functional strength and mobility of the affected arm.

 

PMID: 16713864

 

Rating: 5b

 

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Martinez-Silvestrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P, Arendt KW. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther. 2005 Oct-Dec;18(4):411-9, quiz 420.

 

Baystate Medical Education and Research Foundation, Springfield, MA, USA.

 

At six weeks, significant gains were made in all three groups as assessed with pain-free grip strength, Patient-rated Forearm Evaluation Questionnaire, Disabilities of the Arm, Shoulder, and Hand questionnaire, Short Form 36, and visual analog pain scale. No significant differences in outcome measures were noted among the three groups. Although there were no significant differences in outcome among the groups, eccentric strengthening did not cause subjects to worsen.

 

PMID: 16271688

 

Rating: 2c

 

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Mazzocca AD, Spang JT, Arciero RA. Distal biceps rupture. Orthop Clin North Am. 2008 Apr;39(2):237-49, vii.

 

Department of Orthopaedic Surgery, University of Connecticut, John Dempsey Hospital, 263 Farmington Avenue, Farmington, CT 06034-4037, USA. admazzocca@yahoo.com

 

Recognition and treatment of distal biceps tendon ruptures is increasing, likely because of greater clinical awareness and the greater activity and demands of the middle-aged population.

 

PMID: 18374814

 

Rating: 5b

 

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Minnesota Rules, Department Of Labor And Industry, 5221.6300, Upper Extremity Disorders, 11/01/01

 

Rating: 7c

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Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006 Nov;34(11):1774-8. Epub 2006 May 30.

 

Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, 1300 Crane Street, Menlo Park, CA 94025, USA. allan_mishra@yahoo.com

 

METHODS: Twenty of these patients had significant persistent pain for a mean of 15 months (mean, 82 of 100; range, 60-100 of 100 on a visual analog pain scale), despite these interventions. All patients were considering surgery. RESULTS: Eight weeks after the treatment, the platelet-rich plasma patients noted 60% improvement in their visual analog pain scores versus 16% improvement in control patients (P =.001). Sixty percent (3 of 5) of the control subjects withdrew or sought other treatments after the 8-week period, preventing further direct analysis. Therefore, only the patients treated with platelet-rich plasma were available for continued evaluation. At 6 months, the patients treated with platelet-rich plasma noted 81% improvement in their visual analog pain scores (P =.0001). CONCLUSION: Finally, platelet-rich plasma should be considered before surgical intervention.

 

PMID: 16735582

 

Rating: 3c

 

Specially-prepared platelets taken from the patient which are then re-injected into the tendon of the affected elbow provides more relief than more commonly-used therapies which have failed to yield results, often resulting in surgery, concludes study authors Allan Mishra MD and Terri Pavelko, PAC, PT, of the Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, Calif. "Ours is the first in vivo human investigation of this novel biologic treatment for chronic severe elbow tendonitis in patients who have simply 'flunked out' of other treatments," says Dr. Mishra. "Ninety-three percent of patients in our study did well, which is as good a result as patients who have tendon surgery. There is very little risk here; we are using the patient's own blood taken right in the doctor's office, and the whole procedure takes less than an hour," Mishra says. "The results of our pilot study indicate this therapy is as effective as surgery, with sustained and significant improvement over time, no side effects, and high patient acceptance." Platelet-rich plasma contains powerful growth factors that initiate healing in the tendon, but may also send signals to other cells in the body drawing them to the injured area to help in repair, Mishra theorizes. Early studies have shown PRP therapy to be useful in maxillofacial surgery, wound healing, microfracture repair, and in the treatment of plantar faciitis. Treatment with PRP is still considered investigational and further research is needed before it can be made available to the general population. "The body has an extraordinary ability to heal itself," says Mishra. "All we did was speed the process by taking blood from a different area, concentrating it, and putting it back into an area where there was relatively poor blood supply to help repair the damage."

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Mowlavi A, Andrews K, Lille S, Verhulst S, Zook EG, Milner S. The management of cubital tunnel syndrome: a meta-analysis of clinical studies. Plast Reconstr Surg 2000 Aug;106(2):327-34.

 

(1) Southern Illinois University, Institute for Plastic and Reconstructive Surgery, Springfield, USA. amowlavi@siumed.edu

 

A meta-analysis of 30 studies with accurate preoperative and postoperative staging was undertaken. For minimum-staged patients, all modalities produced similar degrees of satisfaction. However, total relief occurred most after medial epicondylectomy and least after anterior subcutaneous transposition. Patients treated nonoperatively had the highest rate of recurrence. For moderate-staged patients, submuscular transposition was most efficacious, whereas patients with nonoperative management fared the worst. Finally, for severe-staged patients, current therapeutic modalities were not consistently effective, with medial epicondylectomy producing the poorest operative result.

 

Rating: 1c

 

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Muller LP, Kamineni S, Rommens PM, Morrey BF. Primary total elbow replacement for fractures of the distal humerus. Oper Orthop Traumatol. 2005 Jun;17(2):119-42.

 

Klinik und Poliklinik fur Unfallchirurgie, Johannes Gutenberg-Universitat, Mainz. mueller@unfall.klinik.uni-mainz.de

 

OBJECTIVE: Achieving stability and pain-free function for osteoporotic intraarticular multifragmentary fractures of the distal humerus in elderly patients by primary total elbow replacement (TER). INDICATIONS: Non-soft-tissue-attached fragments, poor-quality bone, where stable osteosynthesis is not attainable. Severely comminuted intraarticular closed type C fractures according to the AO classification with multiple small bone/cartilage fragments. In case of degenerative joint diseases and/or previous surgery in rheumatoid patients also type A and B fractures. High compliance, low demand, and old patient > 65 years. CONTRAINDICATIONS: Type II or III Gustilo-Anderson open fractures (primary irrigation and debridement). Preexisting infection, open wounds. Younger, high-demand or noncompliant patient. Paralysis of the biceps muscle. POSTOPERATIVE MANAGEMENT: No formal physical-therapy sessions. Avoid single-event weight lifting of > 5 kg and repetitive lifting of > 1 kg. Discourage playing racquets sports. RESULTS: 49 acute distal humeral fractures in 48 patients (average age: 67 years) were treated with TER. The retrospective review supports recommendation for TER for the treatment of an acute distal humeral fracture, when strict inclusion criteria are observed.

 

PMID: 16007382

 

Rating: 3b

 

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Müller MC, Burger C, Wirtz DC, Weber O. Replacement of the comminuted radial head fracture by a bipolar radial head prosthesis. Oper Orthop Traumatol. 2011 Feb;23(1):37-45.

 

INDICATIONS: In acute trauma, a radial head fracture not suitable for internal fixation without (Mason grade III) and with (Mason grade IV) concomitant destabilizing injury, Essex-Lopresti injury, sequelae following radial head resection (e.g., elbow instability or wrist pain), failed reconstruction of the radial head, and tumor-associated radial head or neck resection. RESULTS: A total of 13 patients with 15 radial head prosthesis were analyzed at a mean follow-up of 29.5±20.8 months. In all patients, the elbow was stable. Subjectively, good and excellent results were found with one exception.

 

PMID: 21327953

 

Rating: 4c

 

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Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg [Br]. 2005 Oct;30(5):521-4.

 

Department of Neurosurgery, University Hospital of Saarland, Homburg, Germany.

 

The purpose of this prospective randomised study was to evaluate which operative technique for treatment of cubital tunnel syndrome is preferable: subcutaneous anterior transposition or nerve decompression without transposition. There were no significant differences between the outcomes of the two groups at either postoperative follow-up examination. We recommend simple decompression of the nerve in cases without deformity of the elbow, as this is the less invasive operative procedure.

 

PMID: 16061314

 

Rating: 3c

 

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Nabhan A, Kelm J, Steudel WI, Shariat K, Sova L, Ahlhelm F. Cubital tunnel syndrome - simple nerve decompression or decompression with subcutaneous anterior transposition? Fortschr Neurol Psychiatr. 2007 Mar;75(3):168-71.

 

Neurochirurgische Universitatsklinik, Universitatsklinikum des Saarlandes, Homburg/Saar (Direktor: Prof. Dr. W. Steudel).

 

This study included 66 patients suffering from pain and/either neurological deficits with clinically and electrographically proven cubital tunnel syndrome. Irrespectively of operative procedures (simple decompression vs. subcutaneous anterior transposition) there were no significant differences between the outcomes of the two groups at either postoperative follow-up examination (p > 0.05).

 

PMID: 17230307

 

Rating: 2b

 

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Nathan PA, Istvan JA, Meadows KD. Intermediate and long-term outcomes following simple decompression of the ulnar nerve at the elbow. Chir Main. 2005 Feb;24(1):29-34.

 

Portland Hand Surgery and Rehabilitation Center, Portland, OR 97210-2997, USA. drnathan@qwest.net

 

INTRODUCTION: There is currently little consensus regarding the appropriate surgical approach to treatment of cubital tunnel syndrome (CubTS), and few studies have reported long-term follow-up of patients who have received surgical treatment for ulnar nerve compression at the elbow. METHOD: Seventy-four patients with a total of 102 cases of CubTS treated with simple decompression of the ulnar nerve were examined 1.0-12.4 years postoperatively. RESULTS: Women reported greater clinical improvement than men, and weight gain in men (but not women) predicted less improvement. Relief of cubital tunnel symptoms was greatest for those arms receiving carpal tunnel release surgery simultaneous or subsequent to cubital tunnel release. DISCUSSION: Simple decompression may offer excellent intermediate and long-term relief of symptoms associated with CubTS. Although improvement in ulnar motor nerve conduction velocity occurs following treatment of CubTS, it may not be a consistent marker of perceived symptom relief. Finally, these findings suggest that less complete relief of symptoms following ulnar nerve decompression may be related to unrecognized carpal tunnel syndrome or weight gain.

 

PMID: 15754708

 

Rating: 4b

 

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Nathan PA, Myers LD, Keniston RC, Meadows KD. Simple decompression of the ulnar nerve: an alternative to anterior transposition. J Hand Surg Br. 1992 Jun;17(3):251-4.

 

The post-operative clinical and electrophysiological results of 52 cases of simple decompression (41 patients) are summarized. The advantages of simple decompression make it the procedure of choice for most cases of ulnar neuropathy.

 

PMID: 1624853

 

Rating: 4b

 

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Newcomer KL, Laskowski ER, Idank DM, McLean TJ, Egan KS. Corticosteroid injection in early treatment of lateral epicondylitis. Clin J Sport Med 2001 Oct; 11(4):214-22.

 

Department of Physical Medicine and Rehabilitation, and Section of Biostatistics, Mayo Clinic, Rochester, Minnesota 55905, USA. newcomer.karen@mayo.edu

 

A corticosteroid injection does not provide a clinically significant improvement in the outcome of LE, and rehabilitation should be the first line of treatment in patients with a short duration of symptoms.

 

PMID: 11753057

 

Rating: 2b

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Nirschl RP, Rodin DM, Ochiai DH, Maartmann-Moe C; DEX-AHE-01-99 Study Group, Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. A randomized, double-blinded, placebo-controlled study, Am J Sports Med. 2003 Mar-Apr;31(2):189-95.

 

Nirschl Orthopedic & Sportsmedicine Clinic, Virginia Hospital Center Arlington, Arlington, Virginia 22205, USA.

 

DESIGN: Randomized, double-blinded, placebo-controlled study. METHODS: On six occasions, 1 to 3 days apart within 15 days, 199 patients with elbow epicondylitis received 40 mA-minutes of either active or placebo treatment. RESULTS: More patients treated with dexamethasone than those treated with placebo scored moderate or better on the investigator's global improvement scale (52% versus 33%) at 2 days, but the difference was not significant at 1 month (54% versus 49%). CONCLUSIONS: Iontophoresis treatment was well tolerated by most patients and was effective in reducing symptoms of epicondylitis at short-term follow-up. Copyright 2003 American Orthopaedic Society for Sports Medicine

 

PMID: 12642251

 

Rating: 2b

 

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Novak CB, Mackinnon SE, Stuebe AM. Patient self-reported outcome after ulnar nerve transposition. Ann Plast Surg 2002 Mar;48(3):274-80.

 

Division of Plastic & Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.

 

This study found, “Sixty-one patients who underwent unilateral procedures reported improvement, and there was no difference in 13 unilateral cases.

 

PMID: 11862032

 

Rating: 4b, 100 cases

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Ogilvie-Harris DJ, Gilbart M. Endoscopic bursal resection: the olecranon bursa and prepatellar bursa. Arthroscopy 2000 Apr;16(3):249-53.

 

Toronto Hospital and University of Toronto, Toronto, Ontario, Canada.

 

We treated 31 cases of olecranon bursitis and 19 cases of prepatellar bursitis. The average duration of symptoms before surgery was 1.1 years with a range of 3 months to 4 years. All patients had had preoperative aspiration and injection of cortisone. Patients underwent an arthroscopic bursal resection, removing all the bursal sack that could be seen. The results indicated that 86% of patients after olecranon bursectomy had no pain whatsoever. In the patients with prepatellar bursitis, 66% had no pain whatsoever, but we did note some residual tenderness in 24% of the patients, and 10% had pain on kneeling. There were 2 recurrences; 1 patient had rheumatoid arthritis and 1 repetitive daily trauma to the knee. There were no significant complications.

 

PMID: 10750004

 

Rating: 4c

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Owens BD, Murphy KP, Kuklo TR. Arthroscopic release for lateral epicondylitis. Arthroscopy 2001 Jul;17(6):582-7.

 

Orthopaedic Surgery Service, Walter Reed Army Medical Center, Washington, D.C. 20307, U.S.A.

 

Arthroscopic release effectively treats lateral epicondylitis while also affording visualization of the joint space to address associated intra-articular pathology. Additionally, arthroscopic release is minimally invasive and allows early rehabilitation and return to normal activities.

 

PMID: 11447544

 

Rating:4c

 

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Ozturan KE, Yucel I, Cakici H, Guven M, Sungur I. Autologous blood and corticosteroid injection and extracoporeal shock wave therapy in the treatment of lateral epicondylitis. Orthopedics. 2010 Feb;33(2):84-91. doi: 10.3928/01477447-20100104-09.

 

Autologous blood injection and extracorporeal shock wave therapy gave significantly better Thomsen provocative test results and upper extremity functional scores at 52 weeks; the success rate of corticosteroid injection was 50%, which was significantly lower than the success rates for autologous blood injection (83.3%) and extracorporeal shock wave therapy (89.9%). Corticosteroid injection provided a high success rate in the short term. However, autologous blood injection and extracorporeal shock wave therapy gave better long-term results, especially considering the high recurrence rate with corticosteroid injection. We suggest that the treatment of choice for lateral epicondylitis be autologous blood injection.

 

PMID: 20192142

 

Rating: 2b

 

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Pascarelli EF, Hsu YP. Understanding work-related upper extremity disorders: clinical findings in 485 computer users, musicians, and others. J Occup Rehabil 2001 Mar;11(1):1-21.

 

(1) Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, USA. efp1@columbia.edu

 

A comprehensive upper-body examination produces findings that cannot be obtained through laboratory tests and surveys alone and lays the ground work for generating hypotheses about the etiology of work related upper-extremity disorders that can be tested in controlled investigations.

 

PMID: 11706773

 

Rating: 3a

 

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Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010 Feb;38(2):255-62. doi: 10.1177/0363546509355445.

 

The results showed that, according to the visual analog scores, 24 of the 49 patients (49%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was significantly different (P <.001). The corticosteroid group was better initially and then declined, whereas the PRP group progressively improved. Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection.

 

PMID: 20448192

 

Rating: 2a

 

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Peters T, Baker CL Jr. Lateral epicondylitis. Clin Sports Med 2001 Jul;20(3):549-63.

 

Hughston Clinic, PC, Columbus, Georgia, USA.

 

This article concluded, “More study is needed on outcomes of both nonoperative treatment and operative treatment so that each patient can attain maximal improvement.

 

PMID: 11494841

 

Rating: 5c

 

 

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Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005 Jun;87(6):1297-304.

 

Commonwealth Orthopaedics, 1635 North George Mason Drive, Suite 310, Arlington, VA 22205, USA.

 

BACKGROUND: The use of extracorporeal shock wave therapy for the treatment of lateral epicondylitis is controversial. The purpose of this study was to evaluate the use of extracorporeal shock wave therapy without local anesthesia to treat chronic lateral epicondylitis. METHODS: One hundred and fourteen patients with a minimum six-month history of lateral epicondylitis that was unresponsive to conventional therapy were randomized into double-blind active treatment and placebo groups. The protocol consisted of three weekly treatments of either low-dose shock wave therapy without anesthetic or a sham treatment. RESULTS: A significant difference (p = 0.001) in pain reduction was observed at twelve weeks in the intent-to-treat cohort, with an improvement in the pain score of at least 50% seen in 61% (thirty-four) of the fifty-six patients in the active treatment group who were treated according to protocol compared with 29% (seventeen) of the fifty-eight subjects in the placebo group. This improvement persisted in those followed to one year. Functional activity scores, activity-specific evaluation, and the overall impression of the disease state all showed significant improvement as well (p < 0.05). CONCLUSIONS: These results demonstrate that low-dose shock wave therapy without anesthetic is a safe and effective treatment for chronic lateral epicondylitis.

 

PMID: 15930540

 

Rating: 2b

 

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Pienimaki T, Karinen P, Kemila T, Koivukangas P, Vanharanta H. Long-term follow-up of conservatively treated chronic tennis elbow patients. A prospective and retrospective analysis. Scand J Rehabil Med 1998 Sep;30(3):159-66.

 

Department of Physical Medicine and Rehabilitation, Oulu University Hospital, Finland.

 

This study aimed to assess the long-term outcome of progressive exercise and local pulsed ultrasound in the treatment of 30 chronic tennis elbow patients (2 men, 18 women, mean age 42.3 years).  The progressive exercise evaluated in this study showed beneficial long-term effects compared to ultrasound treatment in terms of pain alleviation and working ability, and the functional overall condition of the exercise patients was also better. Exercise may be able to prevent chronicity and should hence be tried and recommended.

 

PMID: 9782543

 

Rating: 2b

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Piligian G, Herbert R, Hearns M, Dropkin J, Landsbergis P, Cherniack M. Evaluation and management of chronic work-related musculoskeletal disorders of the distal upper extremity. Am J Ind Med 2000 Jan;37(1):75-93.

 

Mount Sinai School of Medicine, The Mount Sinai Hospital, One Gustave L. Levy Place, New York, NY, USA.

 

This clinical review will describe the epidemiology, clinical presentation, and management of the following work-related musculoskeletal disorders (WMSDs) of the distal upper extremity: deQuervain's disease, extensor and flexor forearm tendinitis/tendinosis, lateral and medial epicondylitis, cubital tunnel syndrome, and hand-arm vibration syndrome (HAVS).

 

PMID: 10573598

 

Rating: 5b

 

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Placzek R, Drescher W, Deuretzbacher G, Meiss AL, Hempfing A. Treatment of chronic radial epicondylitis with botulinum toxin a. A double-blind, placebo-controlled, randomized multicenter study. J Bone Joint Surg Am. 2007 Feb;89(2):255-60.

 

Centrum fur Muskuloskeletale Chirurgie, Kliniken fur Orthopadie, Unfall- und Wiederherstellungschirurgie, Campus Virchow-Klinikum, Charite-Universitatsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. richard.placzek@charite.de.

 

BACKGROUND: A preliminary study of injections of botulinum toxin A in patients with chronic epicondylitis has shown promising results. METHODS: In the present prospective, controlled, double-blinded clinical trial, 130 patients were examined at sixteen study centers. RESULTS: The group treated with botulinum toxin A was found to have a significant improvement in the clinical findings, compared with those in the placebo group, as early as the second week after injection (p = 0.003). As was expected as a side effect, extension of the third finger was observed to be significantly weakened at two weeks but this complication had completely resolved at eighteen weeks. CONCLUSIONS: We concluded that local injection of botulinum toxin A is a beneficial treatment for radial epicondylitis (tennis elbow). The treatment can be performed in an outpatient setting and does not impair the patient's ability to work. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

 

PMID: 17272437

 

Rating: 2b

 

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Posner MA. Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-17.

 

New York University School of Medicine, USA.

 

He reported that treatment was most successful for mild neuropathies, a conclusion few would challenge. Excellent results were also achieved in 50% of patients with mild neuropathies that were treated nonsurgically and in more than 90% treated by surgery, regardless of the procedure. For moderate neuropathies, nonsurgical treatment was generally unsuccessful, as were decompressions in situ. Medial epicondylectomies were effective in only 50% of cases and they had the highest recurrence rate. Regarding ulnar nerve transpositions, each method has its proponents, usually based on the training and experience of the surgeon. Subcutaneous transposition is the least complicated. It is an effective procedure, particularly in the elderly and in patients who have a thick layer of adipose tissue in their arms. It is the procedure of choice for repositioning the nerve during surgical reductions of acute fractures, arthroplasties of the elbow, and secondary neurorrhaphies. Intramuscular and submuscular transpositions are more complicated procedures. Although proponents of intramuscular transposition report favorable results, the procedure can result in severe postoperative perineural scarring. Submuscular transposition has a high degree of success and is generally accepted to be the preferred procedure when prior surgery has been unsuccessful.

 

PMID: 10829185

 

Rating: 5b

 

 

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Posner MA. Compressive ulnar neuropathies at the elbow: II. treatment. J Am Acad Orthop Surg. 1998 Sep-Oct;6(5):289-97.

 

Operative procedures include decompression without transposition of the nerve (in situ or by means of medial epicondylectomy) and decompression with transposition of the nerve carried out in a subcutaneous, intramuscular, or submuscular fashion.

 

PMID: 9753756

 

Rating: 5b

 

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Putnam MD, Cohen M. Painful conditions around the elbow. Orthop Clin North Am 1999 Jan;30(1):109-18.

 

Department of Orthopedic Surgery, University of Minnesota Hospital, Minnesota 55455, USA.

 

PMID: 9882729

 

Rating: 5c

 

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Rabago D, Best TM, Zgierska AE, Zeisig E, Ryan M, Crane D. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. Br J Sports Med. 2009 Jul;43(7):471-81. Epub 2008 Nov 21.

 

RESULTS: Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. CONCLUSIONS: There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.

 

PMID: 19028733

 

Rating: 1b

 

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Reeser JC, Smith DT, Fischer V, Berg R, Liu K, Untiedt C, Kubista M. Static magnetic fields neither prevent nor diminish symptoms and signs of delayed onset muscle soreness. Arch Phys Med Rehabil. 2005 Mar;86(3):565-70.

 

Department of Physical Medicine and Rehabilitation, Marshfield Clinic, Marshfield, WI, USA. reeser.jonathan@marshfieldclinic.org

 

PARTICIPANTS: Twenty-three healthy volunteers (18 women; mean age, 30 y; range, 18-40 y; 5 men; mean age, 29 y; range, 19-39 y). INTERVENTION: After exhaustive eccentric exercise of both the right and left elbow flexor muscle groups, subjects received daily treatment with either a 350G magnet or a placebo device for 5 consecutive days. RESULTS: No significant difference in outcome variables existed between the treated and control arms. Participants reported less pain in both treated and control arms after each session, suggesting a placebo effect. CONCLUSIONS: Static magnetic fields were no more effective than placebo in preventing DOMS.

 

PMID: 15759245

 

Rating: 2c

 

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Reveille JD. Soft-tissue rheumatism: diagnosis and treatment. Am J Med 1997 Jan 27;102(1A):23S-29S.

 

(2) Division of Rheumatology/Immunogenetics, University of Texas-Houston Health Sciences Center 77030, USA.

 

The keys to the diagnosis of soft-tissue rheumatism are the history and, more importantly, the physical examination. Extensive laboratory testing and radiographs are not as helpful in evaluating patients with these complaints. Treatment consists of nonsteroidal anti-inflammatory drugs (NSAIDs) and nonnarcotic analgesics. Especially in patients with localized disorders, intralesional injections of corticosteroids are particularly effective and safe and should be part of the armamentarium of the primary care practitioner.

 

PMID: 9217556

 

Rating: 5b

 

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Robertson C, Saratsiotis J. A review of compressive ulnar neuropathy at the elbow. J Manipulative Physiol Ther. 2005 Jun;28(5):345.

 

A definitive diagnosis can best be made using clinical tests along with nerve conduction studies and electromyography, conservative treatment can be effective in treating this neuropathy in mild cases; in moderate or severe cases, surgery may be necessary.

 

PMID: 15965409

 

Rating: 5c

 

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Roe C, Odegaard TT, Hilde F, Maehlum S, Halvorsen T. No effect of supplement of essential fatty acids on lateral epicondylitis. Tidsskr Nor Laegeforen. 2005 Oct 6;125(19):2615-8.

 

Norsk idrettsmedisinsk institutt (NIMI), Sognsveien 75D, 0855 Oslo. cecilie.roe@ulleval.no

 

BACKGROUND: Essential fatty acids influence the production of prostaglandins, which is suggested to be of importance for the development of chronic degenerative changes in tendons. MATERIAL AND METHODS: 55 patients with unilateral epicondylitis were treated with eccentric training of the wrist extensor muscles for 6 months. CONCLUSION: Reported pain was reduced and force increased gradually over 6 months with eccentric training. No additional effect was observed with a fatty acid supplement.

 

PMID: 16215602

 

Rating: 2b

 

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Rompe JD, Riedel C, Betz U, Fink C. Chronic lateral epicondylitis of the elbow: A prospective study of low-energy shockwave therapy and low-energy shockwave therapy plus manual therapy of the cervical spine. Arch Phys Med Rehabil 2001 May;82(5):578-82.

 

Department of Orthopaedics, Johannes Gutenberg University School of Medicine, Mainz, Germany. rompe@mail.uni-mainz.de

 

This study of 30 patients concluded, “ESWT may be an effective conservative treatment method for unilateral chronic tennis elbow. The efficacy of additional cervical manual therapy for lateral epicondylitis remains questionable.

 

PMID: 11346831

 

Rating: 2c

 

 

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Rompe JD, Decking J, Schoellner C, Theis C. Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med. 2004 Apr-May;32(3):734-43.

 

Department of Orthopaedic Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany. rompe@mail.uni-mainz.de

 

BACKGROUND: There is conflicting evidence regarding extracorporeal shock wave treatment for chronic tennis elbow. METHODS: Seventy-eight patients enrolled in a placebo-controlled trial. All patients were tennis players with recalcitrant MRI-confirmed tennis elbow of at least 12 months' duration. RESULTS: In the treatment group, 65% of patients achieved at least a 50% reduction of pain, compared with 28% of patients in the sham group (P =.001 for between-group difference). CONCLUSION: Low-energy extracorporeal shock wave treatment as applied is superior to sham treatment for tennis elbow.

 

PMID: 15090392

 

Rating: 2b

 

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Rotini R, Fontana M, Catamo L, Noia F, Magnani M. Lateral epicondylitis: clinical classification and proposal for treatment. Chir Organi Mov 2000 Jan-Mar;85(1):57-64

 

Modulo di Chirurgia della Spalla e del Gomito della 1a Divisione, Istituto Ortopedico Rizzoli, Bologna.

 

They conclude with the proposal to classify 3 clinical forms for epicondylitis (acute, chronic recurrent, and chronic persistent) and to follow a corresponding treatment protocol, aimed at improving results.

 

PMID: 11569029

 

Rating: 3b

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Runeson L, Haker E, Iontophoresis with cortisone in the treatment of lateral epicondylalgia (tennis elbow)--a double-blind study, Scand J Med Sci Sports. 2002 Jun;12(3):136-42

 

Borashalsan, Boras, Sweden.

 

Sixty-four patients suffering from lateral epicondylalgia were consecutively randomized into two groups for corticosteroid or placebo iontophoresis. The results of the present study do not support the use of corticosteroid iontophoresis in lateral epicondylalgia.

 

PMID: 12135445

 

Rating: 2c

 

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Scarpone M, Rabago DP, Zgierska A, Arbogast G, Snell E. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008 May;18(3):248-54.

 

PARTICIPANTS: Twenty-four adults with at least 6 months of refractory lateral epicondylosis. CONCLUSIONS: Prolotherapy with dextrose and sodium morrhuate was well tolerated, effectively decreased elbow pain, and improved strength testing in subjects with refractory lateral epicondylosis compared to Control group injections.

 

PMID: 18469566

 

Rating: 2b

 

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Schweitzer M, Morrison WB. Arthropathies and inflammatory conditions of the elbow. Magn Reson Imaging Clin N Am 1997 Aug;5(3):603-17.

 

Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

 

MR imaging of arthropathies and inflammatory conditions affecting the elbow are presented. Noninfectious conditions discussed include osteoarthritis, disorders characterized by synovial proliferation, pigmented villo- nodular synovitis, synovial osteochondromatosis, crystal deposition disorders, and neuropathic osteoarthropathy. Infectious conditions discussed include septic olecranon bursitis, septic arthritis, osteomyelitis, and pyomyositis.

 

PMID: 9219721

 

Rating: 5c

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Sennoune B, Costa V, Dumontier C. Arthroscopic treatment of tennis elbow: preliminary experience with 14 patients. Rev Chir Orthop Reparatrice Appar Mot. 2005 Apr;91(2):158-64.

 

Service de Chirurgie Orthopedique, CHU Ibn R'ch, Casablanca, Maroc.

 

Between September 2000 and February 2004, we treated arthroscopically fourteen patients with epicondylitis which failed to respond to medical treatment given for a mean duration of 15.8 months. We used the Mayo Clinic score to assess outcome which was excellent or good in nine patients, fair in one and poor in four. The ideal treatment remains a question of discussion.

 

PMID: 15908886

 

Rating: 4c

 

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Seradge H. Cubital tunnel release and medial epicondylectomy: effect of timing of mobilization. J Hand Surg [Am] 1997 Sep;22(5):863-6.

 

Hand Center of Oklahoma, Oklahoma City 73109, USA.

 

Institution of ROM exercises immediately after surgery was found to be more effective in preventing elbow flexion contractures, obtaining a quicker recovery, and allowing return to work with no ill effects.

 

PMID: 9330146

 

Rating: 2c 

 

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Seradge H, Owen W. Cubital tunnel release with medial epicondylectomy factors influencing the outcome. J Hand Surg [Am] 1998 May;23(3):483-91.

 

Department of Orthopaedics, The Hand Institute of Oklahoma, Orthopaedic & Reconstructive Center, Oklahoma City 73109, USA.

 

Therefore, higher recurrence rates should be anticipated in female patients, in patients with concomitant ipsilateral thoracic outlet syndrome and/or carpal tunnel syndrome, in patients in their third or fourth decade of life, or in patients not returning to work within 3 months after surgery.

 

PMID: 9620189

 

Rating: 3a

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Seror P. Treatment of ulnar nerve palsy at the elbow with a night splint. J Bone Joint Surg Br 1993 Mar;75(2):322-7.

 

Laboratoire d'Electromyographie, Paris, France.

 

Twenty-two patients with ulnar nerve palsy at the elbow, confirmed by electromyography, were treated by a night splint which prevented flexion of the elbow beyond 60 degrees. There was improvement in the symptoms in every patient, including three who had failed to respond to surgical decompression.

 

PMID: 8444959

 

Rating: 4c

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Sevier TL, Wilson JK. Treating lateral epicondylitis. Sports Med 1999 Nov; 28(5):375-80

 

Ball Memorial Sports Medicine Fellowship, Muncie, Indiana, USA.

 

Over 40 different treatment methods for lateral epicondylitis have been reported in the literature. Initially, lateral epicondylitis can be treated with rest, ice, tennis brace and/or injections. Injections are one of the most popular methods utilised, with a high success rate. However, when the condition is chronic or not responding to initial treatment, physical therapy is initiated. Common rehabilitation modalities utilised are ultrasound, phonophoresis, electrical stimulation, manipulation, soft tissue mobilisation, neural tension, friction massage, augmented soft tissue mobilisation (ASTM) and stretching and strengthening exercise. ASTM is becoming a more popular modality due to the detection of changes in the soft tissue texture as the patient progresses through the rehabilitation process. Other new modalities include laser and acupuncture. As a last resort for chronic or resistant cases, lateral epicondylitis may undergo surgery. Scientific research has found that all these methods have been inconsistently effective in treating lateral epicondylitis.

 

PMID: 10593647

 

Rating: 5b

 

 

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Simunovic Z, Trobonjaca T, Trobonjaca Z. Treatment of medial and lateral epicondylitis--tennis and golfer's elbow--with low level laser therapy: a multicenter double blind, placebo-controlled clinical study on 324 patients. J Clin Laser Med Surg 1998 Jun;16(3):145-51.

 

Laser Center, Locarno, Switzerland. tzlatko@mamed.medri.hr

 

RESULTS: Total relief of the pain with consequently improved functional ability was achieved in 82% of acute and 66% of chronic cases, all of which were treated by combination of TPs and scanner technique. CONCLUSIONS: This clinical study has demonstrated that the best results are obtained using combination treatment (i.e., TPs and scanner technique). Good results are obtained from adequate treatment technique correctly applied, individual energy doses, adequate medical education, clinical experience, and correct approach of laser therapists.

 

PMID: 9743652

 

Rating: 2a 

 

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Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002 Feb 23; 359(9307): 657-62.

 

Institute for Research in Extramural Medicine, Faculty of Medicine, VU University Medical Centre, 1081 BT Amsterdam, Netherlands. n.smidt.emgo@med.vu.nl

 

FINDINGS: 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. INTERPRETATION: 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.

 

Rating: 2b

 

 

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Smidt N, Assendelft WJJ, Windt DAWM van der, Hay EM, Buchbinder R, Bouter LM. Corticosteroid injections for tennis elbow (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.

 

PMID: 11932058

 

Rating: 1b

 

Assendelft concluded that corticosteroid injections appear to be relatively safe and seem to have a short-term effect (2-6 weeks) when administered in a secondary care setting.

 

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Smidt N, Assendelft WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, van der Windt DA, Bouter LM, Effectiveness of physiotherapy for lateral epicondylitis: a systematic review, Ann Med. 2003;35(1):51-62.

 

Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands. n.smidt.emgo@med.vu.nl

 

RESULTS: 23 RCTs were included in the review, evaluating the effects of lasertherapy, ultrasound treatment, electrotherapy, and exercises and mobilisation techniques. The pooled estimate of the treatment effects of two studies on ultrasound compared to placebo ultrasound, showed statistically significant and clinically relevant differences in favour of ultrasound. There is insufficient evidence either to demonstrate benefit or lack of effect of lasertherapy, electrotherapy, exercises and mobilisation techniques for lateral epicondylitis. 

 

PMID: 12693613

 

Rating: 1c

 

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Smidt N, Lewis M, Hay EM, Van der Windt DA, Bouter LM, Croft P. A comparison of two primary care trials on tennis elbow: issues of external validity. Ann Rheum Dis. 2005 Oct;64(10):1406-9. Epub 2005 Mar 30.

 

Primary Care Science Research Centre, Keele University, Keele, Staffordshire, UK. n.smidt@vumc.nl

 

RESULTS: Local injections differed between the two studies with respect to volume, number, and steroid preparation. However, after 1, 6, and 12 months, the treatment effects of steroid injections were very similar between the study populations. CONCLUSIONS: Despite large differences in study population at baseline, the responses to steroid injections were remarkably similar.

 

PMID: 15800009

 

Rating: 1c

 

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Smith NA. Lateral epicondylitis in a hospital phlebotomist--an ergonomic solution. Occup Med (Lond) 2001 Dec;51(8):513-5.

 

Occupational Health Department, Airedale General Hospital, Skipton Road, Steeton, Nr Keighley, West Yorkshire BD20 6TD, UK. NSmith2@bradford-ha.nhs.uk

 

This report outlines a case of lateral epicondylitis in a hospital phlebotomist thought to be due to the forceful gripping, and repetitive twisting, involved in breaking the seals on green vacutainer needles. An ergonomic solution in the form of a device to aid breaking of the vacutainer seals is presented. The importance of seeking ergonomic solutions with manufacturers is highlighted.

 

PMID: 11741085

 

Rating: 11c

 

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Speed CA, Nichols D, Richards C, Humphreys H, Wies JT, Burnet S, Hazleman BL, Extracorporeal shock wave therapy for lateral epicondylitis--a double blind randomised controlled trial, J Orthop Res. 2002 Sep;20(5):895-8.

 

Rheumatology Research Unit, Addenbrooke's Hospital, Cambridge, UK. cas50@medschl.cam.ac.uk

 

RESULTS: Seventy-five subjects participated and there were no significant differences between the two groups at baseline. Both groups showed significant improvements from two months. No significant difference existed between the groups with respect to the degrees of change in pain scores over the study period. CONCLUSIONS: There appears to be a significant placebo effect of moderate dose ESWT in subjects with lateral epicondylitis but there is no evidence of added benefit of treatment when compared to sham therapy.

 

PMID: 12382950

 

Rating: 2c

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Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis. A prospective study of sixty elbows. J Bone Joint Surg Am 1997 Nov;79(11):1648-52.

 

Department of Plastic and Reconstructive Surgery, Rambam Medical Center, Haifa, Israel.

 

We believe that the improvement observed in both groups primarily reflects the natural history of the disorder, and we conclude that the local injection of steroids provides only short-term benefits in the treatment of medial epicondylitis.

 

PMID: 9384424

 

Rating: 2b

 

 

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Stal M, Hagert CG, Englund JE. Pronator syndrome: a retrospective study of median nerve entrapment at the elbow in female machine milkers. J Agric Saf Health. 2004 Nov;10(4):247-56.

 

Department of Agricultural Biosystems and Technology, Swedish University of Agricultural Sciences, Alnarp, Sweden. marianne.stal@jbt.slu.se

 

Pronator syndrome (median nerve entrapment at the elbow) is a rare condition, but it is more common among women than men. clinical examination focused on two parameters: focal tenderness and individual muscle strength. The results showed that the surgical group had no focal tenderness on palpation over the median nerve at the elbow and no selective weakness in the muscles examined, as compared to what was found before surgery. In the non-surgical group, focal tenderness was found in 12 out of 14, and 10 out of 14 showed the same weakness as in an earlier examination. While this study has limitations in sample size, surgical release of the median nerve at the elbow level, in cases of pronator syndrome, appears to provide an immediate as well as long-term return to normal strength of FPL and FDP II, along with a significant improvement in subjective status. In the non-surgical group, spontaneous improvement of the strength of FPL and FDP II was found in only four out of the 14 cases.

 

PMID: 15603224

 

Rating: 3b

 

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Stefanou A, Marshall N, Holdan W, Siddiqui A. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg Am. 2012 Jan;37(1):104-9.

 

Dexamethasone via iontophoresis produced short-term benefits because for this group grip strength and unrestricted return to work were significantly better. This study suggests that this iontophoresis technique for delivery of corticosteroid may be considered a treatment option for patients with lateral epicondylitis.

 

PMID: 22196293

 

Rating: 2b

 

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Solveborn SA. Radial epicondylalgia ('tennis elbow'): treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements. Scand J Med Sci Sports 1997 Aug;7(4):229-37.

 

 Department of Orthopaedics, Academic Hospital, Uppsala, Sweden.

 

Stretching or upper forearm bands were used in the treatment of radial epicondylalgia ('tennis elbow') in a prospective study of 185 patients. Both treatments were successful with a continuous symptom reduction, but the outcome was statistically significant in favour of stretching at all follow-ups, as assessed by subjective evaluation on a visual analogue pain scale, tabulated pain and condition alternatives on questionnaires, and objective findings such as palpation tenderness at the radial epicondyle, the (Mills') 'tennis elbow pain test', and range-of-motion.

 

PMID: 9241029

 

Rating: 3b

 

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Spacca G, Necozione S, Cacchio A. Radial shock wave therapy for lateral epicondylitis: a prospective randomised controlled single-blind study. Eura Medicophys. 2005 Mar;41(1):17-25.

 

Physical Medicine and Rehabilitation Unit, Department of Neuroscience, San Salvatore Hospital, L'Aquila, Italy.

 

METHODS: In a prospective randomized controlled single-blind study, of 75 eligible patients, 62 with tennis elbow were randomly assigned to study group and control group. CONCLUSION: The use of RSWT allowed a decrease of pain, and functional impairment, and an increase of the pain-free grip strength test, in patients with tennis elbow. The RSWT is safe and effective and must be considered as possible therapy for the treatment of patients with tennis elbow.

 

PMID: 16175767

 

Rating: 2b

 

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Staples MP, Forbes A, Ptasznik R, Gordon J, Buchbinder R. A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow). J Rheumatol. 2008 Oct;35(10):2038-46. Epub 2008 Sep 15.

 

Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia.

 

METHODS: Sixty-eight patients from community-based referring doctors were randomized to receive 3 ESWT treatments or 3 treatments at a subtherapeutic dose given at weekly intervals. CONCLUSION: Our study found little evidence to support the use of ESWT for the treatment of lateral epicondylitis and is in keeping with recent systematic reviews of ESWT for lateral epicondylitis that have drawn similar conclusions.

 

PMID: 18792997

 

Rating: 2b

 

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Stasinopoulos D. The use of polarized polychromatic non-coherent light as therapy for acute tennis elbow/lateral epicondylalgia: a pilot study. Photomed Laser Surg. 2005 Feb;23(1):66-9.

 

Rheumatolory and Rehabilitation Centre, Orfanidou 16, Patissia, Athens 11141, Greece. d_stasinopoulous@yahoo.com

 

OBJECTIVE: The aim of this study was to assess the efficacy of polarized, polychromatic, non-coherent, low energy light (Bioptron 2, Bioptron AG, Switzerland) in the treatment of acute tennis elbow. METHODS: A pilot study was carried out with 25 patients who had acute tennis elbow. CONCLUSION: Although the results suggested that the Bioptron 2 could reduce patients' symptoms with acute tennis elbow, future controlled studies are needed to establish the relative and absolute effectiveness of Bioptron 2.

 

PMID: 15782036

 

Rating: 4c

 

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Stasinopoulos D, Johnson MI. Effectiveness of extracorporeal shock wave therapy for tennis elbow (lateral epicondylitis). Br J Sports Med. 2005 Mar;39(3):132-6.

 

Centre of Rheumatology and Rehabilitation, Athens, Greece. d_stasinopoulos@yahoo.gr

 

Seven relevant trials were found, which had satisfactory methodology but conflicting results. Further research with well designed randomised control trials is needed to establish the absolute and relative effectiveness of this intervention for tennis elbow.

 

PMID: 15728688

 

Rating: 1c

 

 

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Stasinopoulos D, Stasinopoulou K, Johnson MI. An exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med. 2005 Dec;39(12):944-7.

 

School of Health and Human Sciences, Faculty of Health, Leeds Metropolitan University, Leeds LS1 3HE, UK. d_stasinopoulos@yahoo.gr

 

STRETCHING EXERCISES: Static stretching is defined as passively stretching a given muscle-tendon unit by slowly placing and maintaining it in a maximal position of stretch.

 

PMID: 16306504

 

Rating: 5c

 

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Stasinopoulos DI, Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg. 2005 Aug;23(4):425-30.

 

School of Health and Human Sciences, Leeds Metropolitan University, Leeds, UK. d_stasinopoulos@yahoo.gr

 

CONCLUSIONS: LLLT need not be ruled out for LET as it is a dose-response modality, and the optimal treatment dose has obviously not yet have been discovered. Further research with well-designed RCTs is needed to establish the absolute and relative effectiveness of this intervention for LET.

 

PMID: 16144488

 

Rating: 1c

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Stell IM. Management of acute bursitis: outcome study of a structured approach. J R Soc Med 1999 Oct;92(10):516-21.

Accident & Emergency Department, Guy's Hospital, London, UK.

 

In patients with septic bursitis the indications for admission and surgical intervention remain unclear, and practice has varied widely. The effectiveness of a conservative outpatient based approach was assessed by an outcome study in a prospective case series. The management protocol, with specific criteria for admission and surgical intervention, thus produced good results with little need for operation or admission.

 

PMID: 10692903

 

Rating: 4c

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Steven Moore J. Biomechanical models for the pathogenesis of specific distal upper extremity disorders. Am J Ind Med 2002 May;41(5):353-369 [epub ahead of print].

 

(3) Department of Occupational and Environmental Health, School of Rural Public Health, Texas A&M Health Science Center.

 

Two models were proposed for lateral epicondylitis. One emphasized the role of eccentric exertions; the other emphasized contact pressure from the radial head. ConclusionsIt is possible to propose biologically plausible models of pathogenesis that are both coherent with current knowledge of tissue responses and consistent with clinical observations; however, more than one model was plausible for some conditions. Additional research is needed to determine which, if any, of the proposed models might be correct.. Am. J. Ind. Med. 41:353-369, 2002. Copyright 2002 Wiley-Liss, Inc.

 

PMID: 12071489

 

Rating: 5b

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Stewart NJ, Manzanares JB, Morrey BF. Surgical treatment of aseptic olecranon bursitis. J Shoulder Elbow Surg 1997 Jan-Feb;6(1):49-54.

 

Department of Orthopedics, Mayo Clinic, Rochester, MN 55905, USA.

 

This article found, “Most cases of aseptic olecranon bursitis respond to conservative treatment, yet some will develop a chronic bursitis with sufficient symptoms to warrant surgery Properly performed surgical treatment of aseptic olecranon bursitis appears to offer long-lasting symptomatic relief to patients without rheumatoid arthritis.

 

PMID: 9071682

 

Rating: 4a

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Struijs PA, Spruyt M, Assendelft WJ, van Dijk CN. The predictive value of diagnostic sonography for the effectiveness of conservative treatment of tennis elbow. AJR Am J Roentgenol. 2005 Nov;185(5):1113-8.

 

Department of Orthopaedic Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD Amsterdam, The Netherlands.

 

SUBJECTS AND METHODS: Patients with tennis elbow complaints were randomized. Sonography was performed before randomization in 57 patients. CONCLUSION: No predictive value of sonography for the detection of abnormalities was identified in this study. Its diagnostic capability showed limited value. However, limitations in this study necessitate drawing definitive conclusions with care.

 

PMID: 16247118

 

Rating: 2c

 

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Struijs PA, Smidt N, Arola H, van Dijk CN, Buchbinder R, Assendelft WJ. Orthotic devices for tennis elbow: a systematic review. Br J Gen Pract 2001 Nov;51(472):924-9.

 

Academic Medical Center, Department of Orthopaedic Surgery, Amsterdam, The Netherlands. p.a.struys@amc.uva.nl

 

No definitive conclusions can be drawn concerning effectiveness of orthotic devices for lateral epicondylitis. More well-designed and well-conducted RCTs of sufficient power are warranted.

 

 PMID: 11869609

 

Rating: 1b

 

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Struijs PA, Damen PJ, Bakker EW, Blankevoort L, Assendelft WJ, van Dijk CN, Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study, Phys Ther. 2003 Jul;83(7):608-16.

 

Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, PO Box 22600, 1100 DD Amsterdam, The Netherlands. paastruijs@hotmail.com

 

BACKGROUND AND PURPOSE: Lateral epicondylitis ("tennis elbow") is a common entity. Several nonoperative interventions, with varying success rates, have been described. The aim of this study was to compare the effectiveness of 2 protocols for the management of lateral epicondylitis: (1) manipulation of the wrist and (2) ultrasound, friction massage, and muscle stretching and strengthening exercises. SUBJECTS AND METHODS: Thirty-one subjects with a history and examination results consistent with lateral epicondylitis participated in the study. RESULTS: Differences were found for 2 outcome measures: success rate at 3 weeks and decrease in pain at 6 weeks. Both findings indicated manipulation was more effective than the other protocol. After 3 weeks of intervention, the success rate in group 1 was 62%, as compared with 20% in group 2. After 6 weeks of intervention, improvement in pain as measured on an 11-point numeric scale was 5.2 (SD=2.4) in group 1, as compared with 3.2 (SD=2.1) in group 2. DISCUSSION AND CONCLUSION: Manipulation of the wrist appeared to be more effective than ultrasound, friction massage, and muscle stretching and strengthening exercises for the management of lateral epicondylitis when there was a short-term follow-up. However, replication of our results is needed in a large-scale randomized clinical trial with a control group and a longer-term follow-up.

 

PMID: 12837122

 

Rating: 2c

 

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Struijs PA, Kerkhoffs GM, Assendelft WJ, Van Dijk CN. Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both-a randomized clinical trial. Am J Sports Med. 2004 Mar;32(2):462-9.

 

Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands. paastrujis@hotmail.com

 

BACKGROUND: The authors evaluated the effectiveness of brace-only treatment, physical therapy, and the combination of these for patients with tennis elbow. RESULTS: A total of 180 patients were randomized. Physical therapy was superior to brace only at 6 weeks for pain, disability, and satisfaction. Contrarily, brace-only treatment was superior on ability of daily activities. Combination treatment was superior to brace on severity of complaints, disability, and satisfaction. At 26 weeks and 52 weeks, no significant differences were identified. CONCLUSION: Conflicting results were found. Brace treatment might be useful as initial therapy. Combination therapy has no additional advantage compared to physical therapy but is superior to brace only for the short term.

 

PMID: 14977675

 

Rating: 2b

 

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Struijs PA, Korthals-de Bos IB, van Tulder MW, van Dijk CN, Bouter LM, Assendelft WJ. Cost effectiveness of brace, physiotherapy, or both for treatment of tennis elbow. Br J Sports Med. 2006 Jul;40(7):637-43; discussion 643.

 

Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, The Netherlands. paastruijs@hotmail.com

 

OBJECTIVES: The hypothesis of the trial was that no difference exists in the cost effectiveness of physiotherapy, braces, and a combination of the two for treatment of tennis elbow. CONCLUSION: No clinically relevant or statistically significant differences in costs were identified between the three strategies.

 

PMID: 16687482

 

Rating: 2b

 

 

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Struijs PA, Smit G, Steller EP. Radial head fractures: effectiveness of conservative treatment versus surgical intervention : A systematic review. Arch Orthop Trauma Surg. 2007 Feb;127(2):125-30.

 

Department of General Surgery and traumatology, St. Lucas Andreas Hospital, Frederik Hendrikplantsoen 74-2, 1052 XW, Amsterdam, The Netherlands, paastruijs@hotmail.com.

 

MATERIALS AND METHODS: Electronic databases from 1966 to 2004 were screened. Based on our inclusion criteria, 24 studies, describing 825 patients, were included. CONCLUSIONS: There is insufficient evidence to be able to draw definitive conclusions on optimal treatment of type II-IV radial head fractures. Evidence is currently limited to a maximum level II evidence. There is great need for sufficiently powered randomized controlled trials.

 

PMID: 17066285

 

Rating: 1b

 

 

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Suresh SP, Ali KE, Jones H, Connell DA. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment? Br J Sports Med. 2006 Nov;40(11):935-9; discussion 939.

 

Department of Radiology, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.

 

METHODS: Twenty patients (13 men, 7 women) with refractory medial epicondylitis with symptom duration of 12 months underwent sonographic evaluationDISCUSSION: The combined action of dry needling and autologous blood injection under ultrasound guidance appears to be an effective treatment for refractory medial epicondylitis as demonstrated by a significant decrease in VAS pain and a fall in the modified Nirschl scores.

 

PMID: 16990441

 

Rating: 4c

 

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Szabo SJ, Savoie FH 3rd, Field LD, Ramsey JR, Hosemann CD. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):721-7. Epub 2006 Sep 11.

 

Orthopaedic Specialists of Gastonia, Gastonia, NC, USA.

 

The purpose of this report is to compare 3 operative methods for treatment of recalcitrant lateral epicondylitis-open, arthroscopic, and percutaneous. We included 109 patients in the study: 24 percutaneous, 44 arthroscopic, and 41 open procedures. Open, arthroscopic, and percutaneous treatments of lateral epicondylitis offer 3 highly effective ways for the clinician to address this common clinical problem.

 

PMID: 16963287

 

Rating: 3b

 

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Technology Evaluation Center, Blue Cross Blue Shield Association. Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications. Technol Eval Cent Asses Program Exec Summ. 2003 Feb;18(5):1-3.

 

Extracorporeal shock wave treatment for musculoskeletal indications does not meet the Blue Cross and Blue Shield Association Technology Evaluation Center (TEC) criteria for evidence-based medicine.

 

Rating: 1b

 

Plantar Fasciitis. The scientific evidence does not permit conclusions concerning the effect of the technology on health outcomes of plantar fasciitis. The literature on ESWT for plantar fasciitis is the most robust body of evidence of any of the indications considered in this Assessment. There are 3 randomized double-blind, placebo-controlled trials that together include over 600 patients. Two of these trials (HealthTronics, Dornier) report a statistically significant improvement in pain measures, but the improvement is small and not generally accompanied by improvement in activity or use of pain medication. The third trial (Buchbinder) reported that ESWT was no better than placebo. Overall, the results of the trials are inconclusive. Because the above conclusion is a reversal of the 2001 TEC Assessment on ESWT for plantar fasciitis, the evidence bases for the 2001 and 2003 Assessments are compared in the following paragraphs.

Tendinitis of the Shoulder. There is not sufficient evidence to permit conclusions on whether ESWT improves outcomes for patients with tendinitis of the shoulder. The highest quality evidence, 2 randomized, placebo-controlled (n=114 total) trials including one that was doubleblinded found no significant differences between treatment and control groups. Outcomes measured were shoulder pain and disability index, Constant and Murley score for functional assessment of the shoulder, pain at rest and pain with activity. Two other studies (n=159 total) were nonrandomized and uncontrolled, including one that compared ESWT with surgery. These studies reported significant results favoring ESWT, but represent a poor quality of trial design.

Tendinitis of the Elbow. There are 2 trials that evaluated ESWT for tendinitis of the elbow. Both were randomized, double-blind, placebo-controlled trials. The first (n=114) reported statistically significant improvement in pain on resisted extension and the upper extremity function score. The second (n=75) reported no group differences on elbow pain during the day or at night. This study appeared to have some group differences at baseline, although none was reported as statistically significant. Thus, the existing evidence from randomized, controlled trials does not permit conclusions on the effect of ESWT for tendinitis of the elbow.

Therefore, based on the above, extracorporeal shock wave treatment for musculoskeletal

indications does not meet the TEC criteria.

 

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Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A. Platelet-Rich Plasma Versus Autologous Whole Blood for the Treatment of Chronic Lateral Elbow Epicondylitis: A Randomized Controlled Clinical Trial. Am J Sports Med. 2011 Aug 2. [Epub ahead of print]

 

Methods: Twenty-eight patients were divided equally into 2 groups, after blocked randomization. Conclusion: Regarding pain reduction, PRP treatment seems to be an effective treatment for chronic lateral elbow epicondylitis and superior to autologous blood in the short term. Defining details of indications, best PRP concentration, number and time of injections, as well as rehabilitation protocol might increase the method's effectiveness.

 

PMID: 21813443

 

Rating: 2c

 

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Theis C, Herber S, Meurer A, Lehr HA, Rompe JD. Evidence-based evaluation of present guidelines for the treatment of tennis elbow -- a review. Zentralbl Chir. 2004 Aug;129(4):252-60.

 

Orthopadische Klinik und Poliklinik der Johannes Gutenberg-Universitat Mainz.

 

For the acute phase, reviews or RCTs failed to show a clinical effect beyond placebo if follow-up was extended over 6 weeks. For the chronic phase a current Cochrane review failed to identify any controlled trial regarding surgical procedures during the last decades. Therefore surgery is not indicated before repetitive low-energy extracorporeal shock wave therapy (ESWT) has been applied. This novel treatment, under strictly standardized conditions, showed effects beyond placebo in independent randomised placebo-controlled trials for follow-up periods of 3 and 6 months.

 

PMID: 15354245

 

Rating: 1c

 

 

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Thompson JD. Comparison of flexion versus extension splinting in the treatment of Mason type I radial head and neck fractures. J Orthop Trauma. 1988;2(2):117-9.

 

Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee.

 

At an average of 18.4 months after fracture, 20 adult patients with nondisplaced radial head or neck fractures were examined regarding manner of treatment and functional outcome: 11 patients were initially immobilized in 90 degrees flexion and nine patients were immobilized in straight extension. The manner of initial treatment did not seem to affect ultimate outcome; symptomatic treatment and splinting followed by early range of motion would appear to produce uniformly good results.

 

PMID: 3230494

 

Rating: 4b

 

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Thurston AJ. Conservative and surgical treatment of tennis elbow: a study of outcome. Aust N Z J Surg 1998 Aug;68(8):568-72.

 

Department of Surgery, Wellington School of Medicine, New Zealand. surgat@kokako.wnmeds.ac.nz

 

RESULTS: In this study we found that 67% of patients who presented with tennis elbow received relief through steroid injections either alone or in combination with a tennis elbow band or nonsteroidal anti-inflammatory drugs.

 

PMID: 9715133

 

Rating: 3c

 

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Tomaino MM, Brach PJ, Vansickle DP. The rationale for and efficacy of surgical intervention for electrodiagnostic-negative cubital tunnel syndrome. J Hand Surg [Am] 2001 Nov;26(6):1077-81.

 

Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.

 

Because the results of surgery are known to be inferior once objective motor weakness and abnormal 2-point sensory discrimination (McGowan grades 2 and 3) develop, however, we advocate surgical intervention for patients with symptoms only, even when electrodiagnostic studies are normal. We enrolled 16 patients (18 elbows) with McGowan I cubital syndrome who underwent in situ ulnar nerve release and medial epicondylectomy. Paresthesias resolved in all cases, and both elbow range of motion and grip strength returned to normal in 17 of 18 elbows. The elbow flexion test resolved in all cases, and a Tinel's sign was present at final review in 5 elbows (28%).

 

PMID: 11721254

 

Rating: 4c

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Tonks JH, Pai SK, Murali SR. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial. Int J Clin Pract. 2007 Feb;61(2):240-6.

 

The Department of Orthopaedic Surgery, Royal Albert Edward Infirmary (part of Wigan, Wrightington and Leigh NHS Trust), Wigan, UK.

 

The relative merits of a watch and wait policy, physiotherapy alone, steroid injection therapy alone, and physiotherapy and steroid injection therapy combined, for the treatment of tennis elbow, were assessed using a prospective randomised controlled trial (RCT) of factorial design. On the basis of the results of this study, the authors advocate steroid injection alone as the first line of treatment for patients presenting with tennis elbow demanding a quick return to daily activities.

 

PMID: 17166184

 

Rating: 2c

 

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Trebinjac S, Mujic-Skikic E, Ninkovic M, Karaikovic E. Extracorporeal shock wave therapy in orthopaedic diseases. Bosn J Basic Med Sci. 2005 May;5(2):27-32.

 

Physical Medicine & Rehabilitation Department, Rashid Hospital, Dubai, UAE. s4965@hotmail.com

 

The application of extracorporeal shock wave therapy (ESWT) as a treatment for different orthopaedic conditions has experienced a rapid increase over the last several years. However the mechanism of action and the therapeutic effect is not clear. The aim of this study was to review the literature about the efficacy of ESWT in the treatment of plantar fasciitis, lateral epicondylitis, shoulder painful disorders and non-union fractures. Only randomized controlled studies published in the last 5 years were retrieved from electronic database and manual search. Results on efficacy of ESWT are controversial. Studies that have claimed therapeutic benefit did not fulfill scientific criteria and controlled randomized trials were not able to confirm significant improvement after treatment with ESWT.

 

PMID: 16053451

 

Rating: 5b

 

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Trinh KV, Phillips SD, Ho E, Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford). 2004 Sep;43(9):1085-90. Epub 2004 Jun 22.

 

School of Medicine, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5.

 

METHODS: From the six studies that met inclusion criteria, the first author, year of publication, population studied, dropout rate, treatment plan, assessment scale and outcome measures were extracted. RESULTS: All the studies suggested that acupuncture was effective in the short-term relief of lateral epicondyle pain. Five of six studies indicated that acupuncture treatment was more effective compared to a control treatment. CONCLUSIONS: There is strong evidence suggesting that acupuncture is effective in the short-term relief of lateral epicondyle pain.

 

PMID: 15213328

 

Rating: 1b

 

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Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther. 2004 Apr-Jun;17(2):243-66.

 

Canadian Forces Base Kingston, Ontario, Canada.

 

A total of 209 studies were located; however, only 31 of these met the study inclusion criteria. Each of the articles was randomly allocated to reviewers and critically appraised using a structured critical appraisal tool with 23 items. This review has determined, with at least level 2b evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, Rebox, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. There is also at least level 2b evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of this condition.

 

PMID: 15162109

 

Rating: 1a

 

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Tsai TM, Chen IC, Majd ME, Lim BH. Cubital tunnel release with endoscopic assistance: results of a new technique. J Hand Surg [Am] 1999 Jan;24(1):21-9.

 

(1) Christine M. Kleinert Institute for Hand and Micro Surgery, Louisville, KY 40202, USA.

 

The results of this study support our recommendation of cubital tunnel release with endoscopic assistance as a safe and reliable technique for the treatment of cubital tunnel syndrome, especially in patients with mild to moderate symptoms.

 

PMID: 10048512

 

Rating: 3b

 

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Tyler TF, Karas SG. Eccentric Exercise Technique Offers Easy, Affordable Intervention for Chronic Lateral Epicondylitis. American Orthopaedic Society for Sports Medicine (AOSSM) 35th Annual Meeting: Abstract 8345. Presented July 11, 2009.

 

Eccentric exercises with a simple wrist-extending rubber cylinder could help alleviate pain for people with chronic lateral epicondylitis and offer a practical, cost-effective alternative to treatments such as cortisone injections, topical nitric oxide, and isokinetic dynamometry. Timothy F. Tyler, PT, ATC, a clinical research associate at the Nicholas Institute of Sports Medicine and Athletic Trauma in New York City, and colleagues randomized patients with pain from chronic lateral epicondylitis resulting from tennis or golf that lasted at least 6 weeks and who had undergone no previous surgical treatment into 2 groups: an eccentric group of 6 men and 5 women (average age, 47 ± 2 years); and a standard-treatment group of 4 men and 6 women (average age, 51 ± 4 years). Both groups received wrist-extensor stretching, ultrasound, cross-friction massage, and heat and ice therapy. The standard-treatment group performed isotonic wrist-extensor strengthening, and the eccentric group performed isolated eccentric wrist-extensor strengthening using a rubber cylinder, called the Flexbar (Hygenic Corp). The exercises involved twisting the cylinder with concentric wrist flexion of the noninvolved arm, and releasing the twist with eccentric wrist extension of the involved arm. The exercise was performed in 3 sets of 15 repetitions daily, and the intensity increased over the treatment period. Results were recorded at baseline and after the treatment period using a Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and a visual analog pain scale (VAS). Tenderness was recorded with a hand-held myometer just distal to the lateral epicondyle, and wrist and middle finger extension strength was measured with a hand-held dynamometer. The eccentric group reported an improvement of 76% in their DASH score; the standard-treatment group reported an improvement of 12% (P = .01). VAS improvement was 81% for the eccentric group and 22% for the standard-treatment group (P = .002), tenderness was improved by 70% in the eccentric group and 4% in the standard-treatment group (P = .003), and strength of the wrist and middle finger was improved 72% in the eccentric group and 11% in the standard-treatment group (P = .032). The eccentric group had a significant improvement in the amount of disability [reported in the DASH score], compared to the standard-treatment group, and there was also a significant decrease in pain, compared to the standard-treatment group. As for wrist extension, there was a percent deficit from the involved to noninvolved arm, with a significant increase in strength and decrease in deficit between the eccentric [and] standard-treatment groups," he added. "And there was a marked reduction in tenderness in the eccentric group. Mr. Tyler noted that physical-therapy facilities are not always accessible or affordable. The wrist-extensor device, which he said sells for $8, represents a highly valuable therapy for many. The exercise Tyler and his coauthors described is a simple, home-based program that eliminates the need for expensive machines and can be done in the convenience and comfort of the patient's home.

 

Rating: 10a

 

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Uzunca K, Birtane M, Tastekin N. Effectiveness of pulsed electromagnetic field therapy in lateral epicondylitis. Clin Rheumatol. 2007 Jan;26(1):69-74.

 

Trakya University Medical Faculty Physical Medicine and Rehabilitation Department, Edirne, Turkey. druzunca@yahoo.com

 

We aimed to investigate the efficacy of pulsed electromagnetic field (PEMF) in lateral epicondylitis comparing the modality with sham PEMF and local steroid injection. Sixty patients with lateral epicondylitis were randomly and equally distributed into three groups as follows: Group I received PEMF, Group II sham PEMF, and Group III a corticosteroid + anesthetic agent injection. VAS values during activity and pain levels during resisted wrist dorsiflexion were significantly lower in Group III than Group I at the third week. Group I patients had lower pain during rest, activity and nighttime than Group III at third month. PEMF seems to reduce lateral epicondylitis pain better than sham PEMF. Corticosteroid and anesthetic agent injections can be used in patients for rapid return to activities.

 

PMID: 16633709

 

Rating: 2b

 

 

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van Brakel RW, Eygendaal D. Intra-articular injection of hyaluronic acid is not effective for the treatment of post-traumatic osteoarthritis of the elbow. Arthroscopy. 2006 Nov;22(11):1199-203.

 

Department of Orthopaedics, Amphia Hospital, Breda, The Netherlands.

 

METHODS: In 18 patients. CONCLUSIONS: Because the use of viscosupplementation for the treatment of post-traumatic osteoarthritis of the elbow provides only slight, short-term pain relief and a very limited decrease in activity impairment and the other parameters were not modified, we believe that viscosupplementation is not suitable for this indication.

 

PMID: 17084297

 

Rating: 3c

 

 

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Van De Streek MD, Van Der Schans CP, De Greef MH, Postema K. The effect of a forearm/hand splint compared with an elbow band as a treatment for lateral epicondylitis. Prosthet Orthot Int. 2004 Aug;28(2):183-9.

 

Institute of Human Movement Sciences, University of Groningen, Groningen, The Netherlands.

 

The aim of the present study was to compare the effect of a new prefabricated Thamert forearm/hand splint with the effect of a simple elbow band as a treatment for lateral epicondylitis. Forty-three (43) patients that met the inclusion criteria were randomly assigned to the elbow band group and the splint group. Main effect for time was significant for maximal grip strength and sum scores on the PRFEQ, but no differences between groups were found, even when a distinction between acute and chronic symptoms was made. The conclusion is that the forearm/hand splint is not more effective than the elbow band as a treatment for lateral epicondylitis.

 

PMID: 15382812

 

Rating: 2b

 

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Varitimidis SE, Vardakas DG, Goebel F, Sotereanos DG. Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein insulator. J Hand Surg [Am] 2001 Mar;26(2):296-302.

 

 Department of Orthopaedics, University of Pittsburgh Medical Center, Kaufmann Bldg., 3471 Fifth Ave., Pittsburgh, PA 15213, USA.

 

All patients reported reduction in pain and the sensory disturbances secondary to the compression of the median or ulnar nerve. Two-point discrimination and electrodiagnostic findings also improved.

 

PMID: 11279577

 

Rating: 3c

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Vogt W, Dubs B. The value of shockwave therapy in treatment of humero-radial epicondylitis. Swiss Surg 2001;7(3):110-5.

 

Arzteteam Unfallmedizin, Schweizerische Unfallversicherungsanstalt Suva. walter.vogt@suva.ch

 

Scientific proof of enhanced efficacy of ESWT compared to other treatments of radial Epicondylitis is still lacking. Prospective, randomized follow-up studies of large patient populations under standardized technical conditions are needed. Based on current knowledge, ESWT of radial Epicondylitis should only be applied if three conditions are fulfilled: 1) the diagnosis of radial Epicondylitis has been ascertained, 2) conservative therapies for at least one year failed, and 3) the only alternative is surgery.

 

PMID: 11407037

 

Rating: 5c

 

 

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Wang CJ, An overview of shock wave therapy in musculoskeletal disorders, Chang Gung Med J. 2003 Apr;26(4):220-32.

 

Department of Orthopedic Surgery, Chang Gung Memorial Hospital, 123, Dabi Road, Niaosung Shiang, Kaohsiung, Taiwan 833, ROC. w281211@adm.cgmh.com.tw

 

Shock wave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shock wave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce neovascularization, improve blood supply and tissue regeneration. The application of shock wave therapy in certain musculoskeletal disorders has been around for approximately 15 years, and the success rate in non-union of long bone fracture, calcifying tendonitis of the shoulder, lateral epicondylitis of the elbow and proximal plantar fasciitis ranged from 65% to 91%. The complications are low and negligible. Additional information including the cellular and molecular changes after shock wave therapy are needed for further clarification on the mechanism of shock wave therapy in musculoskeletal system.

 

PMID: 12846521

 

Rating: 5b

 

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Wang CJ, Chen HS, Shock wave therapy for patients with lateral epicondylitis of the elbow: a one- to two-year follow-up study, Am J Sports Med. 2002 May-Jun;30(3):422-5.

 

Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan.

 

HYPOTHESIS: Shock wave therapy is an effective treatment for patients with lateral epicondylitis of the elbow and long-term results will be as favorable as short-term ones. STUDY DESIGN: Case series. METHODS: The effect of shock wave therapy was investigated in 57 patients with lateral epicondylitis of the elbow. RESULTS: Twenty-seven elbows (61.4%) were free of complaints, 13 (29.5%) were significantly better, 3 (6.8%) were slightly better, and 1 (2.3%) was unchanged. In the control group, the results were unchanged in all six patients. There were no device-related problems and no systemic or local complications. CONCLUSIONS: Shock wave therapy is a safe and effective modality in the treatment of patients with lateral epicondylitis of the elbow.

 

PMID: 12016085

 

Rating: 4c

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Wang X. Seventy cases of external humeral epicondylitis treated by local blocking and massotherapy. J Tradit Chin Med 2001 Mar;21(1):52-3.

 

Ma'anshan Municipal People's Hospital, Ma'anshan 243000, Anhui Province.

 

PMID: 11360542

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Waugh EJ, Jaglal SB, Davis AM, Tomlinson G, Verrier MC. Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy. Arch Phys Med Rehabil. 2004 Feb;85(2):308-18.

 

Department of Physical Therapy, University of Toronto, Toronto, ON, Canada. e.waugh@utoronto.ca

 

This study concluded, “Women and patients who report nerve symptoms are more likely to experience a poorer short-term outcome after PT management of lateral epicondylitis. Work-related onsets, repetitive keyboarding jobs, and cervical joint signs have a prognostic influence on women.

 

PMID: 14966719

 

Rating: 4b

 

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Weirich SD, Gelberman RH, Best SA, Abrahamsson SO, Furcolo DC, Lins RE. Rehabilitation after subcutaneous transposition of the ulnar nerve: immediate versus delayed mobilization. J Shoulder Elbow Surg 1998 May-Jun;7(3):244-9.

 

(1) Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA.

 

This study of 36 patients concluded, “anterior subcutaneous transposition provides a high degree of satisfaction and relief of symptoms regardless of when mobilization is initiated. However, immediately mobilizing the patient significantly influenced how early the patient returned to work and resumed activities of daily living.

 

PMID: 9658349

 

Rating: 2c

 

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Werner RA, Franzblau A, Gell N, Hartigan A, Ebersole M, Armstrong TJ. J Occup Rehabil. Predictors of persistent elbow tendonitis among auto assembly workers. 2005 Sep;15(3):393-400.

 

Department of Physical Medicine and Rehabilitation, University of Michigan Health System, Ann Arbor, Michigan, USA. rawerner@med.umich.edu

 

CONCLUSIONS: Older workers with jobs requiring more repetition and awkward wrist postures, and less decision authority were less likely to have resolution of their elbow tendonitis. IMPLICATIONS: Workers at highest risk for persistent elbow tendonitis should be placed at jobs with lower repetition levels and that use more neutral wrist postures.

 

PMID: 16119229

 

Rating: 3c

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Wiesler ER, Chloros GD, Cartwright MS, Shin HW, Walker FO. Ultrasound in the diagnosis of ulnar neuropathy at the cubital tunnel. J Hand Surg [Am]. 2006 Sep;31(7):1088-93.

 

Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA. ewiesler@wfubmc.edu

 

High-resolution US is a noninvasive, safe, and reliable modality for imaging the ulnar nerve at the elbow and it may provide a valuable adjunct to NCS in the diagnosis of UCT.

 

PMID: 16945708

 

Rating: 4c

 

 

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WLDI. ODG ICD9-CPT® Crosswalk UR Advisor file. 2007.

 

Rating: 4a

 

Sample below for tennis elbow shows surgery is done in only about 5% of workers' compensation cases.

 

ICD9-CPT Crosswalk UR Advisor - ICD9 Code 726.32 Lateral epicondylitis

CPT Code

CPT Name

Incidence Rate per 100,000 Workers

% CPT Frequency for ICD9

Visits 25th %

Visits 50th %

Visits 75th %

Visits Mean

Costs Mean

ODG CAA

Bill Review Payment Flag

20550

Inject tendon/ligament/cyst

2.22

10.13%

1

1

2

1.47

$179.20

n/a

Yellow

20551

Inject tendon origin/insert

0.65

2.96%

1

1

1

1.26

$142.09

n/a

Yellow

20600

Drain/inject, joint/bursa

0.29

1.30%

1

1

1

1.16

$109.30

n/a

Red

20605

Drain/inject, joint/bursa

3.20

14.62%

1

1

2

1.51

$163.86

n/a

Yellow

20610

Drain/inject, joint/bursa

0.75

3.42%

1

1

1

1.20

$152.71

n/a

Yellow

24350

Repair of tennis elbow

0.72

3.26%

1

1

1

1.23

$1,238.21

n/a

Red

24351

Repair of tennis elbow

0.52

2.37%

1

1

1

1.27

$1,270.15

n/a

Red

24356

Revision of tennis elbow

1.16

5.30%

1

1

2

1.41

$1,854.83

n/a

Red

29125

Apply forearm splint

0.62

2.83%

1

1

1

1.05

$95.16

n/a

Yellow

29260

Strapping of elbow or wrist

0.70

3.21%

1

1

1

1.21

$81.00

n/a

Yellow

36415

Collection of venous blood by venipuncture

1.02

4.67%

1

1

1

1.16

$9.09

n/a

Yellow

71020

Chest x-ray

0.33

1.50%

1

1

1

1.00

$87.55

n/a

Red

73030

X-ray exam of shoulder

0.83

3.77%

1

1

1

1.19

$99.81

n/a

Yellow

73070

X-ray exam of elbow

3.80

17.33%

1

1

1

1.19

$64.17

1

Green

73080

X-ray exam of elbow

5.86

26.74%

1

1

1

1.12

$89.49

1

Green

73090

X-ray exam of forearm

0.40

1.83%

1

1

1

1.15

$85.26

n/a

Red

73110

X-ray exam of wrist

0.60

2.73%

1

1

1

1.09

$79.99

n/a

Yellow

73221

Mri joint upr extrem w/o dye

1.59

7.24%

1

1

1

1.12

$1,044.23

1

Green

93005

Electrocardiogram, tracing

0.59

2.70%

1

1

1

1.06

$60.10

n/a

Yellow

93010

Electrocardiogram report

0.28

1.27%

1

1

1

1.06

$13.49

n/a

Yellow

95860

Muscle test, one limb

1.51

6.89%

1

1