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1.  Self-reported physical exposure association with medial and lateral epicondylitis incidence in a large longitudinal study 
Although previous studies have related occupational exposure and epicondylitis, the evidence is moderate, and mostly based on cross-sectional studies. Suspected physical exposures were tested over a three year period in a large longitudinal cohort study of workers in the United States.
In a population-based study including a variety of industries, 1107 newly employed workers were examined; only workers without elbow symptoms at baseline were included. Baseline questionnaires collected information on personal characteristics and self-reported physical work exposures and psychosocial measures for the current or most recent job at 6 months. Epicondylitis (lateral and medial) was the main outcome, assessed at 36 months based on symptoms and physical examination (palpation or provocation test). Logistic models included the most relevant associated variables.
Of 699 workers tested after 36 months who did not have elbow symptoms at baseline, 48 suffered from medial or lateral epicondylitis (6.9%), with 34 cases of lateral epicondylitis (4.9%), 30 cases of medial epicondylitis (4.3%), and 16 workers who had both. After adjusting for age, lack of social support, and obesity, consistent associations were observed between self-reported wrist bending/twisting and forearm twisting/rotating/screwing motion and future cases of medial or lateral epicondylitis (odds ratios 2.8 [1.2;6.2] and 3.6 [1.2;11.0] respectively in men and women).
Self-reported physical exposures that implicate repetitive and extensive/prolonged wrist bend/twisting and forearm movements were associated with incident cases of lateral and medial epicondylitis in a large longitudinal study, although other studies are needed to better specify the exposures involved.
PMCID: PMC4059355  PMID: 23825198
epicondylitis; observational study; occupational; risk factor; epidemiology
2.  The Prevalence of Medial Epicondylitis Among Patients With C6 and C7 Radiculopathy 
Sports Health  2010;2(4):334-336.
Medial epicondylitis, or golfer’s/pitcher’s elbow, develops as a result of medial stress overload on the flexor muscles at the elbow and presents as pain at the medial epicondyle. Cervical radiculopathy has been associated with lateral epicondylitis, but few associations between the cervical spine and medial epicondylitis have been made. Researchers propose that there is an association, suggesting that the weakness and imbalance in the elbow flexor and extensor muscles from C6 and C7 radiculopathy allow for easy onset of medial epicondylitis.
Medial epicondylitis will present in over half the patients diagnosed with C6 and C7 radiculopathy.
A total of 102 patients initially presenting with upper extremity or neck symptoms were diagnosed with cervical radiculopathy. They were then examined for medial epicondylitis. Data were collected by referring to patient charts from February 2008 until June 2009.
Fifty-five patients were diagnosed with medial epicondylitis. Of these, 44 had C6 and C7 radiculopathy whereas 11 presented with just C6 radiculopathy.
Medial epicondylitis presented with cervical radiculopathy in slightly more than half the patients. Weakening of the flexor carpi radialis and pronator teres and imbalance of the flexor and extensor muscles from the C6 and C7 radiculopathy allow for easy onset of medial epicondylitis. Patients with medial epicondylitis should be examined for C6 and C7 radiculopathy to ensure proper treatment. Physicians dealing with golfers, pitchers, or other patients with medial epicondylitis should be aware of the association between these 2 diagnoses to optimize care.
PMCID: PMC3445092  PMID: 23015956
cervical radiculopathy; epicondylitis; golfer’s elbow
3.  Incidence of ulnar nerve entrapment at the elbow in repetitive work 
Despite the high frequency of work-related musculoskeletal disorders (WRMD), the relations between working conditions and ulnar nerve entrapment at the elbow (UNEE) has not been the object of much study. We studied the predictive factors for UNEE in a three-year prospective survey of upper-limb WRMD in repetitive work.
In 1993–1994 and three years later, 598 workers whose jobs involve repetitive work were examined by their occupational health physicians and completed a self-administered questionnaire. Predictive factors associated with the onset of UNEE were studied with bivariate and multivariate analysis.
Annual incidence was estimated at 0.8% per person year, based on 15 new cases during this three-year period. Holding a tool in position was the only predictive biomechanical factor (OR = 4.1, CI 1.4–12.0). Obesity increased the risk of UNEE (OR = 4.3, CI 1.2–16.2), as did presence of medial epicondylitis, carpal tunnel syndrome, radial tunnel syndrome, and cervicobrachial neuralgia. The associations with “holding a tool in position” and obesity were unchanged when the presence of other diagnoses was taken into account.
Despite the limitations of the study, the results suggest that UNEE incidence is associated with one biomechanical risk factor (holding a tool in position, repetitively), with overweight, and with other upper-limb WRMD, especially medial epicondylitis and other nerve entrapment disorders (cervicobrachial neuralgia, carpal and radial tunnel syndromes).
PMCID: PMC2988822  PMID: 15250652
Adult; Comorbidity; Cubital Tunnel Syndrome; epidemiology; etiology; Cumulative Trauma Disorders; complications; epidemiology; Female; France; epidemiology; Humans; Incidence; Logistic Models; Male; Middle Aged; Musculoskeletal Diseases; classification; epidemiology; Obesity; complications; Occupational Diseases; complications; epidemiology; Occupations; classification; Posture; physiology; Prospective Studies; Questionnaires; Risk Factors; Workplace; psychology; elbow; repetitive work; ulnar nerve entrapment; work-related musculoskeletal disorder
4.  The Snapping Elbow Syndrome as a Reason for Chronic Elbow Neuralgia in a Tennis Player – MR, US and Sonoelastography Evaluation 
Polish Journal of Radiology  2014;79:467-471.
Ulnar neuropathy is the second most common peripheral nerve neuropathy after median neuropathy, with an incidence of 25 cases per 100 000 men and 19 cases per 100 000 women each year. Skipping (snapping) elbow syndrome is an uncommon cause of pain in the posterior-medial elbow area, sometimes complicated by injury of the ulnar nerve. One of the reason is the dislocation of the abnormal insertion of the medial triceps head over the medial epicondyle during flexion and extension movements. Others are: lack of the Osboune fascia leading to ulnar nerve instability and focal soft tissue tumors (fibromas, lipomas, etc). Recurrent subluxation of the nerve at the elbow results in a tractional and frictional neuritis with classical symptoms of peripheral neuralgia. As far as we know snapping triceps syndrome had never been evaluated in sonoelastography.
Case Report
A 28yo semi-professional left handed tennis player was complaining about pain in posterior-medial elbow area. Initial US examination suggest golfers elbow syndrome which occurs quite commonly and has a prevalence of 0.3–0.6% in males and 0–3–1.1% in women and may be associated (approx. 50% of cases) with ulnar neuropathy. However subsequently made MRI revealed unusual distal triceps anatomy, moderate ulnar nerve swelling and lack of medial epicondylitis symptoms. Followed (second) US examination and sonoelastography have detected slipping of the both ulnar nerve and the additional band of the medial triceps head.
Snapping elbow syndrome is a poorly known medical condition, sometimes misdiagnosed as the medial epicondylitis. It describes a broad range of pathologies and anatomical abnormalities. One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence. Simultaneously presence of two or more “snapping reasons” is rare but should be always taken under consideration.
There are no sonoelastography studies describing golfers elbow syndrome, additional triceps band and ulnar neuritis. Our data suggest that the sonoelastography signs are similar to those seen in well described lateral epicondylitis syndrome, Achilles tendinitis and medial nerve neuralgia.
PMCID: PMC4269067  PMID: 25525475
Elasticity Imaging Techniques; Elbow Joint; Ulnar Nerve Compression Syndromes
5.  The role of physical examinations in studies of musculoskeletal disorders of the elbow 
To present data on pain and physical findings from the elbow region, and to discuss the role of diagnostic criteria in epidemiological studies of epicondylitis.
From a cohort of computer workers a subgroup of 1369 participants, who reported at least moderate pain in the neck and upper extremities, were invited to a standardised physical examination. Two independent physical examinations were performed—one blinded and one not blinded to the medical history. Information concerning musculoskeletal symptoms was obtained by a baseline questionnaire and a similar questionnaire completed on the day of examination.
349 participants met the authors' criteria for being an arm case and 249 were elbow cases. Among the 1369 participants the prevalence of at least mild palpation tenderness and indirect tenderness at the lateral epicondyle was 5.8%. The occurrence of physical findings increased markedly by level of pain score. Only about one half with physical findings fulfilled the authors' pain criteria for having lateral epicondylitis. A large part with physical findings reported no pain at all in the elbow in any of the two questionnaires, 28% and 22%, respectively. Inter‐examiner reliability between blinded and not blinded examination was found to be low (kappa value (0.34–0.40)).
Very few with at least moderate pain in the elbow region met common specific criteria for lateral epicondylitis. The occurrence of physical findings increased markedly by level of pain score and the associations were strongest with pain intensity scores given just before the examination. Physical signs were commonly found in subjects with no pain complaints. No further impact was achieved if the physical examination was not blinded to the medical history. Furthermore, the authors propose that pain, clinical signs and disability are studied as separate outcomes, and that the diagnoses of lateral epicondylitis should be used only for cases with classical signs of inflammation reflected by severe pain, which for example conveys some disability.
PMCID: PMC2078422  PMID: 17522132
6.  Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study 
Aims: To assess the importance of physical and psychosocial risk factors for lateral epicondylitis (tennis elbow).
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.
Results: Manual job tasks were associated with tennis elbow (odds ratio (OR) 3.1, 95% confidence interval (CI) 1.9 to 5.1). The self reported physical risk factors "posture" and "forceful work" were related to tennis elbow. Among women, work involving performing repeated movements of the arms was related to tennis elbow (OR 3.7, CI 1.7 to 8.3). Among men, work with precision demanding movements was related to tennis elbow (OR 5.2, CI 1.5 to 17.9). Among both males and females, the results for work with hand held vibrating tools were inconsistent, partly because of few exposed subjects. A physical strain index was established based on posture, repetition, and force. The adjusted ORs for tennis elbow at low, medium, and high strain were 1.4 (CI 0.8 to 2.7), 2.0 (CI 1.1 to 3.7), and 4.4 (CI 2.3 to 8.7). Low social support at work, adjusted for physical strain, was a risk factor among women (OR 2.4, CI 1.3 to 4.6).
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.
PMCID: PMC1740535  PMID: 12709516
7.  Bilateral Ulnar Nerve Entrapment in a Patient with Demyelinating Disease and Neuropathic Elbows 
The Iowa Orthopaedic Journal  1991;11:149-152.
A 67 year old man with advanced neuropathic changes of both elbow joints associated with a demyelinating disease and diabetes mellitus is presented. The presenting complaint was caused by entrapment of the ulnar nerve within the elbow joint. The absence of diffuse peripheral neuropathy suggested that the demyelinating disease was the cause of the arthropathy. Operative exploration showed the ulnar nerve entrapped between the lateral side of the medial epicondyle and the olecranon. Excision of the medial epicondyle and anterior transposition of the ulnar nerves resulted in relief of the paresthesias and satisfactory sensory recovery. Excision of the trochlea was performed on the right elbow as well. It is suggested that patients with neuropathic or resorbing elbow joints who present with ulnar nerve entrapment should have prompt anterior transposition of the ulnar nerve. Impingement of the nerve between the bony processes of the elbow joint can cause mechanical disruption and irreversible injury.
PMCID: PMC2328957
8.  Origin of the medial ulnar collateral ligament on the pediatric elbow 
Surgical reconstruction of the adult anterior bundle of the medial ulnar collateral elbow ligament (UCL) is a common and established treatment that yields satisfactory results. Children sustain these injuries less frequently, and surgical intervention is complicated by the juxtaposed medial epicondyle apophysis. The purpose of this study was to identify the anatomical origin of the pediatric UCL and determine if this location changes with elbow maturity.
A retrospective analysis of children with an elbow MRI between 2009 and 2012 was performed. Ninety children (68 boys, 22 girls), mean age 12.8 years (range 6–18), were grouped by age (<11, 11–13, and >13) and gender. Measurements of UCL width and UCL midpoint distance from medial epicondyle apophysis were recorded on coronal T1 images utilizing digital PACS software.
Across all groups, boys had a wider UCL than girls (4.05 ± 0.16 mm vs 3.72 ± 0.20 mm, p = 0.03); however, there was no difference in the anatomical origin of the UCL relative to the medial epicondyle apophysis between gender (p = 0.52), between gender age-matched groups, or within gender age-matched groups. Yet, the anatomic origin of the UCL always remained medial to the cartilaginous interface of the apophysis with the osseous distal humerus and was centered approximately 3 mm medial to the lateral edge of the apophysis.
Regardless of age or gender, the humeral origin for the medial ulnar collateral ligament is medial to the interface between the medial epicondyle apophysis and distal humerus, which has surgical implications for anatomic reconstruction in children.
PMCID: PMC3799926  PMID: 24432094
Children; Medial epicondyle apophysis; Ulnar collateral ligament; Reconstruction
9.  Alternative technique for open reduction and fixation of displaced pediatric medial epicondyle fractures 
To describe an alternative positioning technique for the fixation of pediatric medial epicondyle fractures which offers some significant advantages over traditional supine positioning.
At our institution, 27 patients with a displaced medial epicondyle fracture requiring open reduction and fixation were positioned prone for the procedure. The internally rotated operative arm lies on the hand table with the elbow in a natural flexed, pronated position. The elbow can be brought into extension and flexion for appropriate intraoperative radiographs. The fracture is then reduced with the arm in flexion and pronation, without having to pull excessively on the fragment. After reduction, the fragment is held easily in place for surgical fixation. A similar group of patients from the same time period positioned supine was also examined and compared to the patients who had the surgery prone.
The average age of the 27 patients was 11.2 years (range 5.1–16.9 years). Indications for operative treatment were displaced medial epicondyle fracture (14), medial epicondyle fracture with associated elbow dislocation (12), and medial epicondyle fracture with ulnar nerve symptoms (1). At a mean of 4.5 months of follow up (1–11 months), 7 patients required the removal of hardware for screw irritation. There were no infections in the 27 surgeries and there were no other intraoperative or postoperative complications. Mild loss of flexion and extension was common in the group. Patients who had surgery in the supine position were similar with regards to patient demographics and postoperative complications, including the need for screw removal.
While displaced medial epicondyle fractures can be treated successfully with traditional positioning, placing patients prone for the fixation of pediatric medial epicondyle fractures offers some significant advantages over supine positioning.
PMCID: PMC3364344  PMID: 23730340
Medial epicondyle; Prone positioning; Technique
10.  Evaluation and Management of Elbow Tendinopathy 
Sports Health  2012;4(5):384-393.
Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations.
Evidence Acquisitions:
The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy.
Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments.
Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.
PMCID: PMC3435941  PMID: 23016111
tendinopathy; lateral epicondylitis; medial epicondylitis; distal biceps rupture; distal triceps rupture
11.  Mechanical solution for a mechanical problem: Tennis elbow 
World Journal of Orthopedics  2013;4(3):103-106.
Lateral epicondylitis is a relatively common clinical problem, easily recognized on palpation of the lateral protuberance on the elbow. Despite the “itis” suffix, it is not an inflammatory process. Therapeutic approaches with topical non-steroidal anti-inflammatory drugs, corticosteroids and anesthetics have limited benefit, as would be expected if inflammation is not involved. Other approaches have included provision of healing cytokines from blood products or stem cells, based on the recognition that this repetitive effort-derived disorder represents injury. Noting calcification/ossification of tendon attachments to the lateral epicondyle (enthesitis), dry needling, radiofrequency, shock wave treatments and surgical approaches have also been pursued. Physiologic approaches, including manipulation, therapeutic ultrasound, phonophoresis, iontophoresis, acupuncture and exposure of the area to low level laser light, has also had limited success. This contrasts with the benefit of a simple mechanical intervention, reducing the stress on the attachment area. This is based on displacement of the stress by use of a thin (3/4-1 inch) band applied just distal to the epicondyle. Thin bands are required, as thick bands (e.g., 2-3 inch wide) simply reduce muscle strength, without significantly reducing stress. This approach appears to be associated with a failure rate less than 1%, assuming the afflicted individual modifies the activity that repeatedly stresses the epicondylar attachments.
PMCID: PMC3717240  PMID: 23878775
Epicondylitis; Tennis elbow; Adaptive equipment; Mechanical overload; Elbow; Inflammation
12.  A novel method for assessing elbow pain resulting from epicondylitis 
Journal of Chiropractic Medicine  2002;1(3):117-121.
To describe a novel orthopedic test (Polk's test) which can assist the clinician in differentiating between me- dial and lateral epicondylitis, 2 of the most common causes of elbow pain. This test has not been previously described in the literature.
Clinical Features
The testing procedure described in this paper is easy to learn, simple to perform and may provide the clinician with a quick and effective method of differentiating between lateral and medial epicondylitis. The test also helps to elucidate normal activities of daily living that the patient may unknowingly be performing on a repetitive basis that are hindering recovery. The results of this simple test allow the clinician to make immediate lifestyle recommendations to the patient that should improve and hasten the response to subsequent treatment. It may be used in conjunction with other orthopedic testing procedures, as it correlates well with other clinical tests for assessing epicondylitis.
The use of Polk's Test may help the clinician to diagnostically differentiate between lateral and medial epicondylitis, as well as supply information relative to choosing proper instructions for the patient to follow as part of their treatment program. Further research, performed in an academic setting, should prove helpful in more thoroughly evaluating the merits of this test. In the meantime, clinical experience over the years suggests that the practicing physician should find a great deal of clinical utility in utilizing this simple, yet effective, diagnostic procedure.
PMCID: PMC2646935  PMID: 19674572
Orthopedic Tests; Elbow; Lateral Epicondylitis; Medial Epicondylitis
13.  Molecular composition and pathology of entheses on the medial and lateral epicondyles of the humerus: a structural basis for epicondylitis 
Annals of the Rheumatic Diseases  2004;63(9):1015-1021.
Objectives: To improve the understanding of epicondylitis by describing the normal structure and composition of the entheses associated with the medial and lateral epicondyles and their histopathology in elderly cadavers.
Methods: Medial and lateral epicondyles were obtained from 12 cadavers. Six middle aged cadavers (mean 47 years) were used to assess the molecular composition of "normal" entheses from people within an age range vulnerable to epicondylitis. Cryosections of epicondylar entheses were immunolabelled with monoclonal antibodies against molecules associated with fibrocartilage and related tissues. A further six elderly cadavers (mean 84 years) were used for histology to assess features of entheses related to increasing age.
Results: Tendon entheses on both epicondyles fused with those of the collateral ligaments and formed a more extensive structure than hitherto appreciated. Fibrocartilage (which labelled for type II collagen and aggrecan) was a constant feature of all entheses. Entheses from elderly subjects showed extensive microscopic damage, hitherto regarded as a hallmark of epicondylitis.
Conclusions: Fibrocartilage is a normal feature and not always a sign of enthesopathy. Furthermore, pathological changes documented in patients with epicondylitis may also be seen in elderly people. The fusion of the common extensor and flexor tendon entheses with those of the collateral ligaments suggests that the latter may be implicated as well. This may explain why pain and tenderness in epicondylitis may extend locally beyond the tendon enthesis and why some patients are refractory to local treatments.
PMCID: PMC1755120  PMID: 15308511
14.  Psychological factors at work and musculoskeletal disorders: a one year prospective study 
Rheumatology International  2013;33(12):2975-2983.
The etiology of musculoskeletal disorders is complex, with physical and psychosocial working conditions playing an important role. This study aimed to determine the relationship between psychosocial work conditions, such as psychological job demands, decision latitude, social support and job insecurity and musculoskeletal complains (MSCs) and (repetitive strain injuries (RSIs) in a 1-year prospective study. The job content questionnaire, the Nordic musculoskeletal questionnaire and provocation tests were used to study 725 employees aged 20–70 years. Pain in the lower back (58 % of subjects), neck (57 %), wrists/hands (47 %) and upper back (44 %) was most frequent. The carpal tunnel syndrome (CTS) (33.6 %), rotator cuff tendinitis (15.4 %), Guyon’s canal syndrome (13.4 %), lateral epicondylitis (7.6 %), medial epicondylitis (5.3 %), tendinitis of forearm–wrist extensors (7.8 %) and tendinitis of forearm–wrist flexors (7.3 %) were the most frequent RSIs. Logistic analysis showed that increased psychological job demands statistically significantly increased the probability of lateral and medial epicondylitis, and increased control (decision latitude) statistically significantly decreased the risk of CTS. There was no relationship between job insecurity, social support and the studied RSIs. Psychosocial factors at work predict prevalence of MSCs and RSIs, irrespectively of demographic factors, e.g., age or gender, and organizational and physical factors.
PMCID: PMC3832752  PMID: 23934521
MSDs; Psychosocial factors; Work demands
15.  Mini-open Muscle Resection Procedure under Local Anesthesia for Lateral and Medial Epicondylitis 
Clinics in Orthopedic Surgery  2009;1(3):123-127.
This study examined the clinical results of surgical treatment using a mini-open muscle resection procedure under local anesthesia for intractable lateral or medial epicondylitis.
Forty two elbows (41 patients) were treated surgically for lateral or medial epicondylitis. The indication for surgery was refractory pain after six months of conservative treatment, or a history of more than three local injections of steroid, or severe functional impairment in the occupational activities. The treatment results were assessed in terms of the pain using the visual analogue scale (VAS), Roles & Maudsley score, and Nirschl & Pettrone grade.
The preoperative VAS scores of pain were an average of 5.36 at rest, 6.44 at daily activities, and 8.2 at sports or occupational activities. After surgery, the VAS scores improved significantly (p < 0.01): 0.3 at rest, 1.46 at daily activities, and 2.21 at sports or occupational activities. The preoperative Roles & Maudsley score was acceptable in 6 cases, and poor in 36 cases, which was changed to excellent in 23 cases, good in 16 cases, acceptable in 3 cases after surgery. According to the grading system by Nirschl & Pettrone, 23 cases were excellent, 18 cases were good, and the remaining 1 case was fair. Overall, 41 cases (97.6%) achieved satisfactory results. Postoperative complications were encountered in three cases. Subcutaneous seroma due to the leakage of joint fluid in two patients was managed by additional surgery and suction drainage, and resulted in a satisfactory outcome. One patient complained of continuous pain on occupational activity, but her pain at rest was improved greatly.
The mini-open muscle resection procedure under local anesthesia appears to be one of effective methods for intractable lateral or medial epicondylitis.
PMCID: PMC2766749  PMID: 19885046
Lateral epicondylitis; Medial epicondylitis; Local anesthesia; Mini-open; Muscle resection
16.  Autologous Blood Injection and Wrist Immobilisation for Chronic Lateral Epicondylitis 
Advances in Orthopedics  2012;2012:387829.
Purpose. This study explored the effect of autologous blood injection (with ultrasound guidance) to the elbows of patients who had radiologically assessed degeneration of the origin of extensor carpi radialis brevis and failed cortisone injection/s to the lateral epicondylitis. Methods. This prospective longitudinal series involved preinjection assessment of pain, grip strength, and function, using the patient-rated tennis elbow evaluation. Patients were injected with blood from the contralateral limb and then wore a customised wrist support for five days, after which they commenced a stretching, strengthening, and massage programme with an occupational therapist. These patients were assessed after six months and then finally between 18 months and five years after injection, using the patient-rated tennis elbow evaluation. Results. Thirty-eight of 40 patients completed the study, showing significant improvement in pain; the worst pain decreased by two to five points out of a 10-point visual analogue for pain. Self-perceived function improved by 11–25 points out of 100. Women showed significant increase in grip, but men did not. Conclusions. Autologous blood injection improved pain and function in a worker's compensation cohort of patients with chronic lateral epicondylitis, who had not had relief with cortisone injection.
PMCID: PMC3521482  PMID: 23251809
17.  Treatment of Medial Epicondyle Fracture without Associated Elbow Dislocation in Older Children and Adolescents 
Yonsei Medical Journal  2012;53(6):1190-1196.
Displaced medial humeral epicondyle fractures with or without elbow dislocation have been treated with open reduction and fixation using K-wires or screws. The purpose of this study is to evaluate the clinical and radiological outcomes of surgical treatments of medial humeral epicondyle fracture without elbow dislocation according to the fixation methods.
Materials and Methods
Thirty-one patients who had undergone open reduction and fixation of the displaced medial humeral epicondyle fracture without elbow dislocation were included. Group I consisted of 21 patients who underwent fixation with K-wires, and Group II comprised 10 patients who underwent fixation with cannulated screws. Immediate postoperative, final follow-up and normal anteroposterior radiographs were compared and the clinical outcome was assessed using the final Japanese Orthopaedic Association (JOA) elbow assessment score.
On the immediate postoperative radiographs, the distal humeral width in Group II was larger than that in Group I. On the final follow-up radiographs, the epicondylar position in Group I was lower than that in Group II. There was no significant difference in the distal humeral width, epicondylar position and joint space tilt between the immediate postoperative, final follow-up radiographs and the normal side within each group. There was no significant difference in the final JOA score between groups.
Open reduction followed by K-wire fixation or screw fixation of the displaced medial humeral epicondyle fracture without elbow dislocation in older children and adolescents resulted in improved radiologic outcome and good elbow function in spite of diverse radiologic deformities.
PMCID: PMC3481389  PMID: 23074121
Medial epicondyle fracture; elbow dislocation; fracture fixation
18.  Orthotic devices for tennis elbow: a systematic review. 
Lateral epicondylitis (tennis elbow) is af requently reported condition. A wide variety of treatment strategies has been described. Asy et, no optimal strategy has been identified. The aim of this review was to assess the effectiveness of orthotic devices for treatment of tennis elbow. An electronic database search was conducted using MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trial Register Current Contents, and reference listsf rom all retrieved articles. Experts on the subjects were approachedfor additional trials. All randomised controlled trials (RCTs) descrbiing individuals with diagnosed lateral epicondylitis and assessing the use of an orthotic device as a treatment strategy were evaluatedfor inclusion. Two reviewers independently assessed the validity of the included trials and extracted data on relevant outcome measures. Dichotomous outcomes were expressed as relative risks and continuous outcomes as standardised mean differences, both with corresponding 95% confidence intervals. Statistical pooling and subgroup analyses were intended. Five small-size RCTs (n = 7-49 per group) were included the validity score ranged from three to nine positive items out of 11. Subgroup analyses were not performed owing to the small number of trials. The limited number of included trials present few outcome measures and limited long-term results. Pooling was not possible owing to the high level of heterogeneity of the trials. 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.
PMCID: PMC1314152  PMID: 11761209
19.  Posterolateral instability of the elbow in an adolescent boy with a lateral epicondyle fracture: a case report 
Hand (New York, N.Y.)  2010;6(1):71-75.
Posterolateral rotatory instability of elbow is considered to be due to the disruption of the ulnar part of the lateral collateral ligament (LUCL). This instability pattern may also be induced by a fracture of components of the lateral column.
We present the case of a 16-year-old boy who fell on his left outstretched arm as he attempted to jump over a tennis net. On initial physical examination, the elbow had instability found on varus stress and the radial head could be felt posteriorly. With attempted valgus and supination force combined with axial loading, the elbow gapped open and the patient had a sense of increased instability. X-rays showed a fracture of the lateral humeral epicondyle and posterolateral subluxation of the elbow. In the operating room, the patient was found to have reproducible posterolateral instability of the elbow. The lateral epicondyle was found to be fractured off the humerus with the LUCL still attached to the fragment. The elbow was reduced, and the injury was stabilized with small screws and suture anchors. At 6-month follow-up, the patient was pain-free, and physical examination revealed 170° of flexion, full extension, 90° of pronation, and 65° of supination. X-rays showed healing of the fracture with concentric reduction of the elbow joint.
In lateral epicondyle fractures, the affected elbow should be assessed for any signs of associated instability. If signs of clear instability are seen that would prohibit proper postinjury rehabilitation, then surgical reduction and fixation of the epicondyle with reinforcement of the LUCL is an effective method of treatment.
PMCID: PMC3041873  PMID: 22379442
Elbow; Rotatory; Instability; Ulnar collateral ligament
20.  Epicondylectomy versus denervation for lateral humeral epicondylitis 
Hand (New York, N.Y.)  2011;6(2):174-178.
Traditional management of lateral humeral epicondylitis (“tennis elbow”) relies upon antiinflammatory medication, rehabilitation, steroid injection, counterforce splinting, and, finally, surgery to the common extensor origin. The diversity of surgical approaches for lateral humeral epicondylitis (LHE) suggests perhaps that the ideal technique has not been determined. Denervation of the lateral humeral epicondyle is the concept of interrupting the neural pathway that transmits the pain message. Epicondylectomy may accomplish its relief of LHE by denervating the epicondyle.
Since it is known that the posterior branch of the posterior cutaneous nerve of the forearm innervates the lateral humeral epicondyle, 30 patients who were treated surgically for refractory LHE were retrospectively evaluated. Group 1 consisted of 17 patients who were treated with epicondylectomy alone, group II consisted of seven patients who were treated with lateral epicondylectomy plus neurectomy, and group III consisted of seven patients treated with lateral denervation alone.
Denervation alone gave statistically significantly greater improvement in pain relief (p < 0.001) and statistically significantly faster return to work than did epicondylectomy alone (p < 0.001). Denervation plus epicondylectomy gave results that were the same as denervation alone.
It is concluded that denervation gives significant relief from LHE once traditional non-surgical treatment has failed.
PMCID: PMC3092894  PMID: 22654700
Epicondylectomy; Tennis elbow; Lateral epicondylectomy
21.  Courses of the Radial Nerve Differ Between Chinese and Caucasians 
We analyzed anatomic distribution of the radial nerve in the upper arms in Chinese-adult embalmed cadavers (120 nerves in 60 cadavers) and compared it with findings reported for Caucasian adults. The acromion, the medial epicondyle, and the lateral epicondyle were used as bony landmarks. We used previously described techniques to quantitatively describe the location of the radial nerve in relation to the surrounding skeleton. Courses of the radial nerve relative to the humeral shaft in Chinese subjects differed from those previously reported for Caucasian subjects. The parameters that differed from Caucasians were: the distances from the acromion to the upper margin (147 ± 21 mm versus 124 ± 12 mm), the acromion to the lower margin (195 ± 36 mm versus 176 ± 17 mm), and the medial epicondyle to the lower margin (111 ± 21 mm versus 131 ± 10 mm). Our study provides information to help identify the radial nerve during surgery and elucidates racial differences in the distribution of the radial nerve between Chinese and Caucasian populations.
PMCID: PMC2505296  PMID: 18196385
22.  Tendinopathy in Sport 
Sports Health  2012;4(3):193-201.
Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited.
Evidence Acquisition:
The authors conducted a MEDLINE search on tendinopathy, or “tendonitis” or “tendinosis” or “epicondylitis” or “jumpers knee” from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature.
Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies.
Novel targeted therapies are emerging, but multicenter trials are needed to confirm the results of exercise and mini-invasive treatments.
PMCID: PMC3435934  PMID: 23016086
tendon; pain; tendinopathy; tendinosis
23.  Bilateral Additional Slips of Triceps Brachii Forming Osseo-Musculo-Fibrous Tunnels for Ulnar Nerves 
Rare additional slips of triceps brachii muscle was found bilaterally in a sixty two year old South Indian male cadaver during routine dissection of upper limb for undergraduate students at Melaka-Manipal Medical College, Manipal University, Manipal, India. On left side, the variant additional muscle slip took origin from the lower part of the medial intermuscular septum about 4 cm proximal to the medial humeral epicondyle. From its origin, the muscle fibres were passing over the ulnar nerve and were joining the triceps muscle to get inserted to the upper surface of olecranon process of ulna. On right side, the additional muscle slip was larger and bulkier and was arising from the lower part of the medial border of the humerus about 4 cm proximal to the medial epicondyle in addition to its attachment to the medial intermuscular septum. On both sides, the additional slips were supplied by twigs from the radial nerve. On both sides, the ulnar nerve was passing between variant additional slip and the lower part of the shaft of the humerus in an osseo-musculo-fibrous tunnel. Such variant additional muscle slips may affect the function of triceps muscle and can lead to snapping of medial head of triceps and ulnar nerve over medial epicondyle and also can dynamically compress the ulnar nerve during the contraction of triceps leading to ulnar neuropathy around the elbow.
PMCID: PMC3793458  PMID: 24116332
Cubital tunnel syndrome; Nerve entrapment; Snapping triceps syndrome; Triceps brachii; Ulnar nerve
24.  Grip strength measurements at two different wrist extension positions in chronic lateral epicondylitis-comparison of involved vs. uninvolved side in athletes and non athletes: a case-control study 
Lateral epicondylitis is a common sports injury of the elbow caused due to altered muscle activation during repetitive wrist extension in many athletic and non-athletic endeavours. The amount of muscle activity and timing of contraction eventually is directly dependent upon joint position during the activity. The purpose of our study was to compare the grip strength in athletes with lateral epicondylalgia in two different wrist extension positions and compare them between involved and uninvolved sides of athletes and non-athletes.
An assessor-blinded case-control study of eight athletes and twenty-two non-athletes was done. The grip strength was measured using JAMAR® hand dynamometer in kilograms-force at 15 degrees (slightly extended) and 35 degrees (moderately extended) wrist extension positions (maintained by wrist splints) on both involved and uninvolved sides of athletes and non-athletes with unilateral lateral epicondylitis of atleast 3 months duration. Their pain was to be elicited with local tenderness and two of three tests being positive- Cozen's, Mill's manoeuvre, resisted middle finger extension tests. For comparisons of grip strength, Wilcoxon signed rank test was used for within-group comparison (between 15 and 35 degrees wrist extension positions) and Mann-Whitney U test was used for between-group (athletes vs. non-athletes) comparisons at 95% confidence interval and were done using SPSS 11.5 for Windows.
Statistically significant greater grip strength was found in 15 degrees (27.75 ± 4.2 kgms in athletes; 16.45 ± 4.2 kgms in non-athletes) wrist extension than at 35 degrees (25.25 ± 3.53 kgm in athletes and 14.18 ± 3.53 kgm in non-athletes). The athletes had greater grip strength than non-athletes in each of test positions (11.3 kgm at 15 degrees and 11.07 kgm at 35 degrees) measured. There was also a significant difference between involved and uninvolved sides' grip strength at both wrist positions (4.44 ± .95 kgm at 15 degrees and 4.44 ± .86 kgm in 35 degrees) which was significant (p < .05) only in non-athletes.
The grip strength was greater in 15 degrees wrist extension position and this position could then be used in athletes with lateral epicondylalgia for grip strength assessment and designing wrist splint in this population.
PMCID: PMC2944326  PMID: 20822520
25.  Current concepts of elbow-joint disorders and their treatment 
Recently, many studies have emphasized the importance of the comprehension of detailed functional anatomy and biomechanics of the elbow and its significant contribution in facilitating good functional outcomes of conservative and surgical treatment in the field of elbow disorders.
The most common disease of elbow disorders and their treatment was reviewed.
Lateral epicondylitis of the elbow, is defined as a microscopic tear of extensor carpi radialis brevis tendon, and microscopic findings show immature reparative tissue (angiofibroblastic hyperplasia). The patient needs coordinated rehabilitation, range-of motion-exercise, stretching, and bracing in the second phase. Ninety-five percent of patients with lateral epicondylitis heal spontaneously or conservatively. The medial collateral ligament injury of the elbow is most common in the overhead-throwing athlete. Jobe’s procedure, the original reconstruction technique, and its modifications in bone-tunnel creation, allow a tendon graft to be wound in a figure-eight configuration through the tunnels. Further modification of Jobe’s procedure in bone-tunnel configuration reduced the total number of tunnels and facilitates easier graft tensioning. Outcomes with these reconstruction techniques have proven effective in returning high-level throwing athletes back to their sport. Arthroscopic surgery for the elbow in the throwing athlete has evolved and has proven successful results. Arthroscopic treatment includes debridement of posteromedial synovitis, loose-body removal, and excision of the olecranon spur. Posteromedial elbow impingement is also a source of disability in the overhead-throwing athlete. Twenty-five percent of these patients require a medial collateral ligament reconstruction after removal of a posteromedial bony spur. Linked and unlinked total elbow arthroplasty are successful treatment procedures for patients with rheumatoid arthritis, posttraumatic osteoarthritis, and elderly patients with comminuted distal humeral fractures and the salvage of distal humeral nonunion. Proper selection and implantation of prostheses are also important to achieve good functional outcome and longevity.
The success of treatment of elbow disorders depends greatly on surgical design and technique, both of which require comprehensive knowledge of detailed anatomy and biomechanics of the elbow.
PMCID: PMC3553418  PMID: 23306537

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