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1.  The Prevalence of Medial Epicondylitis Among Patients With C6 and C7 Radiculopathy 
Sports Health  2010;2(4):334-336.
Background:
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.
Hypothesis:
Medial epicondylitis will present in over half the patients diagnosed with C6 and C7 radiculopathy.
Methodology:
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.
Results:
Fifty-five patients were diagnosed with medial epicondylitis. Of these, 44 had C6 and C7 radiculopathy whereas 11 presented with just C6 radiculopathy.
Conclusion:
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.
doi:10.1177/1941738109357304
PMCID: PMC3445092  PMID: 23015956
cervical radiculopathy; epicondylitis; golfer’s elbow
2.  Evaluation and Management of Elbow Tendinopathy 
Sports Health  2012;4(5):384-393.
Context:
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.
Results:
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.
Conclusions:
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.
doi:10.1177/1941738112454651
PMCID: PMC3435941  PMID: 23016111
tendinopathy; lateral epicondylitis; medial epicondylitis; distal biceps rupture; distal triceps rupture
3.  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.
Images
PMCID: PMC2328957
4.  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.
doi:10.1136/oem.60.5.322
PMCID: PMC1740535  PMID: 12709516
5.  A novel method for assessing elbow pain resulting from epicondylitis 
Journal of Chiropractic Medicine  2002;1(3):117-121.
Abstract
Objective
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.
Conclusion
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.
doi:10.1016/S0899-3467(07)60015-9
PMCID: PMC2646935  PMID: 19674572
Orthopedic Tests; Elbow; Lateral Epicondylitis; Medial Epicondylitis
6.  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.
doi:10.1136/ard.2003.016378
PMCID: PMC1755120  PMID: 15308511
7.  Acupuncture for lateral epicondylitis (tennis elbow): study protocol for a randomized, practitioner-assessor blinded, controlled pilot clinical trial 
Trials  2013;14:174.
Background
Lateral epicondylitis is the most frequent cause of pain around the elbow joint. It causes pain in the region of the elbow joint and results in dysfunction of the elbow and deterioration of the quality of life. The purpose of this study is to compare the effects of ipsilateral acupuncture, contralateral acupuncture and sham acupuncture on lateral epicondylitis.
Methods/design
Forty-five subjects with lateral epicondylitis will be randomized into three groups: the ipsilateral acupuncture group, contralateral acupuncture group and the sham acupuncture group. The inclusion criteria will be as follows: (1) age between 19 and 65 years with pain due to one-sided lateral epicondylitis that persisted for at least four weeks, (2) with tenderness on pressure limited to regions around the elbow joint, (3) complaining of pain during resistive extension of the middle finger or the wrist, (4) with average pain of NRS 4 or higher during the last one week at a screening visit and (5) voluntarily agree to this study and sign a written consent. Acupuncture treatment will be given 10 times in total for 4 weeks to all groups. Follow up observations will be conducted after the completion of the treatment, 8 weeks and 12 weeks after the random assignment. Ipsilateral acupuncture group and contralateral acupuncture group will receive acupuncture on LI4, TE5, LI10, LI11, LU5, LI12 and two Ashi points. The sham acupuncture group will receive treatment on acupuncture points not related to the lateral epicondylitis using a non-invasive method. The needles will be maintained for 20 minutes. The primary outcome will be differences in the visual analogue scale (VAS) for elbow pain between the groups. The secondary outcome will be differences in patient-rated tennis elbow evaluation (PRTEE), pain-free/maximum grip strength (Dynamometer), pressure pain threshold, clinically relevant improvement, patient global assessment, and the EQ-5D. The data will be analyzed with the paired t-test and ANCOVA (P <0.05).
Discussion
The results of this study will allow evaluation of contralateral acupuncture from two aspects. First, if the contralateral acupuncture shows the effects similar to ipsilateral acupuncture, this will establish clinical basis for contralateral acupuncture. Second, if the effects of contralateral acupuncture are not comparable to the effects of ipsilateral acupuncture, but are shown to be similar to the effects of the sham acupuncture, we can establish the basis for using the same acupoints of the unaffected side as a control in acupuncture clinical studies.
Trial registration
This trial has been registered with the ‘Clinical Research Information Service (CRIS)’, Republic of Korea: KCT0000628.
doi:10.1186/1745-6215-14-174
PMCID: PMC3685553  PMID: 23768129
Acupuncture; Tennis elbow; Epicondylitis
8.  Mini-open Muscle Resection Procedure under Local Anesthesia for Lateral and Medial Epicondylitis 
Clinics in Orthopedic Surgery  2009;1(3):123-127.
Background
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.
Methods
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.
Results
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.
Conclusions
The mini-open muscle resection procedure under local anesthesia appears to be one of effective methods for intractable lateral or medial epicondylitis.
doi:10.4055/cios.2009.1.3.123
PMCID: PMC2766749  PMID: 19885046
Lateral epicondylitis; Medial epicondylitis; Local anesthesia; Mini-open; Muscle resection
9.  The prevalence of humeral epicondylitis: a survey in general practice 
The characteristics of all patients with humeral epicondylitis who presented over a two-year period in a group practice were examined to clarify the epidemiological features of this condition. In all 77 patients were seen. There was no observed difference in incidence between the sexes, lateral epicondylitis being more common than medial in both sexes. Medial epicondylitis is more common in the community than is generally recognized. Epicondylitis is a relapsing condition with a strong bias towards the 35-54 years age group. Analysis revealed no relationship between incidence and socioeconomic class.
PMCID: PMC1960610  PMID: 3440991
10.  Treatment of Medial Epicondyle Fracture without Associated Elbow Dislocation in Older Children and Adolescents 
Yonsei Medical Journal  2012;53(6):1190-1196.
Purpose
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.
Results
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.
Conclusion
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.
doi:10.3349/ymj.2012.53.6.1190
PMCID: PMC3481389  PMID: 23074121
Medial epicondyle fracture; elbow dislocation; fracture fixation
11.  Psychological factors at work and musculoskeletal disorders: a one year prospective study 
Rheumatology International  2013;33:2975-2983.
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.
doi:10.1007/s00296-013-2843-8
PMCID: PMC3832752  PMID: 23934521
MSDs; Psychosocial factors; Work demands
12.  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.
doi:10.1007/s11999-007-0019-0
PMCID: PMC2505296  PMID: 18196385
13.  Treatment of symptomatic medial epicondyle nonunion: Case report and review of the literature 
INTRODUCTION
Symptomatic nonunion of humeral medial epicondyle can be problematic and difficult to treat due to high complication rates related to open reduction and internal fixation methods.
PRESENTATION OF CASE
We described four patients with symptomatic medial humeral epicondyle nonunion who underwent open reduction and internal fixation.
DISCUSSION
Symptomatic nonunion of humeral medial epicondyle is a rare entity. Surgical technique can be difficult because of anatomical and biomechanical factors. In the literature, there are a few cases of humeral medial epicondyle treated by open reduction and internal fixation.
CONCLUSION
Open reduction and internally fixation of the medial epicondyle nonunion with one cannulated screw results with improved elbow function.
doi:10.1016/j.ijscr.2012.04.021
PMCID: PMC3397290  PMID: 22743011
Humerus; Epicondyle; Nonunion
14.  Current concepts of elbow-joint disorders and their treatment 
Background
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.
Methods
The most common disease of elbow disorders and their treatment was reviewed.
Results
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.
Conclusion
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.
doi:10.1007/s00776-012-0333-6
PMCID: PMC3553418  PMID: 23306537
15.  Epicondylectomy versus denervation for lateral humeral epicondylitis 
Hand (New York, N.Y.)  2011;6(2):174-178.
Background
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.
Methods
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.
Results
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.
Conclusion
It is concluded that denervation gives significant relief from LHE once traditional non-surgical treatment has failed.
doi:10.1007/s11552-011-9318-8
PMCID: PMC3092894  PMID: 22654700
Epicondylectomy; Tennis elbow; Lateral epicondylectomy
16.  The treatment of iliotibial band friction syndrome. 
Iliotibial band friction syndrome is a common cause of knee pain in long distance runners. The pain is caused by friction of the iliotibial band over the lateral epicondyle of the femur. Two hundred and twenty one cases were seen in a two year period. Tenderness over the lateral epicondyle associated with pain at 30 degrees of flexion on compressing the iliotibial band against the lateral epicondyle is diagnostic. Conservative treatment consisted of treating the cause, mostly training irregularities and the local inflammation mostly with steroid injections and rest. Nine cases failed to respond to conservative treatment and these were treated by surgical release of the posterior fibres of the iliotibial band.
PMCID: PMC1859686  PMID: 465909
17.  Lateral epicondylosis and calcific tendonitis in a golfer: a case report and literature review 
Objective
To detail the progress of a young female amateur golfer who developed chronic left arm pain while playing golf 8 months prior to her first treatment visit.
Clinical Features
Findings included pain slightly distal to the lateral epicondyle of the elbow, decreased grip strength, and positive orthopedic testing. Diagnostic ultrasound showed thickening of the common extensor tendon origin indicating lateral epicondylosis. Radiographs revealed an oval shaped calcified density in the soft tissue adjacent to the lateral humeral epicondyle, indicating calcific tendonitis of the common extensor tendon origin.
Intervention and Outcome
Conventional care was aimed at decreasing the repetitive load on the common extensor tendon, specifically the extensor carpi radialis brevis. Soft tissue techniques, exercises and stretches, and an elbow brace helped to reduce repetitive strain. Outcome measures included subjective pain ratings, and follow up imaging 10 weeks after treatment began.
Conclusion
A young female amateur golfer with chronic arm pain diagnosed as lateral epicondylosis and calcific tendonitis was relieved of her pain after 7 treatments over 10 weeks of soft tissue and physical therapy focusing specifically on optimal healing and decreasing the repetitive load on the extensor carpi radialis brevis.
PMCID: PMC3222709  PMID: 22131570
epicondylosis; calcific tendonitis; golf; epicondylose; tendinite calcifiante; golf
18.  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.
doi:10.1155/2012/387829
PMCID: PMC3521482  PMID: 23251809
19.  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
20.  Open reduction of medial epicondyle fractures: operative tips for technical ease 
In the pediatric population, medial humeral epicondylar fractures account for nearly 12% of all elbow fractures. There is ongoing debate about the surgical management of medial epicondyle fracture cases. Our technique in the operative management of medial epicondyle fractures uses the external application of an Esmarch bandage, as well as provisional fixation with needle rather than K-wire fixation. This technique decreases the need for soft-tissue release and, therefore, theoretically, maintains soft-tissue vascularity of the small fracture fragments. Moreover, it preserves the soft-tissue tension medially. It involves the use of a bandage that is universally available in orthopedic operating rooms, including those in developing nations. It is easy to apply by either the principal or assisting surgeon. With practice, it cuts down operative time and can help substitute for an assistant. This relatively simple operative technique makes for a more seamless operative process, improved reduction, and key preservation of soft-tissue vascularity.
doi:10.1007/s11832-009-0185-6
PMCID: PMC2726869  PMID: 19506930
Medial epicondyle humerus fracture; Pediatric elbow fracture; Medial epicondylar humeral fractures; Valgus overuse elbow injuries; Open reduction humerus fracture
21.  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.
doi:10.5312/wjo.v4.i3.103
PMCID: PMC3717240  PMID: 23878775
Epicondylitis; Tennis elbow; Adaptive equipment; Mechanical overload; Elbow; Inflammation
22.  The role of physical examinations in studies of musculoskeletal disorders of the elbow 
Objectives
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.
Methods
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.
Results
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)).
Conclusion
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.
doi:10.1136/oem.2005.026260
PMCID: PMC2078422  PMID: 17522132
23.  Proximal wrist extensor tendinopathy 
Proximal wrist extensor tendinopathy, which is also known as tennis elbow, is pain at or just distal to the lateral humeral epicondyle within the proximal wrist extensor tendon. It occurs commonly in certain athletes but can also occur in people with jobs that require repetitive movements of the hand and upper limb. In most cases the tendon involved shows no signs of inflammation or tendonitis, but instead shows fibroblasts, vascular hyperplasia, and disorganized collagen. Diagnosis is often made by history and physical exam alone. Most people respond to conservative measures including activity modification, analgesics, manipulation of tissue, and exercise. In some cases, an injection of corticosteroid or botulinum toxin may be used. Surgery is rarely needed.
doi:10.1007/s12178-007-9005-0
PMCID: PMC2684153  PMID: 19468898
Tennis elbow; Elbow pain; Lateral epicondylitis
24.  Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review 
Purpose
There is ongoing debate about the management of medial epicondyle fractures in the pediatric population. This systematic review evaluated non-operative versus operative treatment of medial epicondyle fractures in pediatric and adolescent patients over the last six decades.
Methods
A systematic review of the available literature was performed. Frequency-weighted mean union times were used to compare union rates for closed versus open treatments. Moreover, functional outcomes and range-of-motion variables were correlated with varying treatment modalities. Any complications, including ulnar nerve symptoms, pain, instability, infection, and residual deformity, were cataloged.
Results
Fourteen studies, encompassing 498 patients, met the inclusion/exclusion criteria. There were 261 males and 132 female patients; the frequency-weighted average age was 11.93 years. The follow-up range was 6–216 months. Under the cumulative random effects model, the odds of union with operative fixation was 9.33 times the odds of union with non-operative treatment (P < 0.0001). There was no significant difference between operative and non-operative treatments in terms of pain at final follow-up (P = 0.73) or ulnar nerve symptoms (P = 0.412).
Conclusions
Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures. There was no difference in pain at final follow-up between operative and non-operative treatments. As surgical indications evolve, and the functional demands of pediatric patients increase, surgical fixation should be strongly considered to achieve stable fixation and bony union.
doi:10.1007/s11832-009-0192-7
PMCID: PMC2758175  PMID: 19685254
Children; Pediatric; Medial epicondyle humerus fracture(s); Pediatric elbow fracture; Treatment humerus fracture; Union; Systematic review
25.  Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review 
Purpose
There is ongoing debate about the management of medial epicondyle fractures in the pediatric population. This systematic review evaluated non-operative versus operative treatment of medial epicondyle fractures in pediatric and adolescent patients over the last six decades.
Methods
A systematic review of the available literature was performed. Frequency-weighted mean union times were used to compare union rates for closed versus open treatments. Moreover, functional outcomes and range-of-motion variables were correlated with varying treatment modalities. Any complications, including ulnar nerve symptoms, pain, instability, infection, and residual deformity, were cataloged.
Results
Fourteen studies, encompassing 498 patients, met the inclusion/exclusion criteria. There were 261 males and 132 female patients; the frequency-weighted average age was 11.93 years. The follow-up range was 6–216 months. Under the cumulative random effects model, the odds of union with operative fixation was 9.33 times the odds of union with non-operative treatment (P < 0.0001). There was no significant difference between operative and non-operative treatments in terms of pain at final follow-up (P = 0.73) or ulnar nerve symptoms (P = 0.412).
Conclusions
Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures. There was no difference in pain at final follow-up between operative and non-operative treatments. As surgical indications evolve, and the functional demands of pediatric patients increase, surgical fixation should be strongly considered to achieve stable fixation and bony union.
doi:10.1007/s11832-009-0192-7
PMCID: PMC2758175  PMID: 19685254
Children; Pediatric; Medial epicondyle humerus fracture(s); Pediatric elbow fracture; Treatment humerus fracture; Union; Systematic review

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