feiten bestaan niet, alleen interpretaties. (Nietzsche)
wetenschappelijke publicaties over tennisarm -tenniselleboog etiologie

– Clin J Sport Med  2001 Oct;11(4):214-22
Corticosteroid injection in early treatment of lateral epicondylitis .

Newcomer KL, Laskowski ER, Idank DM, McLean TJ, Egan KS.
Department of Physical Medicine and Rehabilitation, and Section of Biostatistics, Mayo Clinic, Rochester, Minnesota 55905.

OBJECTIVE: To analyze whether a corticosteroid injection in combination with rehabilitation early in the course of lateral epicondylitis (LE) alters the outcome up to 6 months after injection compared with a control injection and rehabilitation.

DESIGN: Randomized, controlled, double-blind study. SETTING: Sports medicine center in a tertiary care center. PARTICIPANTS: Subjects with a diagnosis of LE whose symptoms had been present less than 4 weeks were included. Subjects were recruited by word of mouth and through advertising. The 39 subjects who were recruited were 18 to 65 years old. INTERVENTIONS: 19 subjects were randomized to receive rehabilitation and a sham injection, and 20 were randomized to receive rehabilitation and a corticosteroid injection. At 4 and 8 weeks, they were reevaluated and their treatment programs were modified, if indicated. MAIN OUTCOME MEASURES: Outcome measurements were performed at baseline, 4 weeks, 8 weeks, and 6 months, and included a functional pain questionnaire and a visual analogue pain scale. Painless grip strength on the affected side and maximal grip strength bilaterally were measured at baseline, 4 weeks, and 8 weeks. RESULTS: There were no significant differences in outcome between the two groups with the exception of an improvement in the visual analogue pain scale in the corticosteroid group from 8 weeks to 6 months. Outcome measurements in both groups improved significantly over time; more than 80% of subjects reported improvements from baseline to 6 months for all scales. CONCLUSION: A corticosteroid injection does not provide a clinically significant improvement in the outcome of LE, and rehabilitation should be the first line of treatment in patients with a short duration of symptoms.

-Publication Types: Clinical Trial Randomized Controlled Trial PMID: 11753057 [PubMed – indexed for MEDLINE]
What are the disadvantages and side effects of cortisone injections?

Disadvantages of cortisone injections are the necessity of piercing the skin with a needle as well as potential short and long term side effects. It should be emphasized that each of these side effects is possible, they usually do not occur.

Short term side effects are uncommon, but include shrinkage (atrophy) and lightening of the color (depigmentation) of the skin at the injection site, introduction of bacterial infection into the body, local bleeding from broken blood vessels in the skin or muscle, soreness at the injection site, and aggravation of inflammation in the area injected because of reactions to the corticosteroid medication (postinjection flare). Tendons can be weakened by corticosteroid injections in or near tendons. Tendon ruptures as a result have been reported.
In persons who have diabetes, cortisone injections can elevate the blood sugar. In patients with underlying infections, cortisone injections can suppress somewhat the body’s ability to fight the infection and possibly worsen the infection or may mask the infection by suppressing the symptoms and signs of inflammation. Generally, cortisone injections are used with caution in persons with diabetes and avoided in persons with active infections. Cortisone injections are used cautiously in persons with blood clotting disorders.
Long-term side effects of corticosteroid injections depend on the dose and frequency of the injections. With higher doses and frequent administration, potential side effects include thinning of the skin, easy bruising, weight gain, puffiness of the face, elevation of blood pressure, cataract formation, thinning of the bones (osteoporosis), and a rare but serious damage to the bones of the large joints (avascular necrosis).

– Scand J Med Sci Sports  2001 Dec;11(6):328-34
Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia .
Svernlov B, Adolfsson L.
Department of Plastic Surgery, Hand Surgery and Burns, University Hospital,Linkoping, Sweden.
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 epicondylalgia. The patients were divided into two groups with one group consisting of patients with less than one year duration of symptoms 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. Publication Types: Clinical Trial
Randomized Controlled Trial

PMID: 11782264 [PubMed – indexed for MEDLINE]
– Arch Orthop Trauma Surg  2001 Jun;121(6):329-32

Surgical treatment of resistant tennis elbow. A prospective, randomised study comparing decompression of the posterior interosseous nerve and lengthening of the tendon of the extensor carpi radialis brevis muscle.

Leppilahti J, Raatikainen T, Pienimaki T, Hanninen A, Jalovaara P.Department of Surgery, Oulu University Hospital, Finland.
We compared decompression of the posterior interosseous nerve (PIN) and lengthening of the distal tendon of the extensor carpi radialis brevis (ECRB)for treatment of tennis elbow in a randomised trial of 28 patients. Fourteen underwent decompression of PIN and 14, lengthening of ERCB. The groups did not differ significantly with regard to age, sex and work activities. The average duration of preoperative symptoms was 23 months. The PIN was exposed in the groove between the brachioradialis and brachialis muscles and decompressed at the arcade of Frohse by means of a 1-2 cm incision through the supinator muscle. The ECRB tendon was lengthened by Z-plasty at the dorsilateral aspect of the forearm. No postoperative complications occurred. The outcome after the primary operation was successful in 50% of the PIN group and in 43% of the ECRB group. Four of the 5 patients with a poor outcome were reoperated in the former group and 3 in the latter. The overall outcome after a mean follow-up of 31 months after the primary operation was successful in 60% of the cases.
Publication Types:Clinical Trial Randomized Controlled Trial

PMID: 11482465 [PubMed – indexed for MEDLINE]
– Z Orthop Ihre Grenzgeb  2000 Nov-Dec;138(6):492-5

Effectiveness of epicondylitis bandages from the biomechanical viewpoint
an experimental study]
[Article in German] Schauss S, Helwig U, Karpf M, Plitz W. Department fur Orthopadie und chirurgische Orthopadie, Landeskrankenhaus Villach, Osterreich. QUESTIONS: During extension of the elbow joint (test measurement) and extension of the wrist (control measurement), maximal bandage pressure is desired on the extensor group of the forearm, especially of the M. extensor carpl radialis brevis (ECRB). Do the various commercial epicondylitis bandages produce a mechanical effect on the extensor group of the forearm and how do the maximal pressures of these bandages behave in direct comparison? Are the pressures produced clinically relevant? METHODS: Eleven different epicondylitis bandage constructions were examined for their biomechanical effects. The exerted pressure was measured continously during the above-mentioned movements. A fist-closing strength of ca. 30 N was maintained for the necessary pre-stressing of the forearm muscles. RESULTS: Strap-type bandages were the only bandages to produce adequately high pressures. Bands applied at pressures which approach those of the straps led to obstruction in bloodflow. Stocking designs showed no effect in respect to our study. CONCLUSION: Bandages which apply pressure to relieve the tendon insertion of the extensor muscles must, from a technical standpoint, be of a strap construction in order to build up adequate pressures to be effective.
PMID: 11199412 [PubMed – indexed for MEDLINE]

– Acta Orthop Scand  1997 Jun;68(3):249-54

Sarcomere length in wrist extensor muscles. Changes may provide insights into the etiology of chronic lateral epicondylitis.

Lieber RL, Ljung BO, Friden J. Department of Orthopedics, University of California, San Diego, USA.
Since the etiology of tennis elbow (lateral epicondylitis) is poorly understood, we studied the anatomical changes in the extensor carpl radialis brevis (ECRB) muscle during elbow joint rotation. Specifically, we measured ECRB sarcomere length, using an intraoperative laser diffraction procedure that measures muscle sarcomere length with an accuracy of +/- 0.05 micron. We found an unexpected biphasic response in ECRB sarcomere length as the elbow was rotated from full extension to full flexion. The initial sarcomere length of 3.49 microns, with the elbow extended, was gradually changed to 3.68 microns, 3.34 microns, 3.81 microns, and 3.45 microns with progressive elbow flexion. Based on the very nonlinear mechanical properties of skeletal muscle, this “double lengthening” of the ECRB during progressive flexion would impose intense eccentric contractions on the muscle itself. Given that eccentric contractions cause muscle injury and subsequent inflammation, these findings may provide insights into the etiology of lateral epicondylitis.
PMID: 9246987 [PubMed – indexed for MEDLINE]

-J Orthop Sports Phys Ther  1996 Apr;23(4):251-7

Radial epicondylalgia (tennis elbow): measurement of range of motion of the wrist and the elbow.

Solveborn SA, Olerud C. Department of Orthopaedics, Uppsala University Hospital, Sweden. The aim of the present investigation was to determine the range of motion (ROM)features of the elbow and wrist joints in patients with radial epicondylalgia (tennis elbow), since there have been contradictory statements in previous reports and apparently no accurate study has been published to establish these typical ROM values. The precision of the measuring technique and the active and passive ROMs of these joints were first evaluated in an intratester reliability study in 16 healthy individuals, 12 men and four women with a mean age of 46 years (range = 26-67). The clinical study consisted of 123 patients with unilateral symptoms, 75 men and 48 women with a mean age of 43 years (19-63) and a mean symptom duration of 11 months (0.5-72). All measurements were performed using a simple plastic goniometer. The precision of the measuring procedure, expressed as the standard deviation of the random error of the mean, was 1-6 degrees depending on the actual ROM measured. In patients with unilateral radial epicondylalgia, almost all measured ROMs of the elbow and wrist were found to be limited in the affected arm. This could give a rationale to use stretching in the treatment of radial epicondylalgia. 
PMID: 8775370 [PubMed – indexed for MEDLINE]

-Z Orthop Ihre Grenzgeb  1986 May-Jun;124(3):323-6
A diagnostic sign in so-called epicondylitis humeri radialis [Article in German] Coenen W .

With a simple test – the “finger-snapping-test” – it is possible to narrow down the etiology of lateral epicondylalgia of the humerus. On the basis of a groupof 196 patients it is shown that a positive result of this test is characteristic for an enthesopathy of the extensor carpi radialis brevis muscle, whose insertion is at the radial epicondyle. If the test is negative it must be assumed that the pain is caused by spondylogenic, arthrogenic, or neurogenic phenomena. The importance of the test for the therapeutic approach and with regard to the indication for operation after Hohmann ist pointed out. 
PMID: 3751247 [PubMed – indexed for MEDLINE]

-Clin Orthop  2002 May;(398):239-44

Arterial vascularization of the proximal extensor carpi radialis brevis tendon

. Schneeberger AG, Masquelet AC. Department of Orthopaedic Surgery, Balgrist, University of Zurich, Zurich, Switzerland; and the Department of Orthopaedic Surgery, University of Paris, Hopital Avicenne, Bobigny Cedex, France.
The macroscopic arterial vascularization of the extensor carpi radialis brevis tendon was investigated in 12 elbows from cadavers to provide fundamental anatomic information of this tendon which has been associated with lateral epicondylitis. The arterial blood supply of the extensor carpi radialis brevis tendon was highly consistent. The radial recurrent artery vascularized the entire proximal tendon through direct branches to the medial and lateral border of the tendon forming a network of small vessels on the surface of the tendon. Important contributions were provided by the posterior branch of the radial collateral artery, and minor contributions were provided by the interosseous recurrent artery. The undersurface of the tendon seemed almost avascular. This observation suggests that potential hypovascular zones might be located at theundersurface of the tendon causing degeneration and partial tear of the tendon, and that this might be an etiologic factor in the pathogenesis of lateral epicondylitis. Additional microvascular studies are necessary to investigate this hypothesis.  PMID: 11964656 [PubMed – in process]

-Eur J Histochem  2002;46(1):3-12
Morpho-functional changes in human tendon tissue.
Galliani I, Burattini S, Mariani AR, Riccio M, Cassiani G, Falcieri E.
Department of Human Anatomy, University of Bologna, Italy.

Insertion tissue biopsies of right arm common extensor tendons from 11 patients with chronic lateral epicondylitis were processed for light and electronmicroscopy. The subjects were aged between 38 and 54 years (only one was 25).The specimens showed a variety of structural changes such as biochemical and spatial alteration of collagen, hyaline degeneration, loss of tenocytes,fibrocartilage metaplasia, calcifying processes, neovascularization and vessel wall modifications. Tissue alterations were evident in limited zones of the tendon fibrocartilage in which the surgical resection was generally visible. The areas where the degenerative processes were localized, were restricted and inspatial contiguity with morphologically normal ones. The observed cases presented histological and electron microscopic findings that characterize lateral epicondylitis as a degenerative phenomenon involving all tendon components.
PMID: 12044045 [PubMed – in process]

Effect of elbow position on grip strength in the evaluation of lateral epicondylitis.
Dorf ER, Chhabra AB, Golish SR, McGinty JL, Pannunzio ME.
University of Virginia Hand Center, Charlottesville, VA, and Reconstructive Hand Surgeons of Indiana, Carmel, IN, USA.
PURPOSE: This study evaluated the maximum grip strength in a position of elbow extension versus flexion as a diagnostic tool in the assessment of a patient with suspected lateral epicondylitis (LE). METHODS: From our database we identified 81 patients with grip strength measurements and the diagnosis of LE. From these patient records we collected grip strength measurements with the elbow in full extension and with the elbow in 90 degrees of flexion for the affected and the healthy extremity. We then compared 2 values: the pretreatment grip strength in flexion and extension for the affected extremity and the pretreatment grip strengths of the nonaffected extremity compared with the affected extremity. Grip strengths were compared with paired and unpaired 2-tailed t tests. RESULTS: Grip strength was no different in flexion and extension for the healthy extremity and 29% stronger in flexion than in extension for the affected extremity. The affected arm averaged 50% of the strength of the healthy arm in extension and 69% of the strength of the healthy arm in flexion. These differences were statistically significant. An 8% difference in grip strength between flexion and extension was found to be 83% accurate in distinguishing the affected from the unaffected extremities. CONCLUSIONS: The measurement of extension grip strength is a useful objective tool to aid in the diagnosis of LE. In patients with LE, the grip strength decreases as one moves from a position of flexion to a position of extension.
PMID: 17606071 [PubMed – indexed for MEDLINE]

Anatomic factors related to the cause of tennis elbow.
Bunata RE, Brown DS, Capelo R.
4054 Hildring Drive West, Fort Worth, TX 76109.
BACKGROUND: The pathogenesis of lateral epicondylitis remains unclear. Our purpose was to study the anatomy of the lateral aspect of the elbow under static and dynamic conditions in order to identify bone-to-tendon and tendon-to-tendon contact or rubbing that might cause abrasion of the tissues. METHODS: Eighty-five cadaveric elbows were examined to determine details related to the bone structure and musculotendinous origins. We identified the relative positions of the musculotendinous units and the underlying bone when the elbow was in different degrees of flexion. We also recorded the contact between the extensor carpi radialis brevis and the lateral edge of the capitellum as elbow motion occurred, and we sought to identify the areas of the capitellum and extensor carpi radialis brevis where contact occurs. RESULTS: The average site of origin of the extensor carpi radialis brevis on the humerus lay slightly medial and superior to the outer edge of the capitellum. As the elbow was extended, the undersurface of the extensor carpi radialis brevis rubbed against the lateral edge of the capitellum while the extensor carpi radialis longus compressed the brevis against the underlying bone. CONCLUSIONS: The extensor carpi radialis brevis tendon has a unique anatomic location that makes its undersurface vulnerable to contact and abrasion against the lateral edge of the capitellum during elbow motion. CLINICAL RELEVANCE: This information may help us to understand the pathomechanics of lateral epicondylitis and provide a better rationale for operative and nonoperative treatment.
PMID: 17768192 [PubMed – in process]

-Zeisig E; Ohberg L; Alfredson H

Tennis elbow, extensor carpi radialis brevis (ECRB) tendinosis, is a condition with unknown etiology and pathogenesis, known to be difficult to treat. The pain mechanisms have not been fully clarified, but involvement of a neurogenic inflammation mediated via the neuropeptide Substance-P (SP), has been suggested. In this investigation, grey-scale ultrasonography (US) and colour Doppler (CD) was used to examine the common extensor origin in 17 patients with the diagnose Tennis elbow in altogether 22 elbows, and in 11 controls with 22 pain-free elbows. In 21/22 elbows with chronic pain from the extensor origin, but only in 2/22 pain-free elbows, vascularity was demonstrated in the extensor origin. After US and CD-guided injection of a local anaesthetic, targeting the area with vessels, the patients were pain-free during extensor-loading activity.The area with vascularity found in the extensor origin seems to be related to pain. Most likely, the findings correspond with the vasculo-neural in growth that has been demonstrated in the chronic painful Achilles tendon, and possibly have implications for treatment.

-An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy Jean-Louis Croisier, Marguerite Foidart-Dessalle, France Tinant,

Background: Lateral epicondylitis represents a frequent overuse injury. In spite of many conservative treatment procedures, prolonged symptoms and relapse are frequently observed.

Objective: To compare the outcome of patients performing an isokinetic eccentric training with that of age-, gender-, activity-matched patients receiving a non-strengthening classical rehabilitation.

Methods: Ninety-two patients with unilateral chronic lateral epicondylar tendinopathy (mean duration of symptoms 8±3 months) were assigned either to a control group (n = 46) or to an eccentrically trained group (n = 46). The control group underwent a passive standardised rehabilitation programme that excluded strengthening exercises. In addition to this programme, the trained group also performed eccentric exercises based on the repetitive lengthening of the active musculo-tendinous unit. The latter exercises started with submaximal contraction intensity and slow speed movement. Modalities were progressively intensified (increase in intensity contraction and speed movement) over a long priod of treatment. Programme effectiveness was assessed through pain score evaluation, a disability questionnaire, muscle strength measurement and ultrasonographic examination.

Results: Compared to the non-strengthening control group, the following observations were made in the eccentrically trained group: (1) a significantly more marked reduction of pain intensity, mainly after one month of treatment; (2) an absence of strength deficit on the involved side through bilateral comparison for the forearm supinator and wrist extensor muscles; (3) an improvement of the tendon image as demonstrated by decreasing thickness and a recovered homogenous tendon structure; and (4) a more marked improvement in disability status during occupational, spare time and sports activities.

Conclusion: These results highlight the relevance of implementing isokinetic adapted eccentric training in the management of chronic lateral epicondylar tendinopathy.

-Stasinopoulos D, Stasinopoulos I.Clin Rehabil 2006;20:12–23
Background: There are many possible therapeutic interventions for lateral epicondylopathy (tennis elbow), including physiotherapy, exercise rehabilitation and, recently, polarised polychromatic non-coherent (Bioptron) light.
Research question/s: What is the effectiveness of Cyriax physiotherapy, a supervised exercise and polarised polychromatic non-coherent light (Bioptron light) in the treatment of lateral epicondylitis?
Methodology:Subjects: 75 patients with clinically diagnosed lateral “epicondylitis.
Experimental procedure: Subjects were sequentially allocated to 3 treatment (3/week) groups for 4 weeks: Cyriax physiotherapy (CP = 25), supervised exercise (EX = 25) and polarised polychromatic non-coherent light (Bioptron light) (BIOP = 25). Pain, function and grip strength were assessed before and after 4, 8, 16 and 28 weeks.
Measures of outcome: Pain (visual analogue scale; VAS), function (VAS), pain-free grip strength.
Main finding/s:: Improvement of function was also greatest in the EX group compared with the other groups at any of the follow-up time points (p<0.05).
Conclusion/s: Compared with Cyriax physiotherapy or polarised polychromatic non-coherent light (Bioptron light), a supervised exercise programme was superior in pain reduction and improved function in the management of patients with lateral epicondylitis.

-J Hand Surg Br. 2002 Oct;27(5):405-9.
The role of the extensor digitorum communis muscle in lateral epicondylitis.
Fairbank SM,
A common finding in tennis elbow is pain in the region of the lateral epicondyle during resisted extension of the middle finger (Maudsley’s test). We hypothesized that the pain is due to disease in the extensor digitorum communis muscle, rather than to compression of the radial nerve or disease within extensor carpi radialis brevis. Thirteen human forearm specimens were examined. It was found that the extensor digitorum communis was separable into four parts. The part to the middle finger originated from the lateral epicondyle, but the muscle slips to the other fingers originated more distally. Pain ratings were measured in ten patients diagnosed with lateral epicondylitis during isometric finger and wrist extension tests. The results confirmed the high prevalence of a positive Maudsley’s test in lateral epicondylitis, and also that the patients with tenderness at the site of origin of the extensor digitorum communis slip to the middle finger had the greatest pain during middle finger extension.These anatomical and clinical findings clarify the anatomy of extensor digitorum communis, and suggest that this muscle forms the basis for the Maudsley’s test. The muscle may play a greater role in tennis elbow than previously appreciated.PMID:12367535 [PubMed – indexed for MEDLINE]

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