Perineural injection as an alternative treatment of resistant lateral elbow pain

Background Lateral elbow pain (LEP) or lateral epicondylitis (LE) is a common problem affecting both males and females. Multiple therapeutic modalities are used with different outcomes. Objective The current study aimed at description of the effectiveness of a newly introduced modality, Perineural Injection (PNI) therapy in comparison to the already used therapeutic ultrasound (TUS) as a conventional modality in the treatment of resistant LEP (LE). Patients and methods This is a longitudinal interventional study. Thirty patients of both sexes aged between 21 to 62 years old who had LE were randomly allocated into two groups (15 each). In PNI group, 5% buffered dextrose was injected subcutaneously around the lateral epicondyle once weekly for 8 weeks. In TUS group, continuous US was used 3 sessions per week for 4 weeks. Tenderness grading scale, visual analogue scale (VAS), Patient- Rated Tennis Elbow Evaluation Questionnaire (PRTEE) score, and ultrasonographic evaluation were used before and 12 weeks after treatment. Results In both groups, there was a high significant clinical improvement at 12th week after treatment. However, the improvement was better in the PNI group than the TUS group. By US evaluation at 12th week after treatment, there was a significant decrease in hypoechoic areas and disturbed fibrillar pattern in PNI group compared to before therapy (p < 0.001 and = 0.025) respectively. But in TUS group, there was decrease in hypoechoic areas and tendon thickness compared to before treatment (p = 0.02 and 0.026) respectively. Conclusion Both PNI and TUS therapies for LE gave clinical improvement for pain, functional limitations and some ultrasonographic findings (as echogenity, fibrillar pattern and tendon thickness). However, PNI therapy gave better outcome as compared to TUS.

Imaging Evaluation of Medial and Lateral Elbow Pain: Acute and Chronic Tendon Injuries of the Humeral Epicondyles

Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.

Radial Tunnel Syndrome: Case Report and Comprehensive Critical Review of a Compression Neuropathy Surrounded by Controversy

Radial tunnel syndrome (RTS) is an uncommon controversial entity thought to cause chronic lateral proximal forearm pain due to compression of the deep branch of the radial nerve, without paralysis or sensory changes. Diagnostic confusion for pain conditions in this region results from inconsistent definitions, terminology, tests, and descriptions in the literature of RTS and “tennis elbow,” or lateral epicondylitis. A case of bilateral RTS with signs discordant with traditionally used clinical diagnostic tests was successfully relieved with surgical decompression and led us to perform a comprehensive critical review of the condition. We delineate the controversy surrounding its diagnosis and aim to facilitate appropriate management and identify other areas for further study in this controversial condition. Clinical validity and evidence of anatomical rationale for the traditionally used Maudsley’s provocative test is unclear in diagnosis of RTS or in chronic lateral elbow pain, if at all. Neither imaging nor electrophysiological studies contribute to a clinical diagnosis which is supported by short-term improvement after an injection with long-acting local anesthetic and corticosteroid. Accurate diagnosis and treatment of RTS can significantly improve quality of life, but validity and evidence for traditional clinical tests and definitions must be clarified.

Interrater and Intrarater Reliability of Musculoskeletal Ultrasonographic Findings for the Common Extensor Tendon of the Elbow

Objectives: This retrospective case study evaluated the interrater and intrarater reliability of seven common extensor tendon pathologic features on musculoskeletal ultrasonography (MSK-US). Materials and Methods: A cohort of 50 patients were imaged due to presenting with atraumatic nonradicular lateral elbow pain. Three experienced and two novice readers rated the images on two separate occasions, and AC1 and kappa coefficients were calculated for each feature. Results: The interrater reliability was fair with respect to fascial thickening/scarring (AC1 = 0.26), tearing (AC1 = 0.35), tendon thickening (AC1 = 0.38), and intratendinous calcification (AC1 = 0.33); substantial for enthesophytes (AC1 = 0.80); and near complete for hyperemia (AC1 = 0.83) and hypoechogenicity (AC1 = 0.92). Intrarater reliability was moderate for fascial thickening/scarring (κ = 0.48), tearing (κ = 0.41), tendon thickening (0.47), intratendinous calcification (κ = 0.56), and hypoechogenicity (κ = 0.47); substantial for hyperemia (κ = 0.71); and almost perfect for enthesophytes (κ = 0.86). Conclusion: MSK-US may be a reliable tool to determine soft tissue changes in common extensor tendon pathology.

Synovial plica of the elbow and its clinical relevance

A synovial plica (fold) is normal anatomic finding, and occurs in 86–100% of cases; however, symptomatic plica is much less common (7.2–8.7% of all elbow arthroscopies). Synovial plica syndrome is a painful elbow condition related to symptomatic synovial plica. Synovial plica syndrome is diagnosed by clinical examination (lateral elbow pain) commonly accompanied by local tenderness, pain at terminal extension and/or painful snapping. Synovial plica syndrome may be mimicked by other elbow conditions, commonly tennis elbow, loose bodies, and degenerative arthritis. Magnetic resonance imaging or ultrasound scan may support diagnosis in correlation with clinical findings, but symptomatic plica may also be diagnosed as unexpected during elbow arthroscopy. The arthroscopic resection is effective and safe if conservative treatment fails. Cite this article: EFORT Open Rev 2020;5:549-557. DOI: 10.1302/2058-5241.5.200027