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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.  Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors 
As medial epicondylitis has not been studied alone, we investigated its links between personal and occupational factors in repetitive work, and its course.
1757 workers were examined by an occupational health physician in 1993–94. 598 of them were re-examined three years later.
Prevalence was between 4 and 5%, with annual incidence estimated at 1.5%. Forceful work was a risk factor for medial epicondylitis (OR 1.95 CI [1.15–3.32]), but not exposure to repetitive work (OR 1.11, CI [0.59–2.10]). Workers with medial epicondylitis had a significantly higher prevalence of other work-related upper-limb musculoskeletal disorders (WRMD). Risk factors differed for medial and lateral epicondylitis. The prognosis for medial epicondylitis in this population was good with a three-year recovery rate at 81%.
Medial epicondylitis was clearly associated with forceful work and other upper-limb WRMD, and its prognosis was good.
PMCID: PMC4850209  PMID: 14506342
Adult; Age Distribution; Middle Aged; Occupational Diseases; Occupational Health; Odds Ratio; Pain Measurement; Prevalence; Probab; Confidence Intervals; Cross-Sectional Studies; Cumulative Trauma Disorders; Female; Follow-Up Studies; France; Humans; Male
3.  Chronic hyperglycemia increases the risk of lateral epicondylitis: the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS) 
SpringerPlus  2015;4:407.
Although humeral epicondylitis is a common health problem, there have been no reports that describe its prevalence in Japanese general population, and relatively little is known about its etiology and associated risk factors.
This study aimed to clarify the prevalence of humeral epicondilitis in Japanese general population, and investigate the associated risk factors using the data from a cross-sectional study of the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS).
A total of 1,777 participants who participated in health checkups conducted at rural area in Japan in 2010 were enrolled. The prevalence of lateral and medial epicondylitis was investigated. Logistic regression models were performed to examine the relationship between lateral epicondylitis and correlated factors such as occupational status, smoking and alcohol preferences, and medical characteristics.
The overall prevalence of lateral and medial epicondylitis was 2.5 % and 0.3 %, respectively. A shortened version of the disabilities of the arm, shoulder and hand (The QuickDASH) score was significantly higher in subjects with lateral epicondylitis than in those without (15.0 ± 12.7 vs 8.5 ± 11.1). Subjects with definite chronic hyperglycemia (HbA1c ≥ 6.5) showed a 3.37-times higher risk of lateral epicondylitis than those with favorable glycemic control (HbA1c < 5.5) (95 % confidence interval (CI) 1.16–8.56). Age and sex, as well as occupational status, smoking and alcohol preference, and other metabolic factors were not significantly related to higher risk of lateral epicondylitis.
Lateral epicondylitis influences activities of daily living. Chronic hyperglycemia might be one of the risk factor for lateral epicondylitis.
Clinical relevance
Chronic hyperglycemia is significantly associated with lateral epicondylitis.
PMCID: PMC4530269  PMID: 26266078
4.  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
5.  Multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration 
Musculoskeletal disorders of the elbow, forearm, wrist and hand are associated with pain, functional impairment and decreased productivity in the general population. Combining several interventions in a multimodal program of care is reflective of current clinical practice; however there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand on self-rated recovery, functional recovery, or clinical outcomes in adults or children.
We conducted a systematic review of the literature and best evidence synthesis. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1990 to March 2015. Randomized controlled trials, cohort studies, and case–control studies were eligible. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were synthesized following best evidence synthesis principles.
We screened 5989 articles, and critically appraised eleven articles. Of those, seven had a low risk of bias; one addressed carpal tunnel syndrome and six addressed lateral epicondylitis. Our search did not identify any low risk of bias studies examining the effectiveness of multimodal care for the management of other musculoskeletal disorders of the elbow, forearm, wrist or hand. The evidence suggests that multimodal care for the management of lateral epicondylitis may include education, exercise (strengthening, stretching, occupational exercise), manual therapy (manipulation) and soft tissue therapy (massage). The evidence does not support the use of multimodal care for the management of carpal tunnel syndrome.
The current evidence on the effectiveness of multimodal care for musculoskeletal disorders of the elbow, forearm, wrist and hand is limited. The available evidence suggests that there may be a role for multimodal care in the management of patients with persistent lateral epicondylitis. Future research is needed to examine the effectiveness of multimodal care and guide clinical practice.
Systematic review registration number
Electronic supplementary material
The online version of this article (doi:10.1186/s12998-016-0089-8) contains supplementary material, which is available to authorized users.
PMCID: PMC4780149  PMID: 26955466
Wrist injuries; Hand injuries; Carpal tunnel syndrome; Review literature as topic; Tennis elbow; Epicondylitis; Multimodal treatment
6.  The Prevalence and Clinical Characteristics of Medial Epicondyle Apophysitis in Juvenile Baseball Player - Ultrasonographic Assessment of 2,926 Cases 
Orthopaedic Journal of Sports Medicine  2016;4(7 suppl4):2325967116S00170.
Apophysitis of humeral medial epicondyle, often referred to as “Little Leaguer’s Elbow, is one of the major throwing injuries in juvenile baseball players as common as osteochondritis dissecans of humeral capitellum. Repetitive valgus stress to the skeletally immature elbow can result in fragmentation, hypertrophy, or separation of the medial epicondyle apophysis, and these injuries may induce elbow pain and adversely influence on elbow function and throwing performance. Although several reports have described various morphological variations of the medial epicondyle apophysis, little is known about the natural course and clinical significance of these variations. The purpose of this study was to investigate the prevalence of these variations in each age group and clarify the association with elbow pain using the large epidemiologic data from medical check-ups of juvenile baseball players.
Of 3,626 juvenile baseball players aged 6 to 17 years, 2,926 players were enrolled in this study. Experience of elbow pain was rated by self-completed questionnaires. Ultrasonographic assessment was used to assess the morphological variations of the antero-inferior medial epicondyle (MEC) and humeral capitellum. Regarding MEC lesion, enthesis of medial ulnar collateral ligament (MUCL) was classified into four types: normal, irregular (IR), fragmentation (FG), and hypertrophy (HT). Osteochondral lesion (OCL) of humeral capitellum was judged by the irregularity or fragmentation of subchondral bone. The prevalence of these lesions was investigated in each age group and evaluated the influence on elbow pain using multivariable logistic regression analysis.
The overall prevalence of MEC lesions and capitellum OCL was 49.9% (IR:6.7%, FG:11.7%, HT:31.5%) and 2.1%, respectively. The prevalence of IR and FG gradually increased until reaching its highest at 11-12 years of age. At 12-17 years of age, the prevalence of IR was decreased with age, whereas that of FG persisted at approximately 10% after a temporally decrease. Conversely, the prevalence of HT increased while those of IR and FG simultaneously decreased (Figure 1). Age- and position adjusted multivariable analysis revealed that the presence of MEC lesions were high risk of elbow pain, and significantly higher risk for FG (odds ratio [OR]: 4.25, 95% confidence interval [CI]: 3.23-5.62) compared to IR (OR:3.17, 95%CI:2.31-4.39) and HT (OR:2.12, 95%CI:1.76-2.55). Capitellum OCL of was also significantly high risk of elbow pain (OR:,2.69, 95%CI:1.42-5.45) (Table 1).
Our study demonstrated that morphology of MEC apophysis in juvenile baseball player varied with age. As the presence of FG was a significantly high- risk factor for elbow pain as compared to HT, appropriate management of “Little Leaguer’s Elbow” in the preadolescent period might be quite important to accelerate the bony healing of medial epicondyle apophysitis and decrease preventable adulthood elbow pain.
PMCID: PMC4968309
7.  Supinated forearm is correlated with the onset of medial epicondylitis in professional slalom water-skiers 
prolonged and laborious activities involving wrists and forearms has been long associated with the onset of epicondylitis. Slalom water-skiing can be included in this category. The purpose of the study is to analyse the correlation between the pronated or supinated position of forearms during water-skiing practice and the presence respectively of lateral and medial epicondylitis.
sixty-six pro and semi-pro slalom water-skiers were enrolled in the study. A questionnaire was submitted to each athlete. Diagnosis of lateral or medial epicondylitis was made through anamnesis and clinical exam by an expert orthopaedic surgeon. Chi-squared were performed for categorical variables, and Mann-Whitney U test for continuous ones.
from 116 upper limbs examined, we observed 15 (12.9%) cases of lateral epicondylitis, 30 (25.9%) cases of medial epicondylitis, 10 (8.6%) were affected by both lateral and medial epicondylitis. Lateral and medial epicondylitis were associated (95% C.I.=2,489–26,355; P=<0,001) and the supinated position was correlated with medial epicondylitis (95% C.I.=1,529–9,542; P=0.003).
slalom water-skiing can be considered a high-risk sport for epicondylitis. In slalom water-skiers there is a correlation between development of lateral and medial epicondylitis in the same upper limb. Supinated position of forearms is strongly associated with the diagnosis of medial epicondylitis.
PMCID: PMC4915453  PMID: 27331043
biomechanics; elbow; pain; tendinopathy; water-skiing
8.  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
9.  New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis 
BioMed Research International  2015;2015:439309.
Lateral epicondylitis is a common source of elbow pain. Though it is often a self-limited condition, refractory lateral epicondylitis can lead to problems with activities of daily living and sometimes requires sick leave from work. Therefore prompt treatment is essential. Histopathologic studies have suggested that lateral epicondylitis is a tendinopathy, associated with apoptosis and autophagy, rather than a tendonitis associated with inflammation. Although corticosteroids have been used for short-term treatment, recent studies have suggested that they are not helpful and may even be harmful and delay healing in the treatment of lateral epicondylitis. Researchers have recently begun to investigate the use of biologics as potential treatment options for lateral epicondylitis. Autologous blood preparations including platelet rich plasma (PRP) and autologous whole blood injections (ABIs) have been proposed in order to deliver growth factors and other nutrients to the diseased tendon. Stem cell therapies have also been suggested as a method of improving tendon healing. This review discusses the current evidence for the use of PRP, ABI, and stem cell therapies for treatment of lateral epicondylitis. We also review the evidence for nonbiologic treatments including corticosteroids, prolotherapy, botulinum toxin A, and nitric oxide.
PMCID: PMC4465648  PMID: 26114106
10.  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
11.  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
12.  Origin of the Medial Ulnar Collateral Ligament on the Pediatric Elbow 
Orthopaedic Journal of Sports Medicine  2013;1(4 Suppl):2325967113S00109.
Surgical reconstruction of the torn anterior bundle of the medial ulnar collateral elbow ligament (UCL) is an established treatment that yields satisfactory results in adults. 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 elbow MRI between 2009 and 2012 was performed. Grouped by age (<11, 11-13, and >13) and gender, the exclusion criteria included: poor imaging quality due to motion artifact, elbow flexion beyond 45 degrees, and prior elbow injury obscuring anatomic structures. Measurements of UCL width and UCL midpoint distance from medial epicondyle apophysis were recorded on coronal T1 images utilizing digital PACS software.
Ninety children (68 boys, 22 girls), mean age 12.8 years (range 6-18), met criteria. 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 (Table 1). However, the anatomic origin of the UCL always remained medial to the distal periphery of the apophysis. There was, however, a statistical trend in girls between the <11 and >13 groups for the UCL origin to move closer to the medial epicondyle apophysis with maturity (p=0.053).
Although surgical reconstruction of the UCL in children is infrequent, it may be the best treatment for a given skeletally immature patient with elbow instability. The procedure requires a choice regarding ligament placement on the humerus versus preservation of the medial epicondyle apophysis. This study elucidates the anatomical origin of the UCL across gender and age for the at risk pediatric group and demonstrates no differences in the UCL center of attachment based on skeletal maturity or gender. Therefore, surgical intervention of the pediatric torn elbow UCL does not require specific consideration of age and gender regarding placement of the reconstructed ligament; however, an anatomic reconstruction of the UCL does place the medial epicondyle apophysis at risk for injury.
PMCID: PMC4589008
13.  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
14.  Medial Epicondyle Morphology in Elite Overhead Athletes 
Orthopaedic Journal of Sports Medicine  2014;2(1):2325967113517211.
Prior studies have attempted to determine morphological characteristics of the medial epicondyle in overhead athletes, but no study has reported on precise quantitative differences between elite overhead athletes and control patients.
The medial epicondyle in overhead athletes is larger in volume than those of control patients.
Study Design:
Cross-sectional study; Level of evidence, 3.
Computer simulation modeling from advanced (computed tomography/magnetic resonance imaging) imaging of the elbow of 37 patients (22 elite overhead athletes, 15 control patients) was performed to provide detailed assessment of the morphological characteristics of the medial epicondyle. Several quantitative metrics regarding the medial epicondyle were measured and compared across both cohorts, including that of epicondyle width (medial-lateral), height (superior-inferior), thickness (anterior-posterior), volume, percentage cortical volume, and morphology of the inferior slope of the epicondyle.
The medial epicondyle in overhead athletes was significantly larger than that found in nonathlete controls (4976 vs 3682 mm3; P = .001). There was no significance between the 2 cohorts in medial-lateral width (16.8 vs 16.6 mm; P = .68), but there was a difference in anterior-posterior thickness (16.96 vs 14.40 mm; P = .001) and superior-inferior height (39.55 vs 35.86 mm; P = .09) in athletes versus controls. The epicondyle volume was 97.9% cortical bone in athletes compared with 82.3% in control patients (P < .001). There were no differences in the morphology of the inferior epicondyle slope between the 2 groups.
The medial epicondyle in overhead athletes is larger in volume and anterior-posterior thickness than those of control patients. Additionally, the medial epicondyle is comprised nearly entirely of cortical bone in overhead athletes.
Clinical Relevance:
These quantitative findings support the theory of adaptive remodeling in skeletally immature overhead athletes.
PMCID: PMC4555523  PMID: 26535264
medial epicondyle; overhead athletes
15.  Safe Zone for Superolateral Entry Pin Into the Distal Humerus in Children: An MRI Analysis 
The radial nerve is at risk for iatrogenic injury during placement of pins, screws, or wires around the distal humerus. Unlike adults, detailed anatomic information about the relationship of the nerve to the distal humerus is lacking in children.
This study evaluates the relationship of the radial nerve to the distal humerus in a pediatric population on conventional MRI and proposes an anatomic safe zone using easily identifiable bony landmarks on an AP elbow radiograph.
To determine the course of the radial nerve at the lateral distal humerus, we reviewed 23 elbow radiographs and MRIs of 22 children (mean age, 9 ± 4 years; range, 3–12 years) obtained as part of their workup for various elbow conditions. We described a technique using distance ratios calculated as a percentage of the patient’s own transepicondylar distance, defined as the distance measured between the apices of the medial and lateral epicondyles, on the AP elbow radiograph and the midcoronal MR image. The cross-reference tool on a Picture Archiving and Communication System was then used to identify axial MR image at the level where the transepicondylar distance was measured. On this axial image, a line was drawn connecting the medial and lateral epicondyles (the transepicondylar axis) and its midpoint was determined. The radial nerve angle was measured by a line from the radial nerve to the midpoint of the transepicondylar axis and a line along the lateral half of the transepicondylar axis. On this axial slice, the closest distance from the nerve to the underlying cortex of the distal humerus was measured. To further localize the nerve along the distal humerus, predetermined percentages of the transepicondylar distance were projected proximally from the level of the transepicondylar axis along the longitudinal axis of the humerus on the midcoronal MR image. At these designated heights, the corresponding axial MR image was identified using the cross-reference tool and the nerve was mapped in a similar fashion. We then proposed a simpler method using a best-fit line drawn along the lateral supracondylar ridge on the AP radiograph to define the safe zone for lateral pin entry.
On axial MR images, the radial nerve was located in the anterolateral quadrant with a mean radial nerve angle of 54° (range, 35°–87) at 0% transepicondylar distance (23 MRIs), 41° (range, 24°–63°) at 50% transepicondylar distance (23 MRIs), and ≥ 10° at 75% transepicondylar distance (on the 13 MRIs that extended this far cephalad). The mean closest distance between the radial nerve and the underlying humeral cortex was 10 mm (range, 3–26 mm) at 0% transepicondylar distance and 7 mm (3–16 mm) at 50% transepicondylar distance. On the AP elbow radiograph, the height of the lateral supracondylar ridge, determined by a best-fit line drawn along the lateral cortex of the ridge, diverged from the most proximal extent of the ridge at a point located at 60% transepicondylar distance (range, 51%–76%). At the corresponding location on the axial MR image, the nerve was located anterolaterally with a mean radial nerve angle of 39° (range, 15°–61°) and a mean distance of 6 mm (range, 2–10 mm) from the underlying humerus.
Our data suggest that percutaneous direct lateral entry Kirschner wires and half-pins can be safely inserted in the distal humerus in children along the transepicondylar axis, either at or slightly posterior to the lateral supracondylar ridge, when placed caudal to the point located where the lateral supracondylar ridge line diverges from the proximal extent of the supracondylar ridge on AP elbow radiograph.
PMCID: PMC4397742  PMID: 24532434
16.  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
17.  Factors Associated With Failure of Nonoperative Treatment in Lateral Epicondylitis 
Lateral epicondylitis is a common cause of elbow pain that is treated with a variety of non-operative measures and often improves with time. There is minimal research on patients that fail those non-operative treatments.
To identify baseline patient and disease factors associated with the failure of non-operative treatment of lateral epicondylitis, defined by surgery after a period of non-operative treatment..
We analyzed 580 patients treated for lateral epicondylitis at a tertiary center between 2007 and 2012. Disease-specific and patient demographic characteristics were compared between patient groups (non-operative treatment versus surgical treatment). A multivariable logistic regression model was created based on preliminary univariate testing to determine which characteristics were associated with failure of non-operative treatment.
Ninety-two (16%) of the 580 patients underwent surgical treatment at a mean of 6 months (range, 0 to 31 months) from their initial visit at our center. Univariate analysis demonstrated a potential association (p<0.10) between operative management and the following factors at presentation to our center: increased age, body mass index, duration of symptoms, presence of radial tunnel syndrome, history of prior injection, physical therapy, splinting, smoking, workers’ compensation, a labor occupation, use of narcotics, use of anti-depressant medications, and a history of previous orthopedic surgery. In the final multivariable model, a workers’ compensation claim (OR 8.1), prior injection (OR 5.6), the presence of radial tunnel syndrome (OR 3.1), history of previous orthopedic surgery (OR 3.2), and duration of symptoms greater than 12 months (OR 2.5) remained significant independent predictors of surgical treatment.
We have identified risk factors for surgical treatment for lateral epicondylitis. While these findings do not provide information regarding causal factors associated with surgery, these patient and disease-specific considerations may be helpful when counseling patients regarding treatment options and the likelihood of the success of continued non-operative treatment.
PMCID: PMC4642177  PMID: 26122386
epicondylitis; lateral; elbow; tennis; treatment
18.  Lateral Epicondylitis and Tobacco Use: A Case-Control Study 
The Iowa Orthopaedic Journal  2015;35:114-118.
Although lateral epicondylitis (LE) is a very common tendinopathy, we understand little about the etiology of the disease. Tobacco use has been associated with other tendinopathies, and the purpose of this study is to determine if there is an association between the incidence of lateral epicondylitis and tobacco use.
We performed a retrospective cohort study of adult patients diagnosed with lateral epicondylitis. Patients from a single orthopaedic surgeon's practice with LE were matched to control patients with other common upper extremity conditions based on age, gender, and occupation. A total of 65 case patients and 217 control patients were included in the study. The incidence of smoking in patients with lateral epicondylitis was compared to the incidence of smoking in the control group.
Of the LE patients, 30/65 (46.2%) were non-smokers, 23/65 (35.4%) were former smokers, and 12/65 (18.5%) were current smokers. Of the control patients, 121/217 (55.8%) were non-smokers, 45/217 (20.7%) were former smokers, and 51/217 (23.5%) were current smokers. The odds of LE patients being former or current smokers compared to control patients were 1.45 times higher, but this was not statistically significant. Among people who did not smoke at the time of presentation, the odds of being a former smoker were 2.28 times higher in LE patients than in controls, which was statistically significant
The odds of being a former smoker were significantly higher in patients with lateral epicondylitis compared to patients with other upper extremity conditions. Although it did not reach statistical significance, the odds of being former or current smokers were also higher in the LE group. These results suggest a relationship between smoking history and incidence of lateral epicondylitis, though more research is needed to determine the exact nature of the relationship.
Level of Evidence
Prognostic, Level III
PMCID: PMC4492151  PMID: 26361452
19.  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
20.  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
21.  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
22.  Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials 
Hand (New York, N.Y.)  2014;9(4):419-446.
Non-surgical approaches to treatment of lateral epicondylitis are numerous. The aim of this systematic review is to examine randomized, controlled trials of these treatments.
Numerous databases were systematically searched from earliest records to February 2013. Search terms included “lateral epicondylitis,” “lateral elbow pain,” “tennis elbow,” “lateral epicondylalgia,” and “elbow tendinopathy” combined with “randomized controlled trial.” Two reviewers examined the literature for eligibility via article abstract and full text.
Fifty-eight articles met eligibility criteria: (1) a target population of patients with symptoms of lateral epicondylitis; (2) evaluation of treatment of lateral epicondylitis with the following non-surgical techniques: corticosteroid injection, injection technique, iontophoresis, botulinum toxin A injection, prolotherapy, platelet-rich plasma or autologous blood injection, bracing, physical therapy, shockwave therapy, or laser therapy; and (3) a randomized controlled trial design. Lateral epicondylitis is a condition that is usually self-limited. There may be a short-term pain relief advantage found with the application of corticosteroids, but no demonstrable long-term pain relief. Injection of botulinum toxin A and prolotherapy are superior to placebo but not to corticosteroids, and botulinum toxin A is likely to produce concomitant extensor weakness. Platelet-rich plasma or autologous blood injections have been found to be both more and less effective than corticosteroid injections. Non-invasive treatment methods such as bracing, physical therapy, and extracorporeal shockwave therapy do not appear to provide definitive benefit regarding pain relief. Some studies of low-level laser therapy show superiority to placebo whereas others do not.
There are multiple randomized controlled trials for non-surgical management of lateral epicondylitis, but the existing literature does not provide conclusive evidence that there is one preferred method of non-surgical treatment for this condition. Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment.
Level of Evidence
Therapeutic Level II. See Instructions to Authors for a complete description of level of evidence.
PMCID: PMC4235906  PMID: 25414603
Elbow tendinopathy; Extensor tendinopathy; Lateral elbow pain; Lateral epicondylalgia; Lateral epicondylitis; Tennis elbow
23.  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
24.  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
25.  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

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