Research proposal of a new clinic model for the interpretation of Lateral Elbow Pain: is it time to change?

Abstract

Background. Lateral Elbow Tendinopathy (aka Tennis Elbow or Lateral Elbow Pain), is characterized by a specific pain located in the lateral epicondyle and referred to the dorsal compartment of the forearm. Manual labour and forceful gripping activities can exacerbate pain, by restricting a patient's ability to work, train and perform simple daily tasks. In the framework of an aetiopathogenic complexity, a multimodal approach based upon the exclusive involvement of the common extensor tendon seems to be rather obsolete. This method does not consider any intra-articular pain resulting from micro-instabilities requiring a different approach together with a detection performed in a limited time span, in order to avoid any impairment of the psychosocial condition following the failure of all the proposed conservative treatments. Objectives. The primary objective of this debate was to have elaborated a decisional algorithm called Integrated Approach of Lateral Elbow Pain (I-APPLEp), which could allow the detection of a time-optimized plan for a diagnostic, therapeutic framing. Discussion. Following the above-mentioned research proposal, this clinical approach based upon an evaluative and therapeutic management of patients with LEP allows us to draw some conclusions: 1) using the expression Lateral Elbow Pain (LEP) to refer to this musculoskeletal condition should be preferable, owing to its aetiological and pathophysiological complexity. Moreover, the expression Non-specific Lateral Elbow Pain (NSLEP) in case of suffering of the extra-articular structures (i.e. Tendinopathy) and Specific Lateral Elbow Pain (SLEP) is recommended, within the framework of arthropathy or intra-articular pathology (e.g.: Smile Symptomatic MInor Instabilities of the Lateral Elbpw); 2) an early surgical treatment can be a feasible option in the management of articular micro-instabilities, recalcitrant pathologies and psychosocial profiles with a high risk of unfavorable prognosis. Conclusions. We recommend testing brand-new diagnostic, therapeutic proposals on sampling patients, who must be adequately chosen, in order to estimate the real impact in the short, medium and long term.

Treatment, Diagnostic Criteria and Variability of Terminology for Lateral Elbow Pain: Findings from an Overview of Systematic Reviews

“…In an SR by Bisset et al (2005), 28 RCTs were analysed that dealt with the most effective interventions in the case of “lateral epicondylalgia” [ 27 ]. This terminological and conceptual transition underlines the shift from the biomedical pathology to the musculoskeletal disorder related to the bio–psycho–social sphere [ 11 , 27 , 52 ].…”

“…Following an evaluation algorithm proposed in a previous publication with the I-APPLEp algorithm [ 11 ], we believe that replacing the term “LEP” with “LEDs” is necessary. Our main goal is to describe and identify the lateral problems of the persistent-recalcitrant elbow—longer than three months—as an alternative to the old labels, among which are “epycondilitys,” “tennis elbow,” and “epycondilalgia.” Accordingly, we propose a modified version of the I-APPLE algorithm: LED-APP, the Lateral Elbow Disorders Approach (reported in Figure S1 ).…”

“…In the literature, to date, the terminological framework of this problem is confusing. Indeed, researchers adopted more than 10 names (i.e., lateral elbow tendinopathy, lateral epicondylitis, tennis elbow, lateral epicondylalgia, lateral epicondylosis) to define LEP [ 9 , 10 , 11 ].…”

Neutrophil-Reduced Platelet Rich Plasma with Optimal Platelets Concentrations for Epicondylitis of the Elbow

“…We examined plain X-ray images and magnetic resonance images (MRI) in all elbows and found high intensity areas at the insertional sites of tendons in T2-weighted MRI or short tau inversion recovery (STIR) modes in 21 elbows, obvious synovial fringes of humeroradial joints in 3 elbows, complete full-thickness tears of common extensor tendons at the lateral epicondyles in 2 elbows, or a complete tear of the common flexor tendon at the medial epicondyle in one elbow of the patient after a previous surgery. We excluded cases affected with the arthritis or the osteoarthritis of elbows, rheumatoid arthritis, post-injury deformations of elbows, injuries or damages of extensor muscles located at forearm or cervical spondylo-radiculopathies, of which symptoms medial or lateral elbow pain was involved in for the correction of cases affected with enthesopathies or terminal stage of enthesopathies (26). A visual analog pain scale (VAS) or a modified Mayo Elbow Performance score (MEPS) were obtained for each elbow before the PRP therapies and at 3, 6 or 12 months after completion of the treatment.…”

In vitro effect of triamcinolone and platelet-rich plasma on cytokine levels of elbow lateral epicondylitis-derived cells

“…The pathogenesis of LEE is still controversial. Currently, it has even been suggested that LEE is a multi-factorial process with specific alterations of the psychosocial sphere [4]. Although LEE was initially considered a tendinitis, caused by tendon inflammation [5,6], LEE had its nomenclature changed to angio-fibroblastic tendinosis, since the histopathologic examination showed that the lesion is characterized by the presence of a dense population of fibroblasts, vascular hyperplasia, and disorganized collagen with few inflammatory cells [7][8][9].…”