(LET), also known as tennis elbow or lateral epicondylalgia. Lateral sode.9,14, 50 Estimates suggest that up to 5% of patients do not respond to pushing up with the forearm supinated), meet bone: attachment sites ('entheses') in. Tennis elbow, Lateral epicondylitis, Eccentric, Isometric, Exercise programme, .. in a patient with LET at the end of the treatment and at one month follow-up. treatment. Results: 70 patients met the inclusion criteria. At the end and at the 3 -month follow up; the supervised exercise Lateral elbow tendinopathy (LET), commonly dylalgia, lateral epicondylosis and/or tennis elbow.
Isometric muscle contractions reduce tendon pain. No studies have been investigated the effectiveness of these two kinds of contractions and stretching exercises for the management of LET. The aim of the present case report is to present the effect of eccentric training combined with isometric contraction and static stretching exercises on pain and disability in a patient experiencing LET.
A patient with unilateral LET for 8 months was included in the present report. The patient followed an exercise programme consisted of slow progressive eccentric exercises of wrist extensors, isometric contractions of wrist extensors and static stretching of the extensor muscles of the wrist five times per week for 4 weeks. Outcome measures were pain, using a visual analogue scale, and function, using a visual analogue scale and the pain-free grip strength.
The patients was evaluated at baseline, at the end of treatment week 4and 1 month week 8 after the end of treatment. At the end of the treatment and at the follow — up there was a decline in pain and a rise in function. The results of the present trial suggest that the combination of eccentric training of wrist extensors with isometric contractions of wrist extensors and static stretching exercises of wrist extensors can produce significant improvements in terms of pain and disability in LET.
LET is one of the most common lesions of the arm work-related or sport-related pain disorder. The condition is usually defined as a syndrome of pain in the area of the lateral epicondyle [ 2 - 4 ], that may be degenerative or failed healing tendon response rather than inflammatory [ 5 ].
Hence, the increased presence of fibroblasts, vascular hyperplasia, proteoglycans and glycosaminoglycans together with disorganized and immature collagen may all take place in the absence of inflammatory cells 5. The most commonly affected structure is the origin of the extensor carpi radialis brevis ECRB [ 5 ].
The dominant arm is commonly affected, the peak prevalence of LET is between 30 and 60 years of age [ 26 ] and the disorder appears to be of longer duration and severity in women [ 267 ]. The main complaints of patients with LET are pain and decreased function [ 28 - 12 ] both of which may affect daily activities.
Diagnosis is simple, and a therapist should be able to reproduce this pain in at least one of three ways: Although the signs and symptoms of LET are clear and its diagnosis is easy, to date, no ideal treatment has emerged.
Many clinicians advocate a conservative approach as the treatment of choice for LET [ 28 - 11 ]. Physiotherapy is a conservative treatment that is usually recommended for LET patients [ 11314 ]. A wide array of physiotherapy treatments have been recommended for the management of LET [ 115 - 17 ].
These treatments have different theoretical mechanisms of action, but all have the same aim, to reduce pain and improve function. Such a variety of treatment options suggests that the optimal treatment strategy is not known, and more research is needed to discover the most effective treatment in patients with LET [ 118 - 20 ].
One of the most common physiotherapy treatments for LET is an exercise programme [ 813 - 21 ]. One consisting of eccentric and static stretching exercises has shown good clinical results in LET [ 21 - 23 ] as well as in conditions similar to LET in clinical behaviour and histopathological appearance, such as patellar [ 24 - 28 ] and Achilles tendinopathy [ 29 - 35 ].
Such an exercise programme is used as the first treatment option for our patients with LET [ 36 ]. Eccentric training is not enough for all patients with tendinopathy [ 37 ]. Our research team believes there is a component in the rehabilitation, supplement to eccentric training that decrease pain and improve function more than eccentric training alone in patients with tendinopathy. Isometric muscle contractions reduce tendon pain [ 38 ].
Perhaps if the eccentric training combines to isometric contractions the success rate in the management of tendinopathy will be higher. To our knowledge, there have been no studies to investigate the effectiveness of these two kinds of contractions and static stretching exercises for the management of LET. Therefore, the aim of the present case report is to present the effect of eccentric training combined with isometric contraction and static stretching exercises on pain and disability in a patient experiencing LET.
Case Report History Mrs. The pain was mainly there, but sometimes spread down until the middle of the forearm.
She was not able to describe any particular movements to explain why the pain spread down until that point. At the beginning, she experienced pain after sewing, which she could tolerate.
Later, she had pain during her activity, which she could not tolerate and had to stop her job. Once she had stopped, the pain subsided within two hours. She had a little improvement and her GP referred her to a course of physiotherapy. She had this kind of pain for about eight months. She could sleep, but sometimes she felt a mild pain in gripping objects. During gripping, she was able to tolerate the pain. She did not complain of crepitus, stiffnessparaesthesia, swelling, locking or cervical pain.
She did not have any previous problems in the spine or the peripheral joints.
She did not have cancer, diabetes or epilepsy and none in her family did. She did not have any operation in the past and did not take any medications at the time of assessment. Examination findings Her face, posture and gait were noted in observation.
She was calm and slept without having any pain disturbing her. Her posture as well as her gait was normal. The overall posture was assessed in search of body deformity.
The position of the head, the cervical lordosis and the position of both shoulders were normal. The carrying angle was normal in comparison with the other side and there were not colour changes, muscles wasting or swelling.
Signs of inflammatory activity like heat, swelling and synovial thickening were not found. The movements of the neck and shoulder were pain free, with full range of motion and full power.
The movements of the elbow joint, which were tested, were flexion and extension both passively and under resistance. The passive movements were pain free with full range of motion and normal end feel. The resisted movements were pain free with full power, meaning 5 on the Oxford scale. The movements of the proximal radioulnar, which were tested, were supination and pronation. These movements were tested both passively and under resistance.
The passive movements were pain free with full range of motion and normal end feel and the resisted movements were pain free with full power, meaning 5 on the Oxford scale. The movements of the wrist joint which were tested were flexion and extension. The extension of the wrist with the elbow in extension was pain free, with full range of motion and normal end feel. The wrist flexion with the elbow in extension was slightly painful on the facet of the lateral epicondylebut it involved full range of motion with normal end feel.
The flexion of the wrist with the elbow in extension was pain free and with normal power, meaning 5 on the Oxford scale. There was pain over the common extensor tendon on the facet of the lateral epicondyle of the humerus by palpation. Procedure The patient followed a supervised exercise programme consisting of slow progressive eccentric exercises of the wrist extensors, isometric exercises of the wrist extensors and static stretching exercises of the extensors muscles of the wrist.
The dominant arm is commonly affected, the peak prevalence of LET is between 30 and 60 years of age, [ 26 ] and the disorder appears to be of longer duration and severity in women [ 267 ]. Pain and decreased function are the main complaints of patients with LET [ 25 ].
Although the signs and symptoms of LET are clear and its diagnosis is simple, to date no ideal treatment has emerged. Many clinicians advocate a conservative approach as the treatment of choice for LET [ 25 ].
Physiotherapy is a conservative treatment that is usually recommended for LET patients [ 8 ]. A wide array of physiotherapy treatments have been recommended for the management of LET [ 9 - 11 ]. These treatments have different theoretical mechanisms of action, but all have the same aim: Such a variety of treatment options suggests that the optimal treatment strategy is not known, and more research is needed to discover the most effective treatment in patients with LET.
Ultrasound has attracted much interest in the last decades as it has been applied to common musculoskeletal conditions such as LET by physiotherapists and occupational therapists. Its effectiveness has been evaluated in four previously published systematic reviews, which have addressed the effectiveness of conservative treatments for LET [ 9101213 ]. The conclusion of these four systematic reviews was that there was a lack of scientific evidence supporting physiotherapy treatments such as ultrasound for LET and demonstrate the importance of improving the current physiotherapy management of LET.
To our knowledge, there has been no review to establish only the effectiveness of ultrasound for LET, such as there are reviews for the effectiveness of low level laser therapy for LET [ 1415 ]. In addition, ultrasound is a dose response modality and no review exists to determine if there are appropriate ultrasound parameters for the management of LET.
Therefore, the aim of the present article is not to find out the effectiveness of ultrasound treatment for LET, is to determine the appropriate parameters of ultrasound for the management of LET and to provide recommendations based on this evidence. Methods Search strategy Computerised searches were performed using Medline from to FebruaryEmbase from to FebruaryCinahl from to FebruaryIndex to Chiropractic Literature from to FebruaryChirolars from to February and Sports Discus from to February databases.Let's Meet Up.
Only English language publications were considered. Other references were identified from existing reviews and other papers cited in the publications searched. Further citations were sought from the reference sections of papers retrieved, from contacting experts in the field, and from the Cochrane Collaboration last search Marchan international network of experts who search journals for relevant citations. Unpublished reports and abstracts were not considered.
Keywords and search strategy were selected by the researcher only, without the help of an expert librarian with experience in searching databases to computerized health literature. Selection of studies To be included within the review, studies had to fulfill the following conditions: The treatment had to be any type of ultrasound evaluated against at least one of the following: RCTs in which the ultrasound was given as part of the treatment—for example, non-steroidal anti-inflammatory drugs and ultrasound or ultrasound and exercise programme and Extracorporeal Shock Wave Therapy ESWT -were excluded, because we would not know how each modality contributed to the results.
However, the effectiveness of these management strategies has not been assessed in the literature.
Data were sought for one of the following four primary outcome measures: The description of the ultrasound parameters would be in detail. The titles and abstracts of all studies were assessed for the above eligibility criteria.
There was no blinding to study author, place of publication, or results. The researcher assessed the content of all full text articles, making the selection criteria. Quality assessment The PEDro scale was used to rate the trials for quality. The scored portion of the PEDro scale assesses 8 items pertaining to internal validity and 2 items added to ensure that the statistical results would be interpretable to the reader [ 16 ].
For each item on the PEDro scale; a yes or no response was obtained. A yes response earned 1 point, whereas a no received zero points, for a possible cumulative score of 10 points. The closer the score was to 10, the better the quality of the study. Methodological quality of each trial was independently assessed by the author of the study. Data on adverse events were abstracted from the studies.
Furthermore, basic data were extracted including characteristics of participants e. Results From the initial examination of citations, yielded from the literature search, 13 studies were included. After review of the completed texts, all studies were excluded, leaving zero eligible RCTs, to be included in the review.
The reasons that trials were excluded from the review were: Two studies were pilot and no RCTS [ 1718 ]. Four studies did not support the use of ultrasound with the chosen parameters in the management of LET [ 19 - 22 ]. In four studies ultrasound was used as part of the traditional physiotherapy treatment [ 23 - 26 ]. Three studies showed positive effects with the use of ultrasound, but did not describe in detail the parameters of the modality making replication difficult [ 27 - 29 ].
Discussion The aim of this review was to determine the appropriate ultrasound parameters in the management of LET. Although a plethora of studies was found in the literature research, all these studies were excluded from the review because they did not fulfill the inclusion criteria. Therefore, it is impossible to find out the appropriate ultrasound parameters in the management of LET based on previously conducted RCTs.
Recommendations will be provided based on animal studies and on studies in conditions similar to LET in clinical behavior and histopathological appearance, such as patellar and Achilles tendinopathies. Ultrasound is a modality that physiotherapists use daily in their clinical practice [ 30 ].
There is strong evidence that ultrasound has positive effects on tendon healing [ 3132 ]. This strong evidence is supported by animal studies. The effectiveness of ultrasound based on its parameters. The parameters of ultrasound are: Therapeutic ultrasound has a frequency range between 0,75 and 3.
Higher the frequency the more superficial is the depth of penetration. LET is a superficial condition and the ideal frequency is 3 MHz [ 33 ]. The 4 studies that showed negative effects of ultrasound in the management of LET, the frequency of ultrasound was 1 MHz. Therefore, the negative effects of ultrasound in these studies were expected as one of the most important ultrasound parameter, the frequency, was in wrong direction. The mode of ultrasound can be pulsed or continuous. Continuous ultrasound is used to produce thermal effects, whereas pulsed or continuous ultrasound in low intensities 0.
Pulsed ultrasound is recommended for the management of soft tissue healing [ 35 ].