EFFICACY OF TENNIS ELBOW ( EPICONDYLITIS HUMERI RADIALIS ) TREATMENT IN CBR “ PRAXIS ”

Tennis elbow (Epicondylitis humeri radialis) is the most frequent reason that patients with elbow pain report to a physician. Th e exact cause of elbow pain is still unclear. However, it is certainly causally connected with connective intersection between forearm muscle and bone in the elbow


Introduction
Tennis elbow (Epicondylitis humeri radialis) is a painful syndrome caused by inflammational, nonspecific changes in forearm and hand muscles connection at lateral epicondyle of humerus and radio-humeral joint and its capsule.Epicondylitis humeri radialis is an enthesitis at the point where muscle extensor connects to the lateral epicondyle of humerus.It is a degenerative infl ammation, which either occurs as a result of an injury to radial epicondyle or develops indirectly, as a consequence of hoarse and/ or frequent, synchronous movements of wrist and elbow.Microtrauma to the tendons connection sites result in minor damages and ruptures in tendons fi bers that may develop into necrotic changes and cause deposition of calcium salts.Similar changes may result from metabolic disturbance or rheumatism, although rarely.Th is condition aff ects about - of adult population.The most frequently affected individuals are those who utilize forearm musculature to the maximum capacity: workmen who use pneumatic drills, tailors, barbers, bricklayers, drivers, mechanics, ceramic tiles layers, musicians etc.The second category includes sportsmen: tennis players, spear throwers, fencers, bowlers, and hockey, golf and handball players.Lateral epicondylitis reveals itself in the form of pain in the outer part of elbow joint, at the place of the attachment of tendons of hand and fingers extensors, which occurs during work or sports activity.Pain may appear either suddenly or gradually, sometimes spreading along outer side of forearm.In addition, the affected individual describes hand muscles fatigue, which may disable performing everyday activities such as: handling glass, cutlery, opening the door, handshake, sponge draining, handling light objects.It is  to  times more frequent in radial than in medial humeral epicondyle.It is frequent in middleaged persons, equally frequent in men and women and generally affects dominant hand.Its names are due to higher frequency of these overexertion syndromes in certain sports.Thus, lateral epicondylitis is referred to as tennis elbow while medial one is known as pitcher's elbow for baseball pitchers.Other than in sportsmen, it is a professional ailment in typists, bricklayers, truck drivers, dentists and surgeons, that is in individuals with frequent contractions of extensors and supinators (lateral epicondylitis) or fl exors and pronators (medial epicondylitis).Th e main symptom includes epicondyal pain of various intensities.Pain is accompanied with the loss in hand power.Clinical examination resorts to tests based on the contraction of particular muscle group with resistance, which results in pain, in particular to palpation in epicondyal region.Just like in other overexertion syndromes, treatment may include whole range of procedures, from conservative to surgical treatment.Conservative treatment should be adjusted to the intensity of infl ammation and pain and include control of further activities.Successful treatment depends on the reduction of irritating movement, resting of certain muscle group, adequate cryo-therapy, isotonic and stretching exercises.Should the response to therapy be inadequate corticosteroid injection may be administered.Should the symptoms of epicondylitis persist (- of the aff ected) surgical treatment, which involves desinserction of the aff ected muscle group, may be necessary.Following the surgical treatment subelbow immobilization implemented for one week.Th ereafter, the treatment continues with physical therapy.Diagnostics of epicondylitis humeri radialis relies on a simple test "fi nger snaffi ng", which enables explanation of the etiology of humerus lateral epicondylitis.In our group of  patients, the positive test result was characteristic of entesopathy of extensor carpi radialis brevis muscle, which is inserted in radial epicondyl.When the test is negative pain is considered to be of spondylogenic, arthrogenic or neurogenic nature.Test is signifi cant for the selection of therapeutical approach and establishment of indications for surgical intervention ().In the course of surgery, an unknown submuscular lypoma was found to cause supinatory syndrome with fi ngers extensors paresis.In the cases of pain therapy resistance, in particular in conservative therapy of tennis elbow, non-traumatic supinator syndrome should be considered as diagnostic possibility ().Following the exact verification of tennis elbow and unsuccessful intensive conservative treatment, application of Hohmann procedure that involves incision to the tendon of proximal extensor is clearly advantageous from patho-physiological point of view.This surgical procedure may safely be performed endoscopically ().Following ineff ective conservative treatment,  patients with tennis elbow ( female and  male), of average age , years ( to ), were surgically treated.In  patients surgery involved tendon caput communae extensorum while m.extensor carpi radials was implicated in  persons.In  of the patients who were monitored for prolonged period ( to  months), surgery produced favorable results similar to those recorded by other authors.Th is study concurs with general opinion that surgical treatment be indicated only in patients who received unsuccessful conservative treatment ().
In a study that involved  patients with lateral epicondylitis humeri that resisted long-term therapy, extracorporeal shock wave therapy (ESWT) was applied.All the patients received physical therapy, local injections and other conservative procedures over six months period.Three weeks long ESWT was applied under local anesthesia using Dornier Epos Ultra (energy fl ux density , to , mJ/nm).Complications in the form of small hematoma were encountered in only four patients.Following average monitoring period of , months, it was possible to evaluate  patients using Rolles and Maudsley Sore.Excellent results were found in , good results in ,, satisfactory in , while in , the results were found to be weak ().In a group of  patients, retrospective analysis following the unsuccessful conservative therapy indicated neurophysiological examination whereby the syndrome of nervus radialis compression was established.Surgical treatment by Wilhelm and Wachsmuth method was indicated ().In  patients with epicondylitis who were resistant to conservative therapy and received surgical treatment by Wilhelm procedure, significant reduction in symptoms was observed following observation period of , years on average (- years).Therefore, this surgical procedure was recommended ().In untrained persons, frequently practiced recreational sports activity may result in epicondylitis humeri radialis.In these cases, it is necessary to establish clear diff erential diagnosis in order to distinguish various pain syndromes that are frequently described as elbow pain.Th us, elbow pain is defi ned as syndrome ligamentum anullarae radii that frequently appears as post-traumatic pain of synovial origin.Osteoarthritis and rheumatoid arthritis may also be linked to the pain of post-traumatic origin.Th is group also includes patients with elbow pain caused by frequently unrecognized changes in cervical region of spine.Tennis elbow symptoms may be a consequence of radial nerve irritation which imitates supinator syndrome.Younger patients may suffer from osteonecrosis or epifiseolysis ().

Material and methods
In "PRAXIS" clinic, which is one of CBR -community rehabilitation facilities, retrospective analysis of  patients who have been received with defined RSI diagnosis (Repetitive Strain Injury) over -years period was performed.The analysis was performed in order to establish frequency of the conditions that belong into RSI group, the total requirement for CBR rehabilitation and to evaluate the effects of local instillation of corticosteroid depot on epicondylitis humeri radialis (tennis elbow) treatment.Within the group with RSI syndrome we evaluated treatment effi cacy in  patients with diagnosis epicondylitis humeri radialis.A scale was determined for the grading of clinical condition prior and after the treatment (Table ).Elbow pain is the main symptom that is related to numerous microlocations within the joint itself, not only to the lateral epicondyl humeri for which it is named.Because of anular ligament and radius capitulum elbow performs rotational movements along longitudinal joint axis in addition to fl exion and extension.In our method, manipulation has a major role.It strives to achieve mobility of the joint, which is, at the moment of patients' fi rst examination, functionally "blocked".Simultaneously, joint decompression and relaxation in the conjoint musculature are achieved which result in pain relief.
Following the manipulative therapy, additional instillation of corticosteroids reduces infl ammation and contributes to overall physiological reintegration of function of this complex joint.In therapeutical treatment of this syndrome we applied a synthetic depot preparation -Betamethason ampoule of  ml with the dosage of  +  mg.It has strong anti-infl ammatory and secondary analgesic activity.It is applied locally, in the epicondyl area, and in part, intra-articularly in the area of radio-humeral joint.According to literature data as well as experience, the drug effect and pain relief are expected within  to  hours following the drug administration.Full effect is expected after  hours.Usually, function Assisted mobility with diffi culties Grade "2" two: Mobility with diffi culties using aid Grade "3 " three: Independent mobility using aid Grade "4 " four: Good functional status with minimal sequelae Grade "5 " fi ve Regular functional status Grade "6 " six Further medical treatment needed Grade "7 " seven Treatment terminated and continued in another CBR DŽEMAL PECAR, DIJANA AVDIĆ: EFFICACY OF TENNIS ELBOW EPICONDYLITIS HUMERI RADIALIS TREATMENT IN CBR "PRAXIS" normalization and pain relief occur simultaneously.Thus, evaluation of treatment success may be performed during the fi rst control follow-up.Also, each case may be individually and competently assessed.All the treatment procedures, pre-and post-treatment assessment as well as the results of any additional procedures are entered into adequate database and stored for subsequent professional and academic analysis ().Th e data will be presented in Tables and Graphs.

Results and discussion
General representation of RSI fraction in the total pathology of CBR "Praxis" Sarajevo, observed in the form of  defined diagnoses, reached relatively high value of , or . patients.Of those, there were  patients with epicondylitis humeri radialis or , of the total number of RSI patients.Analysis of the RSI patients gender breakdown (Table , Graph ) reveals slight dominance of female population ().
In the case of epicondylitis humeri radialis frequency of male patients is higher ( : ).
These two parameters, gender breakdown and pronounced pain in pre-treatment initial assessment motivated us to explore every aspect of this ailment.
Following the evaluation and fi nal assessment of functional condition, the analysis shows high level of success and fast recovery.In , patients functional ability was improved and pain reduced in  to  hours following the examination and local instillation of drug.
In eight patients (, cases) only the expected effect was lacking, thus physical therapy was included.

Conclusion
Elbow pain is the main symptom that is related to numerous microlocations within the joint itself, not only to the lateral epicondyl humeri for which it is named.Because of anular ligament and radius capitulum, elbow performs rotational movements along longitudinal joint axis in addition to fl exion and extension.In our method, a major role belongs to manipulation as opposed to immobilization, which is major step in classic clinical method.It strives to achieve mobility of the joint, which is, at the moment of patients' fi rst examination, functionally "blocked".Simultaneously, joint decompression and relaxation in the conjoint musculature are achieved which result in pain relief.Following the manipulative therapy, additional instillation of corticosteroids reduces infl ammation and contributes to overall physiological reintegration of function of this complex joint.
Our results suggest that the application of this method completely diminishes the need for surgical intervention.Also, the functional ability of elbow is, in majority of patients, fully restored.
Cost-benefi t analysis showed higher effi ciency of this treatment since  patients were able to return to work immediately after the first examination and one intervention.Practically, the total cost includes: the price of drug, examination by specialist, application of manual techniques and instillation.There is no loss of working hours in the employed patients.
Expressed in value points it amounts to  points ( point is a relative value defined in Federal health insurance normative) which is  times less than when applying standard protocols.
In the case of this ailment standard protocol proscribes the following steps: .Following the examination by family doctor and orthopedic specialist - days immobilization (cast) is usually applied along with analgesic drugs and sick leave,  initial examinations  points,  follow-up examinations  points, application of immobilization  points, analgesic drugs  points. days disability one third of average wage  points. days physical treatment  points  days disability one half of average wage  points Th ree weeks of treatment and sick leave -total  points.This calculation does not include contribution in working hours at the place of work.The value of this variable is not adequately assessed and cannot be applied in our conditions.In the USA this loss amounts to more than twice the individual wage.

TABLE 1 .
Clinical condition -grading scale