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Treatment of Epicondylalgia and Nerve Entrapments Around the Elbow

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Treatment of Epicondylalgia and Nerve Entrapments Around the Elbow Linköping University Medical Dissertations No. 1262 Treatment of Epicondylalgia and Nerve Entrapments around the Elbow Birgitta Svernlöv Linköping University, Faculty of Health Sciences Department of Clinical and Experimental Medicine Division of Surgery and Clinical Oncology SE-581 85 Linköping, Sweden Linköping 2012 © Birgitta Svernlöv, 2012 Cover: Detail from a painting by Nicolas Poussin (1594-1665) called “Et in Arcadia ego”, the Louvre Museum (Paris, France). Previously published articles have been reprinted with the permission of the copyright holders. Printed in Sweden by LiU-Tryck, Linköping, Sweden 2011 ISBN: 978-91-7393-065-9 ISSN: 0345-0082 To unpathed waters, undreamed shores; A Winter’s Tale (W. Shakespeare 1564‐1616) Our doubts are traitors, and make us lose the good we oft might win, by fearing to attempt; Measure for Measure (W. Shakespeare 1564‐ 1616) CONTENTS CONTENTS ABSTRACT ABBREVIATIONS LIST OF PAPERS INTRODUCTION .........................................................................................................1 HISTORY .............................................................................................................................. 1 BACKGROUND ..........................................................................................................4 ANATOMY ............................................................................................................................ 6 The lateral epicondyle..................................................................................................... 6 The medial epicondyle.................................................................................................... 7 EPICONDYLALGIA ............................................................................................................ 9 Epidemiology and pathomechanics.............................................................................. 9 Diagnosis ........................................................................................................................ 12 TREATMENT METHODS ................................................................................................ 15 Natural course................................................................................................................ 15 Conservative management .......................................................................................... 16 Eccentric (strengthening) exercise ............................................................................. 16 Eccentric exercises and stretching ............................................................................. 18 Stretching........................................................................................................................ 19 Surgery............................................................................................................................ 19 COMPRESSIVE OR ENTRAPMENT NEUROPATHIES AROUND THE ELBOW. 21 Epidemiology and pathomechanics............................................................................ 21 Radial tunnel syndrome (RTS) .................................................................................... 21 Pronator syndrome (PS)............................................................................................... 22 Cubital tunnel syndrome (CuTS)................................................................................. 22 Diagnosis ........................................................................................................................ 23 Radial tunnel syndrome................................................................................................ 23 Pronator syndrome........................................................................................................ 24 Cubital tunnel syndrome............................................................................................... 26 TREATMENT METHODS ................................................................................................ 27 Conservative management .......................................................................................... 27 Radial tunnel syndrome................................................................................................ 27 Pronator syndrome........................................................................................................ 27 Cubital tunnel syndrome............................................................................................... 27 Surgery............................................................................................................................ 28 Radial tunnel syndrome................................................................................................ 28 Pronator syndrome........................................................................................................ 29 Cubital tunnel syndrome............................................................................................... 29 METHODS FOR ASSESSMENTS OF OUTCOME..................................................... 30 Neurophysiological investigations............................................................................... 30 Visual analogue scale (VAS) ....................................................................................... 30 CONTENTS Jamar dynamometer ..................................................................................................... 32 Manual muscle testing (MMT) and digital dynamometer ........................................ 33 Ordinal scales................................................................................................................. 34 The Verhaar score......................................................................................................... 35 The Disability of Arm, Shoulder and Hand Questionnaire (DASH) ....................... 35 The patient-rated elbow evaluation questionnaire (PREE)..................................... 36 The American Shoulder and Elbow Surgeons-Elbow (ASES-E) ........................... 36 The Mayo elbow performance index (MEPI)............................................................. 36 The Canadian Occupational Performance Measure (COPM)................................ 37 The Mos 36-Item Short-Form Health Survey (SF-36) ............................................. 37 Measurement of health-related quality of life (EUROQUAL).................................. 37 AIMS OF THE THESIS..............................................................................................39 GENERAL AIM................................................................................................................... 39 SPECIFIC AIMS: ............................................................................................................... 39 SUMMARY OF STUDIES I - V..................................................................................40 Ethics............................................................................................................................... 40 PATIENTS .......................................................................................................................... 40 Paper I............................................................................................................................. 40 Paper II............................................................................................................................ 42 Paper III........................................................................................................................... 43 Paper IV .......................................................................................................................... 44 Paper V ........................................................................................................................... 45 METHODS OF TREATMENT ......................................................................................... 45 Paper I............................................................................................................................. 45 Paper II............................................................................................................................ 48 Paper III........................................................................................................................... 48 Paper IV .......................................................................................................................... 49 Paper V ........................................................................................................................... 49 METHODS FOR ASSESSMENTS OF OUTCOME..................................................... 51 Evaluation of pain .......................................................................................................... 51 Evaluation of grip and finger adduction strength...................................................... 51 Evaluation of treatment for tennis elbow.................................................................... 52 Self-assessed evaluation of the arm, shoulder and hand function........................ 52 Motor and sensory nerve conduction velocities and electromyography...................... 52 Self-perceived occupational performance and satisfaction .................................... 52 Self-perceived evaluation- change of symptoms...................................................... 52 Self-perceived
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