Efficacy of Plyometric and TheraBand FlexBar Exercises in Tennis Elbow Patients: A Comparative Study.

Background Lateral epicondylitis is a common condition involving the arm. It is caused by degenerative changes or overuse of the tendon connecting the elbow joint to the forearm muscle. Plyometric and TheraBand FlexBar (Theraband, Akron, OH, USA) exercises can relieve elbow discomfort, soreness, and weakness. This study examines the effects of plyometric and TheraBand FlexBar exercises with ultrasound on tennis elbow patients. Methodology It is an experimental study comprising a total of 30 participants, including individuals of both genders with age groups of 20-40 years were selected by specific criteria for inclusion and exclusion. The participants were randomly assigned into two groups. Group A received plyometric exercises with ultrasound, whereas Group B received TheraBand FlexBar exercises with ultrasound. The outcome measures utilized in this study include patient-rated tennis elbow evaluation (PRTEE) and visual analog scale (VAS) for evaluating the functional disability of the hand, arm, and shoulder. Results The results showed a substantial reduction in mean values in Group A compared to Group B, with a p-value of less than 0.001, indicating that plyometric exercises with ultrasound were more effective than TheraBand FlexBar exercises. Conclusion Plyometric exercises combined with ultrasound therapy demonstrated significant reductions in discomfort and improvements in function, with plyometric exercises showing superior efficacy compared to TheraBand FlexBar exercises.

Comparing autologous blood, corticosteroid, and a combined injection of both for treating lateral epicondylitis: a randomized clinical trial.

BACKGROUND: Because lateral epicondylitis is a common musculoskeletal disorder that affects the forearm's extensor tendons, an effective therapeutic approach should reverse the degeneration and promote regeneration. This study aimed to compare the efficacies of autologous blood (AB) injection, corticosteroid (CS) injection, and a combined injection of both in treating lateral epicondylitis (LE), hypothesizing that the combined approach might offer immediate symptom resolution and a lower recurrence. MATERIALS AND METHODS: A total of 120 patients diagnosed with lateral epicondylitis were systematically distributed among three distinct therapeutic injection groups. Those in the AB group were administered 1 ml of autologous venous blood mixed with 2 ml of 2% prilocaine HCl. Participants in the CS category were given 1 ml of 40 mg methylprednisolone acetate mixed with 2 ml of 2% prilocaine HCl. Meanwhile, patients in the combined group received a mixture containing 1 ml each of autologous venous blood and 40 mg methylprednisolone acetate along with 1 ml of 2% prilocaine HCl. Prior to receiving their respective injections, a comprehensive assessment of all participants was carried out. Follow-up assessments were subsequently conducted on days 15, 30, and 90 utilizing metrics of the patient-rated tennis elbow evaluation (PRTEE) and measurements of hand grip strength (HGS). RESULTS: One patient dropped out from the combined group, and 119 patients completed the trial. No complications were recorded during the course of follow-up. By day 15, all groups had demonstrated significant PRTEE improvement, with CS showing the most pronounced reduction (p = 0.001). However, the benefits of CS had deteriorated by day 30 and had deteriorated further by day 90. The AB and AB + CS groups demonstrated sustained improvement, with AB + CS revealing the most effective treatment, achieving a clinically significant improvement in 97.4% of the patients. The improved HGS parallelled the functional enhancements, as it was more substantial in the AB and AB + CS groups (p = 0.001), corroborating the sustained benefits of these treatments. CONCLUSIONS: The study concluded that while AB and CS individually offer distinct benefits, a combined AB + CS approach optimizes therapeutic outcomes, providing swift and sustained functional improvement with a lower recurrence rate. These findings have substantial clinical implications, suggesting a balanced, multimodal treatment strategy for enhanced patient recovery in LE. LEVEL OF EVIDENCE: Randomized clinical trial, level 1 evidence. TRIAL REGISTRATION: NCT06236178.

Assessing the treatment response of lateral elbow tendinopathy using time-dependent ultrasonography, Doppler imaging, and elastography.

OBJECTIVE: To investigate the structural alterations, neovascularity, and elasticity of tendons and the relationship between elasticity and the Patient Rated Tennis Elbow Evaluation score after undergoing US-guided fenestration or surgery in patients with chronic lateral elbow tendinopathy. METHODS: Participants from the per-protocol population of a randomized trial conducted between October 2016 and June 2020 were included. The surgery and fenestration groups included 24 (mean age, 50 ± 7 years [standard deviation], 10 men) and 29 (47 ± 8 years, 18 men) participants, respectively. Ultrasound exams were performed at baseline, 6 months, and 12 months. Statistical analyses included linear mixed effects and generalized equation estimation models. RESULTS: Fenestration had no significant impact on tendon thickness (p = 0.46). Conversely, surgery significantly increased tendon thickness at 6 months (p < 0.0001) and remained elevated at 12 months (p = 0.04). Tendon echostructure exhibited a group effect (p = 0.03), indicating a higher proportion of pathological scores in the surgery group post-intervention compared to the fenestration group. Both groups showed a similar reduction in neovascularity from 6 to 12 months postintervention (p = 0.006). Shear-wave velocity increased in the fenestration group at 6 months (p = 0.04), while the surgery group experienced a nonsignificant decrease at 6 months, with some improvement at 12 months (p = 0.08). Changes in shear-wave velocity did not correlate with clinical outcome. CONCLUSIONS: Fenestration and surgery reduced tendon neovascularity over time. Unlike surgery, fenestration did not impact tendon size while improving tendon echostructure and elasticity. CRITICAL RELEVANCE STATEMENT: Fenestration and surgery equally alleviated symptoms and decreased tendon neovascularity in lateral elbow tendinopathy; however, fenestration did not alter tendon thickness and improved echostructure and shear-wave velocity, suggesting shear-wave velocity's potential for quantitatively monitoring tendon elasticity during healing. KEY POINTS: Reliable markers for monitoring healing response and informing treatment protocols in elbow tendinopathy are lacking. Fenestration and surgery reduced tendon neovascularity, while fenestration improved tendon echostructure and shear-wave velocity. Shear-wave velocity may provide quantitative measures to monitor tendon elasticity in response to treatment.

Efficacy of neural mobilization and Maitland accessory mobilization in patients with tennis elbow- randomized controlled trial.

OBJECTIVE: The objective of the study was to evaluate the efficacy of Maitland accessory mobilization and neural mobilization in patients with tennis elbow. METHOD: Twenty-five patients meeting the selection criteria were randomly assigned to three experimental groups: Group C (conventional treatment), Group B (neural mobilization), and Group A (Maitland mobilization). Quality of life was assessed using the Patient Rated Tennis Elbow Evaluation (PRTEE), while pain, range of motion, and grip strength were evaluated using the Visual Analog Scale (VAS), a universal goniometer, and a handheld dynamometer. The interventions were administered three times per week for four weeks to the respective groups. RESULTS: Non-parametric tests were employed to analyze the results due to the non-normal distribution of the data (p < 0.05). Both the Wilcoxon signed-rank test and the Kruskal-Wallis test were utilized to assess differences within and between groups. The results of the between-group analysis demonstrated significant differences in pain (p = 0.018) and quality of life (p = 0.045) among the three groups. CONCLUSION: After a 4-week intervention, all three groups exhibited notable improvements in discomfort levels, grip strength, and quality of life. Notably, Group B demonstrated the most substantial increase in range of motion (ROM) compared to Groups A and C. Consequently, incorporating neural mobilization into the treatment plan is recommended for patients experiencing Tennis Elbow.

Comparing the efficacy of Agnikarma with therapeutic ultrasound in the management of tennis elbow - A randomised controlled preliminary study.

BACKGROUND: Tennis elbow is a common musculoskeletal disease of elbow and causes restricted movement of forearm. Various treatment modalities like NSAID, corticosteroid injection, counter bracing, physiotherapy, surgery etc are available but safety and efficacy of one treatment over another is under research. Ayurveda classifies this condition as Snayugata vata. According to Sushruta, Agnikarma (thermal cautery) is the one among the treatment modalities for Snayugata vata. Previously published randomised controlled trials have shown that therapeutic ultrasound is safe and effective for tennis elbow. However, the comparative efficacy of these two treatment modalities is unknown. OBJECTIVE: This study compares the effects of Agnikarma (AGK) with Therapeutic Ultrasound (TUS) in reducing pain, tenderness and restores the ability to do various tasks. MATERIALS AND METHODS: A total of 30 patients were enrolled in the study as an open-label, double-armed, prospectively designed comparative clinical study, with 15 patients in each group. Group AGK received two sittings of Agnikarma and Group TUS received therapeutic ultrasound. To analyze the patients, three outcome measures were adopted: pain intensity, assessed with a Numerical Pain Rating Scale, tenderness - Grade 0 to Grade 4 (mentioned in Hutchinson's clinical methods) and pain and functional Disability assessed with the Patient Rated Tennis Elbow Evaluation (PRTEE) questionnaire. Assessment was done on 0th, 8th, 15th, 30th and 60th day. RESULT: Tennis elbow can be effectively treated with AGK and TUS. (p < 0.001 for pain, tenderness and PRTEE). While comparing between the groups, on 8th day and 15th day statistically significant difference in pain and PRTEE (p < 0.05) was noted between AGK and TUS groups. Agnikarma showed better results than therapeutic ultrasound in pain management and showed an improved quality of life from 8th day onwards and for a period up to 2 months. CONCLUSION: Both Agnikarma and therapeutic ultrasound have roles in the management of tennis elbow. However, starting on the 8th day and continuing for up to 2 months, Agnikarma showed a significant benefit in pain management and improved status for quality of life.

Comparison of Clinical Outcomes After Different Surgical Approaches for Lateral Epicondylitis: A Systematic Review and Meta-analysis.

Background: Lateral epicondylitis (LE) is one of the most common causes of lateral elbow pain. When nonoperative treatment fails, 1 of the 3 surgical approaches-open, percutaneous, or arthroscopic-is used. However, determining which approach has the superior clinical outcome remains controversial. Purpose: To review the outcomes of different operative modalities for LE qualitatively and quantitatively. Study Design: Systematic review; Level of evidence, 4. Methods: This review was performed and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies published in PubMed, Medline (via EBSCO), and ScienceDirect databases that treated LE with open, percutaneous, or arthroscopic approaches with at least 12 months of follow-up were included. Study quality was assessed using the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies score. The primary outcome was the success rate of each operative treatment approach-open, percutaneous, and arthroscopic. Results: From an initial search result of 603 studies, 43 studies (n = 1941 elbows) were ultimately included. The arthroscopic approach had the highest success rate (91.9% [95% CI, 89.2%-94.7%]) compared with the percutaneous (91% [95% CI, 87.3%-94.6%]) and open (82.7% [95% CI, 75.6%-89.8%]) approaches for LE surgery with changes in the mean visual analog scale pain score of 5.54, 4.90, and 3.63, respectively. According to the Disabilities of the Arm, Shoulder and Hand score, the functional outcome improved in the arthroscopic group (from 54.11 to 15.47), the percutaneous group (from 44.90 to 10.47), and the open group (from 53.55 to 16.13). The overall improvement was also found in the Mayo Elbow Performance Score, the arthroscopic group (from 55.12 to 90.97), the percutaneous group (from 56.31 to 87.65), and the open group (from 64 to 93.37). Conclusion: Arthroscopic surgery had the highest rate of success and the best improvement in functional outcomes among the 3 approaches of LE surgery.

Adherence to exercise in lateral elbow tendinopathy, a scoping review.

BACKGROUND: Understanding the true effects of exercise in the treatment of lateral elbow tendinopathy (LET) is hampered by insufficient information or a lack of standardisation in defining, measuring, reporting and analysis of exercise adherence. OBJECTIVES: This scoping review aimed to explore both the quantity and scope of reporting of exercise adherence in published studies of participants with LET. METHOD: Six databases were searched to identify original research studies written in English, investigating therapeutic exercise for LET. Eligible studies were first searched for terms related to exercise adherence. If provided, information on the terminology, definition, measurement, results and analysis of adherence were collated and summarised. Recommendations for standardized reporting of exercise adherence were developed. RESULTS: 104 studies were identified, of which 74 (71%) did not report adherence or related terms. Reference to exercise compliance or adherence occurred in 17 and 13 studies respectively. Adherence was most commonly defined as the frequency or percentage of exercise sessions completed compared to the recommendation and measured by self-reported diary. Few studies defined a threshold for adherence, provided comprehensive reporting of results or analysis of exercise adherence. CONCLUSION: Reporting of exercise adherence in studies of LET was limited in both quantity and scope. Recommendations are made to improve the quality and consistency of reporting in future studies.

Association between Platelet-Derived Growth Factor Receptor Alpha Gene Polymorphisms and Platelet-Rich Plasma's Efficiency in Treating Lateral Elbow Tendinopathy-A Prospective Cohort Study.

Individual differences in the response to platelet-rich plasma (PRP) therapy can be observed among patients. The genetic background may be the cause of this variability. The current study focused on the impact of genetic variants on the effectiveness of PRP. The aim of the present study was to analyze the impact of single nucleotide polymorphisms (SNP) of the platelet-derived growth factor receptor alpha (PDGFRA) gene on the effectiveness of treating lateral elbow tendinopathy (LET) with PRP. The treatment's efficacy was analyzed over time (2, 4, 8, 12, 24, 52 and 104 weeks after the PRP injection) on 107 patients using patient-reported outcome measures (PROM) and achievement of a minimal clinically important difference (MCID). Four SNPs of the PDGFRA gene (rs7668190, rs6554164, rs869978 and rs1316926) were genotyped using the TaqMan assay method. Patients with the AA genotypes of the rs7668190 and the rs1316926 polymorphisms, as well as carriers of the T allele of rs6554164 showed greater effectiveness of PRP therapy than carriers of other genotypes. Moreover, the studied SNPs influenced the platelets' parameters both in whole blood and in PRP. These results showed that PDGFRA gene polymorphisms affect the effectiveness of PRP treatment. Genotyping the rs6554164 and the rs1316926 SNPs may be considered for use in individualized patient selection for PRP therapy.

Treatment of Lateral Epicondylitis: Is Surgery Still an Option?

Background: The prevailing trend for the treatment of lateral epicondylitis (LE) is nonsurgical. Although many providers consider LE surgery controversial, others consider surgical intervention in patients with recalcitrant symptoms. The purpose of this study is to analyze epidemiological changes in LE surgery over a 9-year period prior to the coronavirus pandemic in 2019. Methods: A cross-sectional analysis of the Texas health care database from 2010 to 2018 was performed. We analyzed all procedures performed for LE during the set time period using Current Procedure Terminology (CPT) codes. Statistical analyses included procedures performed, patient demographics, zone of residence, and insurance designation. Results: There were a total of 12802 records of LE with 1 or more associated surgical procedures. Lateral epicondylar debridement (with/without tendon repair) was the most common procedure recorded, followed by arthroscopic procedures and tendon lengthening. Overall incidence remained low and did not significantly change during the studied period; however, surgical case volumes were significantly higher in metropolitan areas and increased at a faster rate when compared with those of more rural regions. Commercial insurance was the most prevailing form of payment. The incidence was significantly higher in the age group between 45 and 64 years old and most commonly performed in Caucasian females. Conclusions: The benefit of surgery for the treatment of LE has yet to be completely elucidated; however, surgical intervention continues to be offered. Although the incidence of surgery for the treatment of LE remained low over the study period, the volume of cases in metropolitan areas increased at a fast rate between 2010 and 2018. The results of this study found that surgery is still a treatment option in some patients despite the controversy. Level of Evidence: Economic/Decision Analysis, Level IV.

Defining tennis elbow characteristics - The assessment of magnetic resonance imaging defined tendon pathology in an asymptomatic population.

Background: This radiological study aims to assess the prevalence of lateral elbow pathology in an asymptomatic population using 3.0T magnetic resonance imaging (MRI). Methods: Bilateral elbow MRI was undertaken in 30 asymptomatic volunteers. Exclusion criteria included elbow pain within 3 months, elbow trauma or previous diagnosis of lateral epicondylar tendinopathy. Baseline patient-reported outcome measures were recorded along with age and body mass index (BMI). Two musculoskeletal radiologists independently graded the degree of abnormality at the common extensor tendon. Results: Thirty volunteers were categorised according to age; 35-44 (n = 10), 45-54 (n = 11), and 55-65 (n = 9) with a 1:1 male-to-female ratio. Radiological evidence of tendon abnormality was found in 37% of volunteers. The proportion with abnormal findings increased with age; 35-44 (10%), 45-54 (36%), 55-65 (67%) and BMI; 18-24.9 (23%), 25-29.9 (43%), > 30 (67%). Changes were generally 'mild' or 'moderate', with a single volunteer showing 'severe' pathology. Kappa for the radiographic agreement was 0.91 (0.83-0.98). Discussion: This study has demonstrated MRI findings suggestive of pathology at the common extensor tendon to be prevalent in an asymptomatic population, increasing with age and BMI. This draws into question the diagnostic and prognostic value of MRI imaging in lateral epicondylar tendinopathy, especially in older patients.

Comparison of Interventions for Lateral Elbow Tendinopathy: A Systematic Review and Network Meta-Analysis for Patient-Rated Tennis Elbow Evaluation Pain Outcome.

PURPOSE: There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET), and not all available treatment options have been compared directly with placebo/control. A network meta-analysis was conducted to compare the effectiveness of different LET treatments directly and indirectly against control/placebo based on a validated outcome, the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score. METHODS: Randomized, controlled trials comparing different treatment methods for LET were included, provided they reported outcome data using the PRTEE pain score. A network meta-analysis with random effect was used to combine direct and indirect evidence between treatments compared with placebo in the short term (up to six weeks) and midterm (more than six weeks and up to six months) after intervention. RESULTS: Thirteen studies with 12 comparators including control/placebo were eligible. The results indicated no significant improvement in PRTEE pain score in the short term across all treatments compared with control/placebo. In the midterm, physiotherapy/exercise showed benefit against placebo (mean difference: -4.32, 95% confidence interval: -7.58 and -1.07). Although steroid injections, dry needling, and autologous blood also exhibited potential treatment effects, it is crucial for the clinician to consider certain pitfalls when considering these treatments. The limited number of small studies and paucity of data call for caution in interpreting the results and need for further evidence. CONCLUSIONS: Patients should be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared with control/placebo in the short and medium terms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Reliability and Usefulness of YouTube as a Source of Informative Media for Arthroscopic Tennis Elbow Surgery: A Systematic Review of the Published Videos.

Aims and Objectives: Over the last decade, YouTube has been extensively used as a learning tool for both physicians and patients, but the reliability of this information remains questionable. The purpose of this study was to look for the reliability and quality of videos on tennis elbow arthroscopy on YouTube. Materials and Methods: We used three search terms on YouTube "tennis elbow arthroscopic surgery," "Arthroscopic ECRB release," and "Arthroscopic debridement for tennis elbow," and screened the first 50 videos according to popularity. The videos were included from 2009 to date. Only videos in the English language were included. Repeated videos and videos without sound were excluded. A total of 74 videos were selected for this study and reliability was checked with DISCERN and journal of the American medical association (JAMA) scores. The quality was assessed with the Global Quality Score Criteria (GQSC) score and TEARS (a novel score). Popularity was tested with the video power index (VPI). A pilot study was conducted using 20 videos to validate the TEARS score. Results: In the pilot study, TEARS showed results in accordance with other scores used. The average number of views was 41,644.97, and the average duration was 5.03 ± 3.39 years. The mean value of DISCERN and JAMA was found to be 21.47 ± 6.28 and 1.05 ± 0.92, respectively. GQSC, TEARS, and VPI were found to be 1.70 ± 0.82, 4.17 ± 2.62, and 769,936.9 ± 6,538,851.37. Conclusion: Most of the videos were educational and physicians were targeted. The USA was the major contributor to such videos. The reliability and quality of these videos were found to be of poor quality. The video popularity was however found to be relatively high. The inter-observer reliability was good. Based on the findings, we conclude that the videos are not reliable and could not be used for learning.

Evaluation of the efficiency of an ultrasound-supported infiltration technique in patients with tennis elbow applying the ITEC medical device: a multicenter study.

Background: The treatment of lateral epicondylitis remains unsatisfactory in certain cases. The aim of this study is to investigate the efficiency of an ultrasound-guided infiltration combined with fenestration of the extensor tendon postulating a 50% reduction in pain on exertion within 6 months. Methods: In a prospective, nonrandomized, multicenter study design, 68 patients with chronic lateral epicondylitis and symptoms lasted for at least 6 weeks were included. Each hospital has been assigned for Traumeel (A), autologous whole blood (B), or dextrose (C) in advance. Preinterventional, 6 weeks, 12 weeks, 6 and 12 months after infiltration, patient-related outcome parameter, and dorsal wrist extension strength were documented. Preinterventional (obligate) and after 6 months (optional) radiological evaluation (magnetic resonance imaging) was performed. Results: The Visual Analog Scale showed a significant reduction after 6 months in all groups (A. 4.8-2.5, B. 6.2-2.3, C. 5.8-2.4). Similar results could be observed with Subjective elbow value, Disabilities of Arm, Shoulder, and Hand Score, Mayo Elbow Performance Score, and Patient Rated Tennis Elbow Evaluation. The loss of strength could be completely compensated after about 6 months. Magnetic resonance imaging did not fully reflect clinical convalescence. Re-infiltrations were sometimes necessary for final reduction of symptoms (A = 11, B = 8, C = 4). Switching to surgical intervention was most frequently observed in group C (A = 2, B = 1, C = 5). In 14.5% of the cases, no improvement of the symptoms could be achieved with this method. Conclusion: The primary hypothesis of a significant long-term pain reduction of at least 50% could be achieved regardless of the medication chosen.

Exploring the feasibility and acceptance of an optimised physiotherapy approach for lateral elbow tendinopathy: a qualitative investigation within the OPTimisE trial.

OBJECTIVES: To explore the acceptability of an optimised physiotherapy (OPTimisE) intervention for people with lateral elbow tendinopathy (LET) and feasibility of comparing it to usual care in a randomised controlled trial. DESIGN: Semistructured interviews, analysed using thematic analysis and mapped onto the COM-B model of behaviour change. SETTING: Conducted as part of the OPTimisE Pilot & Feasibility randomised controlled trial within physiotherapy departments in the United Kingdom National Health Service. PARTICIPANTS: 17 patients with LET (purposively sampled to provide representativeness based on age, sex, ethnicity, deprivation index and treatment allocation) and all 8 physiotherapists involved as treating clinicians or site principal investigators. RESULTS: Four themes were identified. First, participants reported the OPTimisE intervention as acceptable. Second, differences between the OPTimisE intervention and usual care were identified, including the use of an orthosis, holistic advice/education including modifiable risk factors, forearm stretches, general upper body strengthening and a more prescriptive exercise-dosing regimen. Third, participants provided feedback related to the trial resources, which were viewed positively, but identified language translation as a need. Fourth, feedback related to trial processes identified the need for changes to outcome collection and reduction of administrative burden. From the perspective of adopting the OPTimisE intervention, we found evidence that participants were able to change their behaviour. Considering the findings through the lens of the COM-B model, the intervention is likely to be deliverable in practice and the trial can be delivered at scale with some additional support for physiotherapists. CONCLUSIONS: Overall, the OPTimisE intervention was found to be different to usual care and acceptable to patients and physiotherapists. The study highlighted the need to refine trial processes and resources prior to a full-scale trial, to reduce administrative burden, increase support for physiotherapists, improve return rate of outcome questionnaires and provide language translation. TRIAL REGISTRATION NUMBER: ISRCTN database 19 July 2021. https://www.isrctn.com/ISRCTN64444585.

Failed surgical treatment for lateral epicondylitis: literature review and treatment considerations for successful outcomes.

Background: Lateral epicondylitis is a common cause of elbow pain in the general population. It is recognized as a degenerative tendinopathy of the common extensor origin believed to be multifactorial, involving elements of repetitive microtrauma associated with certain physiologic and anatomic risk factors. Methods: Initial treatment typically involves a combination of conservative treatment measures, with up to 90% success at 12-18 months. Surgical treatment is reserved for recalcitrant disease; traditionally involving open surgical débridement of the common extensor origin with reported success rates greater than 90%. Results: Failure of surgical treatment can be multifactorial and present a challenge in determining the optimum management. Residual symptoms may be due to an incorrect initial diagnosis, inadequate surgical débridement, new pathology as a complication of the initial surgery and/or other patient-related and physician- related factors. Even more of a challenge is the possibility that etiology can be due to a combination of listed factors. Discussion: In this review, we review the classification scheme for evaluating failed surgical treatment of LE first proposed by Morrey and expand on this classification system based on the senior author's experience. We present the senior author's preferred systematic approach to evaluation and management of these patients, as well as a salvage surgery technique used by the senior author to address the most common etiologies of surgical failure in these patients.

Effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy: A systematic review and meta-analysis.

BACKGROUND: Lateral elbow tendinopathy is a common musculoskeletal disorder. Effectiveness of non-invasive therapies for this health condition are unclear. OBJECTIVE: To investigate the effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy. METHODS: Searches were conducted on MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Library, SPORTDiscus and PsycINFO without language or date restrictions up to May 3rd, 2023. Randomized trials investigating the effectiveness of any non-invasive therapy compared with control or other invasive interventions were included. Two independent reviewers screened eligible trials, extracted data, and assessed the risk of bias of included trials and certainty of the evidence. RESULTS: Twenty-two different therapies investigated in 47 randomized trials were included in the quantitative analysis. Moderate certainty evidence showed that betamethasone valerate medicated plaster may reduce disability (mean difference -6.7; 95% CI -11.4, -2.0) in the short-term when compared with placebo. Low certainty evidence showed that acupuncture may reduce disability (MD -9.1; 95% CI -11.7, -6.4) in the short-term when compared with sham. Moderate to very low certainty of evidence also showed small to no effect of non-invasive therapies on pain intensity, maximum grip strength, and disability outcomes in the short-term compared to control or invasive interventions. Most therapies had only very low certainty of evidence to support their use. CONCLUSIONS: Decision-making processes for lateral elbow tendinopathy should be carefully evaluated, taking into consideration that most investigated interventions have very low certainty of evidence. There is an urgent call for larger high-quality trials.

Comparison of efficacy of ultrasound-guided platelet rich plasma injection versus dry needling in lateral epicondylitis-a randomised controlled trial.

PURPOSE: To assess whether Ultrasound guided dry needling is adequate for both common extensor tendon tears and tendinosis or whether ultrasound guided platelet rich plasma (PRP) has a superior outcome when compared to dry needling when there are tears of the common extensor tendon. MATERIALS AND METHODS: This is a single-centre, single-blinded, randomised controlled trial conducted between November 2018 and April 2020. 40 patients diagnosed with lateral epicondylitis based on clinical and sonographic features and having comparable baseline characteristics were randomly assigned to the two study groups (dry needling and PRP). Inclusion criteria were patients aged 20 years or more who were symptomatic for at least 3 months with sonographic evidence of lateral epicondylitis. Exclusion criteria were complete tear of common extensor tendon confirmed on ultrasound and presence of other associated diseases like osteoarthritis of shoulder and elbow. RESULTS: There was significant improvement in the visual analogue scale pain score in PRP group compared to the dry needling group at 9 months. However, this difference was not evident at 3 and 6 months follow-up. Mean improvement in common extensor tendon thickness in PRP group (5.1 mm at 3 months and 4.3 mm at 6 months) was slightly better than dry needling (4.4 mm at 3 months and 4.0 mm at 6 months). There was no difference in tear (if present) healing between both groups at 3 months. However at 6 months follow up, PRP demonstrated significant (mean-2.5) healing in tear compared to dry needling (mean-3.1). CONCLUSION: Two injections of Ultrasound guided PRP are more beneficial non operative treatment compared to ultrasound guided dry needling, in lateral epicondylitis.

Percutaneous Tenotomy for Chronic Tennis Elbow: A Minimally Invasive Technique with Better Outcomes - A Case Series.

Background: Tennis elbow (lateral epicondylitis elbow) is a self-limiting disease of indeterminate pathogenesis. Conservative therapy is the treatment of choice. In chronic tennis elbow with failure of conservative therapy; surgical treatment is a method of choice. Percutaneous tenotomy of extensor origin for patients with chronic tennis elbow is a minimally invasive technique with better long-term outcomes. Case Report: Ten patients (six males, four females) presented with chronic tennis elbow, who did not respond to conservative treatment/non-surgical intervention for more than 6 months underwent percutaneous tenotomy in an outpatient setting. Two patients were lost to follow-up at 2 months' post-operative. The remaining eight patients were evaluated at a mean follow-up of 3 years and assessed using the numerical rating scale, disabilities of the arm, shoulder and hand questionnaire ,and Oxford elbow score. These scores had a statistically significant difference in baseline to 3-year follow-up values (P < 0.05). No adverse outcomes, recurrence of symptoms, and signs of lateral epicondylitis elbow were noted and none required open surgical release. Conclusion: Percutaneous tenotomy, a minimally invasive technique is an effective and well-tolerated treatment for chronic tennis elbow and gives good pain relief and functional recovery.

Clinical and Ultrasonographic Effectiveness of Two Different Splints Used for the Treatment of Lateral Epicondylitis: A Prospective Randomized Controlled Study.

OBJECTIVE: This study compares the clinical and ultrasonographic efficacy of 2 splint types, the lateral epicondylitis band (LEB) and the wrist extensor splint (WES), for treatment of lateral epicondylitis (LE). DESIGN: Randomized controlled single-blind trial. SETTING: Outpatient clinic. PARTICIPANTS: 159 participants diagnosed with unilateral LE based on clinical and ultrasonographic findings, and 2-12 weeks from symptom onset, were included (N=159). INTERVENTIONS: One group received joint-protection education-only (wait-and-see), while the other 2 groups were fit with splints: one the LEB and the other the WES. Both splint groups received joint-protection education. MAIN OUTCOME MEASURES: The primary outcome measure was the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire. Secondary outcome measures were the Visual Analog Scale (VAS) for pain, hand grip strength by dynamometry, algometric measurements, patient satisfaction, and selected ultrasonographic parameters (maximum tendon thickness measurements (MTTM) in the capitellar-radiocapitellar region and total ultrasonography scale score [TUSS]). All outcomes were assessed at baseline, 3-weeks, and 6-weeks post intervention initiation. RESULTS: Participants' mean age was 46.85±8.63 years. Of the participants, 40.88% (n=65) were male and 59.12% (n=94) were female. The baseline median (1Q-3Q) values of PRTEE-total scores were 58.5 (51-68) for the LEB, 63.5 (56.25-70.25) for the WES and 57 (48-68) for the education-only groups. At 6-weeks, the PRTEE-total scores had decreased by 44 points for those randomized to the LEB, 46 points to the WES and 7 points in the education-only groups(P<.001). While the LEB and WES approaches were superior to the wait-and-see approach in algometric measurements, VAS, and PRTEE scores (P<.05), no significant changes were found in MTTM and TUSS values. The LEB group was superior to the WES group in hand grip strength and patient satisfaction (P<.05). CONCLUSION: Using either splint for 6 weeks can be considered effective for the relief of pain and increased functionality in persons with subacute LE, although the LEB had a more positive effect on grip strength and patient satisfaction than the WES.

A meta-analysis of the risk factors for lateral epicondylitis.

BACKGROUND: Very few meta-analyses discussed risk factors for lateral epicondylitis (LE), and previous meta-analyses reached conflicting conclusions with each other on some specific risk factors. PURPOSE: To investigate the risk factors for LE through meta-analysis. STUDY DESIGN: Meta-analysis. METHODS: PubMed, Embase, and Web of Science databases were searched for relevant studies in January 2022. Raw data were extracted into a predefined worksheet, and quality analysis was conducted by the Quality in Prognosis Studies (QUIPS) tool. Pooled effect sizes and 95% confidence intervals were calculated. R package "meta" was used for statistical analysis. RESULTS: 22 studies were included in the meta-analysis. Female sex (odds ratio [OR]=1.33 and p-value<0.05), smoking history (OR=1.46 and p-value<0.001), manual labor (OR=2.39 and p-value<0.001), and hypercholesterolemia (OR=1.67 and p-value<0.05) were significant risk factors for LE. CONCLUSIONS: Female gender, smoking history, manual labor, and hypercholesterolemia could increase the risk of LE. According to an additional literature review, statin treatment for hypercholesterolemia is described as potentially related to the development of LE.