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Treatment of Epicondylalgia and Nerve Entrapments around the Elbow
Linköping University, Department of Clinical and Experimental Medicine, Plastic Surgery, Hand Surgery and Burns. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Plastic Surgery, Hand surgery UHL.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Disorders causing pain in the elbow region is a common problem and is one of the most frequent forms of work-related health problems. These conditions are thus of major importance from the public health point of view, as well as from that of the suffering individual. Both sensory and motor function may be impaired, particularly in cases where a nerve is involved, resulting in severely impaired hand function.

“Tennis elbow” (lateral epicondylalgia) has been found to be the second most frequently diagnosed musculoskeletal disorder of the upper extremity in the primary health-care setting. “Golfer’s elbow” (medial epicondylalgia) is not that commonly encountered. It has been stated that tennis or golfer’s elbow syndromes are self-limiting. Even so, clinical experience has shown that there are a few cases where symptoms have a painful and long-lasting course, resistant to many forms of therapy. The outcomes of frequently adopted management regimes for treatment of epicondylalgia or nerve entrapments around the elbow were examined in the following five studies:

I: A randomised, prospective study of 38 patients with tennis elbow (lateral epicondylalgia). Groups were assigned to eccentric exercises or stretching. Eccentric exercise gave somewhat better results.In a second part of the study, a 4-year follow-up of 127 patients who used eccentric exercises for tennis elbow was performed. Patients showed decreased pain and increased grip-strength after 3 months treatment. At the time of publication this study was the first to examine eccentric exercises for this condition.

II: A retrospective analysis of long-term results from 51 patients treated with surgical release of the common extensor origin because of “chronic tennis elbow”. Eighty-seven per cent of the patients rated themselves as completely recovered or improved.

III: A randomised, prospective study of 70 patients with ulnar neuropathy in the forearm (cubital tunnel syndrome). Groups assigned the commonly recommended elbow brace at night or nerve gliding exercises were compared with a control group (information only). The majority of patients improved considerably, both subjectively and objectively, after a 3 months period, regardless of group. The study thus showed the effectiveness of information and expectance, and that orthosis or nerve gliding exercises added nothing further to the result.

IV: A retrospective study of 205 patients treated with surgery for suspected nerve entrapment in the forearm. Followup, almost 4 years later, demonstrated a subjective improvement in two of three patients, but only 3% experienced complete relief of all symptoms.

V: A prospective long-term study on 20 patients with golfer’s elbow (medial epicondylalgia) treated with eccentric exercises over 3 months. The results showed decreased pain and increased gripstrength. This is the first study published on the management of this disorder with eccentric exercises.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2012. , 93 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1262
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-72719ISBN: 978-91-7393-065-9 (print)OAI: oai:DiVA.org:liu-72719DiVA: diva2:461794
Public defence
2012-01-28, Ekensalen, Campus US, Linköpings universitet, Linköping, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2011-12-05 Created: 2011-12-05 Last updated: 2011-12-16Bibliographically approved
List of papers
1. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia
Open this publication in new window or tab >>Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia
2001 (English)In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 11, no 6, 328-334 p.Article in journal (Refereed) Published
Abstract [en]

In a pilot study 38 patients with lateral humeral epicondylalgia were randomly allocated to two treatment groups. Group S (stretching) was treated with a contract-relax-stretching program while group E (eccentric exercise) underwent an eccentric exercise program. Both groups also received forearm bands and wrist support nightly. The programs were carried out daily at home during 12 weeks. Evaluation before and 3, 6 and 12 months after treatment, included subjective assessment of symptoms using visual analogue scales and grip strength measurements. Thirty-five patients were available for follow-up. Five patients, three in group S and two in group E, did not complete the programs due to increased pain while 30 (86%) reported complete recovery or improvement. Reduced pain and increased grip strength were seen in both treatment groups but 12 out of 17 patients (71%) in group E rated themselves as completely recovered as compared to 7 out of 18 (39%) in group S (P=0.09), and in group E the increase in grip strength after 6 months was statistically significantly larger than in group S. In a second study the eccentric training regime was used in a consecutive series of 129 patients with lateral epicondy lalgia. The patients were divided into two groups with one group consisting of patients with less than one year duration of symtoms and the other comprised patients with a duration of symptoms for more than one year. The results of treatment were evaluated in the same way as in the pilot study, and also after 3.4 years using the scoring system by Verhaar et al. At the end of the treatment period statistically significant improvements were seen in all VAS recordings and in grip strength. After 3.4 years 38% had excellent, 28% good, 25% fair and 9% poor results according to the score. In the self-rated outcome 54% regarded themselves as completely recovered, 43% improved, 2% unchanged and 2% worse. No significant differences were seen between patients with a duration of symptoms for more than one year compared to patients with symptoms for less than one year. The eccentric training regime can considerably reduce symptoms in a majority of patients with lateral humeral epicondylalgia, regardless of duration, and is possibly superior to conventional stretching.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25400 (URN)9843 (Local ID)9843 (Archive number)9843 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2011-12-05Bibliographically approved
2. Outcome of release of the lateral extensor muscle origin for epicondylitis
Open this publication in new window or tab >>Outcome of release of the lateral extensor muscle origin for epicondylitis
2006 (English)In: Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, ISSN 0284-4311, Vol. 40, no 3, 161-165 p.Article in journal (Refereed) Published
Abstract [en]

Fifty-five elbows in 53 patients affected by lateral epicondylitis for more than a year were operated on with lateral extensor release. Fifty-one patients (53 elbows) were followed-up 90 months postoperatively by two independent observers using Verhaar's score and the subjective grading scheme described by Svernlöv and Adolfsson. According to Verhaar's score 26 (49%) were excellent or good and 27 (51%) fair or poor. Women had significantly worse results than men (p

Keyword
Epicondylitis, surgical treatment, retrospective, sex difference
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-37814 (URN)10.1080/02844310500491492 (DOI)39126 (Local ID)39126 (Archive number)39126 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2011-12-05Bibliographically approved
3. Conservative treatment of the cubital tunnel syndrome
Open this publication in new window or tab >>Conservative treatment of the cubital tunnel syndrome
2009 (English)In: Journal of Hand Surgery: European Volume, ISSN 1753-1934, Vol. 34, no 2, 201-207 p.Article in journal (Refereed) Published
Abstract [en]

Conservative treatment of the cubital tunnel syndrome was evaluated in a randomised study of 70 patients with mild or moderate symptoms (Dellon, 1989). All patients were informed about the cause of symptoms and allocated to three groups: night splinting, nerve gliding and control. Evaluation consisted of Canadian Occupational Performance Measure, visual analogue pain scales, strength measurements and neurophysiological examination, before treatment and after six months. Fifty-seven patients were followed for six months. Fifty-one (89.5%) were improved at the follow-up. There were no significant differences between the groups in any of the recorded variables. Night splints and nerve gliding exercises did not add favourably. Routine neurophysiological examination seems unnecessary since 76% of the patients with typical symptoms had normal findings and 75% with pathological findings improved. Patients with mild or moderate symptoms have a good prognosis if they are informed of the causes of the condition and how to avoid provocation.

Keyword
Elbow; Nerve gliding; Neuropathy; Splinting; Ulnar nerve
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-18739 (URN)10.1177/1753193408098480 (DOI)
Available from: 2009-06-03 Created: 2009-06-03 Last updated: 2011-12-05Bibliographically approved
4. Patient-reported outcome of surgical treatment of nerve entrapments in the proximal forearm
Open this publication in new window or tab >>Patient-reported outcome of surgical treatment of nerve entrapments in the proximal forearm
2011 (English)In: Advances in orthopedics, ISSN 2090-3472, Vol. 2011, 727689- p.Article in journal (Refereed) Published
Abstract [en]

The outcome of decompression for long-standing symptoms of nerve entrapments in the proximal forearm was investigated in a retrospective study of 205 patients using a self-assessment questionnaire, 45 months after the operation. The questionnaire consisted of visual analogue scale recordings of pre- and postoperative pain during rest and activity, questions about remaining symptoms and appreciation of the result and the Disabilities of Arm, Shoulder and Hand form (DASH). Altogether, 59% of the patients were satisfied, 58% considered themselves improved, and 3% as being entirely relieved of all symptoms. Pain decreased significantly (P = 0.001). There was a significant correlation between preoperative duration and patient perceived post-operative pain. Preoperative pain was a chief complaint, and pain reduction appears to be the principal gain of the operation. Although the majority of the patients benefited from the operation, a substantial proportion was not satisfied. There is apparently room for improvement of the diagnostic and surgical methods applied in this study.

Place, publisher, year, edition, pages
Hindawi Publishing Corporation, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-72717 (URN)10.4061/2011/727689 (DOI)21991420 (PubMedID)
Available from: 2011-12-05 Created: 2011-12-05 Last updated: 2014-09-25Bibliographically approved
5. Medial epicondylalgia (golfer’s elbow) treated by eccentric exercise
Open this publication in new window or tab >>Medial epicondylalgia (golfer’s elbow) treated by eccentric exercise
2012 (English)In: Shoulder & Elbow, ISSN 1758-5732, Vol. 4, no 1, 50-55 p.Article in journal (Refereed) Published
Abstract [en]

Background: Eccentric exercises have been successfully used in the treatment of Achilles and patellar tendinopathies, as well as lateral epicondylalgia. No studies have explored the same treatment for medial epicondylalgia (golfer’s elbow).

Methods: Twenty consecutive adults with a clinical diagnosis of medial epicondylalgia were treated with eccentric exercise over 3 months in this prospective case series. The programme was based on home training. There were 11 women and nine men, with a mean age of 47 years, and a mean duration of symptoms of 19 months. At baseline, at 3 months and after a mean of 11 years, pain was assessed by three independent visual analogue scales (VAS) and grip strength using a Jamar dynamometer (Sammons Preston Inc., Jackson, MI, USA). At the 11-year follow-up, patients also reported their satisfaction on a 100-mm VAS and completed the Disabilities of Arm, Shoulder and Hand questionnaire.

Results: Pain decreased significantly in all measured variables at both assessment occasions (all p < 0.0001). Grip strength in the affected arm/hand increased significantly after 3 months (p = 0.009).

Discussion: Twelve weeks of eccentric training reduced pain and increased grip strength in patients with medial epicondylalgia. It is a safe, uncomplicated and cost-effective method, with only a minimum contribution from a physiotherapist.

Place, publisher, year, edition, pages
London, UK: Sage Publications, 2012
Keyword
Elbow;tendinopathies;epicondylitis;golfer's elbow;conservative treatment
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-72718 (URN)10.1111/j.1758-5740.2011.00152.x (DOI)
Available from: 2011-12-05 Created: 2011-12-05 Last updated: 2014-06-18Bibliographically approved

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