Clin Rheumatol (2008) 27:10151019 DOI 10.

1007/s10067-008-0862-8

ORIGINAL ARTICLE

Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices

L. Altan & E. Kanat

Received: 10 October 2007 / Revised: 3 February 2008 / Accepted: 4 February 2008 / Published online: 26 March 2008 # Clinical Rheumatology 2008

Abstract We investigated the effectiveness of braces in the treatment of lateral epicondylitis and compared the effects of two different types of most frequently used braces. A total of 50 patients (seven males and 43 females) with an age range of 34 to 60 who had the diagnosis of lateral epicondylitis were included in the study. The patients were distributed into two groups. In group I, 25 patients (21 females and four males) were given a lateral epicondyle bandage. In group II, 25 patients (22 females and three males) were given a wrist resting splint holding the wrist in slight dorsiflexion. Evaluations of the patients were done before treatment and at the second and sixth weeks of treatment. Evaluation parameters were pain during rest and movement, sensitivity, algometer score, hand grip strength, and evaluation of the response to treatment. The response to treatment was evaluated according to the following categories: excellent, good, medium, and bad. In group I, only pain during rest and movement significantly decreased at 2 weeks while significant improvement was obtained for all parameters at 6 weeks. In group II, all parameters except for algometric sensitivity showed significant improvement at 2 weeks. Significant improvement was obtained for all parameters at 6 weeks in this group. Comparison of the two groups showed significantly better improvement in resting pain in group II at 2 weeks while there was no difference for other parameters including response to treatment at either
L. Altan : E. Kanat Rheumatic Disease and Hydrotherapy Section, Atatrk Rehabilitation Center, Uluda University Medical Faculty, Bursa, Turkey L. Altan (*) Atatrk Rehabilitasyon Merkezi, Kkrtl cad. No. 98, 16080 ekirge, Bursa, Turkey e-mail: lalealtan@uludag.edu.tr

evaluation stage. Braces might be a good strategy to help wait out the natural course of tennis elbow complaints. Although epicondyle bandage was not found to be superior to wrist splint in our study, we may suggest that it could be favored over splint since it is more practical and cosmetically acceptable. Keywords Lateral epicondylitis . Orthotic devices

Introduction Lateral epicondylitis or tennis elbow is a frequently encountered clinical entity characterized by pain in the region of the lateral epicondyle of the humerus which is aggravated during resisted dorsiflexion of the wrist [1]. A force overload exerted on the aponeurosis of the origin of common extensor muscles is believed to be the primary etiologic factor [2]. Lateral epicondylitis has been reported to have an estimated annual incidence of 1% to 3% in the general population and could lead to substantial loss of labor force due to the pain experienced by the patients [3]. Wait-and-see policy, orthotic devices, corticosteroid injections, and physical therapy modalities such as exercise, massage, laser, electrotherapy, and ultrasound are among the previously employed treatment options for treatment of the entity [2, 4, 5]. Different types of braces and orthotic devices have been developed and popularized for the treatment of tennis elbow. The most frequently used devices include a strap placed around the muscle bellies of the wrist extensors and a resting splint blocking the wrist extensors [1, 6]. However, the literature is lacking in definitive reports showing the effectiveness of such devices and in studies making comparisons between different types of braces. The purpose of this clinical study is to investigate whether two different types of most frequently used braces

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are effective in the treatment of lateral epicondylitis and also whether one is superior to the other. Materials and methods A total of 50 patients (seven males and 43 females) with an age range of 34 to 60 (average, 50.367.08) who had the diagnosis of lateral epicondylitis were included in the study. Our criteria for making diagnosis of lateral epicondylitis were the complaint of pain on the lateral side of the elbow and aggravation of the pain with both resisted dorsiflexion of the wrist and pressure applied on the lateral epicondyle of the humerus. The patients who had these symptoms for more than 12 weeks or who were given physical therapy or corticosteroid injections during that period were excluded from the study. The patients were distributed into two groups by giving them odd or even numbers according to the order of admission to the clinic. In group I, 25 patients (21 females and four males) were given a lateral epicondyle bandage (Rehband, Germany). In group II, 25 patients (22 females and three males) were given a wrist resting splint (Rehband, Germany) holding the wrist in 1520 dorsiflexion. The patients were informed on the use and application of the braces according to a standard protocol and were instructed to wear their braces continuously. In the event of discomfort, patients were allowed to take off their braces for no longer than an hour. They were permitted to resume daily activities as much as their braces allowed but were warned to stay away from vigorous activities as well as sports that could overload wrist extensors. All patients were requested to abstain from non-steroidal anti-inflammatory drugs (NSAIDs) but were allowed to take paracetamol for severe pain. For a more accurate pain assessment, patients were asked not to take paracetamol on the morning of assessment. Evaluations of the patients were done before treatment and at the second and sixth weeks of the treatment period by a researcher who was unaware of the particular type of brace each patient used. The following parameters were used during each evaluation stage: 1. Pain during rest and movement: The patients were asked to point their pain severity on a 10-cm scale and the distance of this point from 0 was measured. 2. Sensitivity: A constant force of 4 kg/cm2 was applied over the lateral epicondyle using a standard pressure algometry (Force Dial FDK 60) and the severity of the elicited pain was assessed according to a four-point scale (0=no pain, 1=mild pain, 2=moderate pain (evidenced by mimics or gestures), and 3=severe pain (withdrawal)). Sensitivity was measured as an algometer score. For this purpose, the algometer was applied to the lateral epicondyle three times and the algometer score was calculated as the average of the minimum pain-generating pressure values.

3. Hand grip strength: A Jamar dynamometer was used to measure the grip strength. 4. Response to treatment: Each patient was asked to evaluate the results of the treatment according to the following categories [7]: Excellent: Total relief from pain, no subjective loss in hand grip power, no pain during resisted wrist dorsiflexion, overall patient satisfaction reported Good: Mild pain in the lateral epicondyle following heavy activity, slight or no subjective loss in hand grip power, no pain during resisted wrist dorsiflexion, overall patient satisfaction reported Medium: Mild (but less than before treatment) pain in the lateral epicondyle following heavy activity, slight to moderate subjective loss in hand grip power, moderate pain during resisted wrist dorsiflexion, moderate patient satisfaction reported Bad: No pain reduction, significant loss in hand grip power, severe pain during resisted wrist dorsiflexion, patient dissatisfaction reported The patients who were totally relieved from pain at the end of the second week were discontinued splinting while the splints were maintained for patients with persisting pain. The study ended following the final evaluation at 6 weeks. The patients who still had pain at that time were given supplementary treatment such as NSAIDs, corticosteroid injection, and physical therapy. Statistical analysis Suitability of data to normal distribution was compared using the ShapiroWilk test. Wilcoxon test for comparisons within the groups, difference scores for score values, and percent changes for continuous values for comparisons between the groups were used. Fisher s exact test and chisquare test were used for comparison of categorical values.

Results Evaluations were done in 49 patients while one patient in the resting splint group was excluded for failing to come to control examinations. Table 1 presents demographic data and pre-treatment evaluation results which showed no significant difference between the two groups. In group I, pain during rest and movement was significantly reduced while the parameters of sensitivity measured by pressure algometry and hand grip strength did not show significant improvement at 2 weeks. Significant improvement was obtained for all parameters at 6 weeks in this group (Table 2).

Clin Rheumatol (2008) 27:10151019 Table 1 Pre-treatment data of the two groups Group I Total number of patients Sex (F/M) Age (years) Duration of symptoms (weeks) Pain at rest Pain with movement Sensitivity Algometer score Hand grip strength 24 20/4 50.361.87 6.0800.60 2.550.40 7.030.38 2.120.06 3.400.12 181.86 Group II 25 22/3 50.361.42 5.880.58 2.640.46 7.590.35 3.080.79 3.120.14 19.962.07 p Week 0 >0.5 >0.5 >0.5 >0.5 >0.05 >0.5 >0.5 >0.5 Pain at rest Pain with movement Sensitivity Algometer score Hand grip strength 2.640.46 7.590.35 3.080.79 3.120.14 19.962.07 Week 2 1.380.33** 5.400.48*** 1.640.11** 3.560.20 23.242.61** Week 6

1017 Table 3 Statistical comparison of clinical evaluation parameters before and after treatment in group II

1.140.27** 4.350.58*** 1.280.09*** 3.900.27* 24.642.58**

*p <0.05: **p <0.01: ***p <0.001

In group II, all parameters except for algometric sensitivity showed significant improvement at 2 weeks. Significant improvement was obtained for all parameters at 6 weeks in this group (Table 3). Comparison of the two groups showed significantly better improvement in resting pain in group II at 2 weeks while there was no difference for other parameters at either evaluation stage (Table 4). The response to treatment at 2 weeks was bad in 4.2%, medium in 62.5%, and good in 33.3% of the patients in group I and bad in 4%, medium in 48%, and good in 48% of the patients in group II. The response at 6 weeks was bad in 4.2%, medium in 29.2%, and good in 66.7% of patients in group I and medium in 28% and good in 72% of patients in group II. There was no significant difference for these parameters between the two groups at either evaluation stage.

Discussion In this clinical study investigating the effectiveness of braces in the treatment of lateral epicondylitis, we have found that both commonly used braces are effective and there is no superiority among them. Gaining rapid return to full functioning is the essential goal of lateral epicondylitis treatment. Up to 40 different treatment modalities, among which several types of orthoses have an important part, have been described.
Table 2 Statistical comparison of clinical evaluation parameters before and after treatment in group I Week 0 Pain at rest Pain with movement Sensitivity Algometer score Hand grip strength *p <0.05; **p <0.01 2.550.40 7.030.38 2.120.06 3.400.12 181.86 Week 2 1.530.33* 6.471.25** 2.120.40 3.610.21 20.752.06 Week 6

Forearm support band, developed by Grapel and Nirshl in 1973 provides wide non-elastic support to the muscles [8]. Two mechanisms of action for the forearm band have been suggested most frequently in the literature. According to the first theory, the band inhibits full muscle contraction by constricting the forearm musculature. Inhibition of muscle expansion decreases the magnitude of muscle contraction and tension at the musculotendinous unit proximal to the band is consequently reduced. The second theory suggests that the support band applies direct compression over the extensor carpi radialis brevis (ECRB) muscle belly. This compression supposedly creates a compressive adhesion or secondary origin which leads to the unloading of the origin at the lateral epicondyle [8]. Electromyographic (EMG) studies have confirmed reduced EMG activity in the forearm musculature treated with the forearm support band [9]. In a more recent study by Meyer et al. [10], compression measurement values obtained in cadaver models have been applied in healthy volunteers during motion and activity. They showed that a force reduction of 13% to 15% in the origin of ECRB could be obtained with a forearm support applying adequate compression.

Table 4 Comparison of the two groups on the basis of the posttreatment (both 3 and 6 weeks) percent changes and difference scores relative to pre-treatment values 03 weeks Pain at rest Pain with movement Sensitivity Group Group Group Group Group Group Group Group Group Group I II I II I II I II I II 1.100.47 1.270.35* 0.451.25 2.190.41 00.41 1.440.78 0.050.05 0.190.08 0.060.04 0.190.07 06 weeks 1.280.53 1.500.45 2.360.64 3.240.46 0.710.14 1.800.77 0.150.07 0.320.12 0.500.32 0.300.08

1.320.33* 4.570.56** 1.410.12** 3.980.30* 26.954.41**

Algometer score Hand grip strength

*p <0.01

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Clin Rheumatol (2008) 27:10151019

In our study, significant pain relief during rest and motion at 2 weeks and significant improvement for all parameters at 6 weeks were obtained in group I patients treated with lateral epicondyle bandage. The main goal of resting splints is to hold the wrist extensor muscles in a position of rest. Jansen et al. [11] evaluated the effect of various wrist orthoses on the wrist extensor musculature in an EMG study. This study showed EMG changes in the wrist extensors particularly during activities of lifting objects. The results of our study showed significant improvement in pain during rest and motion, pression sensitivity, hand grip strength at 2 weeks, and for all parameters at 6 weeks in group II patients treated with the resting splint holding the wrist in dorsiflexion. Despite the frequent use of braces, no definitive evidence is present in current literature concerning their effectiveness. Struijs et al. [3] compared the effectiveness of a brace and standardized physical therapy protocol for treatment of lateral epicondylitis in the short, intermediate, and long term in a randomized clinical trial. The authors have interpreted the results as conflicting. Physical therapy was found to be beneficial for pain disability and satisfaction, though only for the short term, while braceonly treatment was superior on inconvenience during daily activities. Combination therapy had no additional advantage compared to physical therapy but was superior to brace-only treatment for the short term. Derebery et al. [12] investigated the effectiveness of splinting in working people in a retrospective study. The patient population consisted of patients receiving primary care for lateral or medial epicondylitis at any clinic within a nationwide network of 253 occupational medical centers. The status of splinting of the subjects was obtained from the electronic recordings during the visits. The researchers reported higher rates of limited duty, more medical visits and charges, higher total charges, and longer treatment durations in splinted patients than in patients without splints. However, it should be noted that the mentioned study is not randomized due to its retrospective nature. Besides, the authors have emphasized that patients with moderate to severe ratings were more likely to receive splints than patients with mild ratings. Another drawback of the study is the lack of assessment between different types of splints. Few studies using these devices have been found in the systematic reviews in the literature. Labelle et al. [13] performed a systematic review of conservative treatment measures for lateral epicondylitis but only one trial concerning an orthotic device was mentioned. In a later review by Struijs et al. [6], only five randomized controlled trials using orthotic devices have been reported as suitable for their criteria. In four of those studies, orthotic devices were compared with conventional treatment modalities

such as corticosteroids/anti-inflammatory ointments or physical therapy. As a result, the authors have concluded that it is not possible to judge the role of orthotic devices in lateral epicondylitis treatment because the present studies lack in number, are mostly heterogeneous, have design limitations, and suggested further research. Some authors believe that splints provide no benefits. In a randomized experimental study of healthy patients, wearing a forearm band was found to increase rather than reduce extensor muscle fatigue as measured by extension force and peak grip isometric force. Such findings suggest that splints might hinder activity and potentially contribute to deconditioning, contrary to indications. In our study, comparison of forearm band and wrist resting splint showed significant improvement only in resting pain at 2 weeks in group II while no significance was found between the two groups for any parameter at 6 weeks. Only one study focusing on the comparison of two different types of splints in lateral epicondylitis treatment was found in our literature survey. Van de Streek et al. [14] compared a forearm hand splint with a simple elbow band and found no difference between them. Although lateral epicondylitis is equally prevalent among males and females according to the literature, women outnumbered men in our study. This might be explained by the fact that our center serves as a spa and rheumatologic disease center to which more female patients tend to admitted in. The main limitation of our study is the lack of a control group. However, patients presenting with acute pain and loss of function expected a more radical intervention and were mostly reluctant to participate in the wait and see group. It has been shown in a previous study that, even though wait and see worked in the long term, 6-week results were not as good [5]. Although epicondyle bandage was not found to be superior to wrist splint in our study, we may suggest that it could be favored over splint since it is more practical and cosmetically acceptable. Moreover, hand activities can be done more comfortably by the patients wearing the bandage.
Conflict of interest statement This study was not funded by any institution and there are no conflicts of interest (personal or institutional) that are relevant to the work reported in this manuscript. We accept full responsibility for the integrity of the data and the accuracy of the data analysis.

References
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Clin Rheumatol (2008) 27:10151019 3. Struijs PAA, Korthals-de Bos IBC, van Tulder MW et al (2006) Cost-effectiveness of brace, physical therapy or both, for treatment of tennis elbow. Br J Sports Med 40:637643 4. Assendelft W, Green S, Buchbinder R (2003) Tennis elbow. Br Med J 327:329 5. Smidt N, van der Windt DA, Assendelft WJ (2002) Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 359:657662 6. Struijs PAA, Smidt N, Arola H et al (2001) Orthotic devices for the treatment of tennis elbow. Cochrane Database Syst Rev 1: CD001821 7. Altay T, Gnal I, ztrk H (2002) Local injection treatment for lateral epicondylitis. Clin Orthop Relat Res 398:127130 8. Wright HH, Rettig AC (1995) Management of common sports injuries. In: Hunter JM, Mackin EJ, Callahan AD (eds) Rehabilitation of the hand: surgery and therapy. 4thth edn. Mosby, St. Louis, pp 18091838 9. Synder-Mackler L, Epler M (1989) Effect of standard and Aircast tennis elbow bands on integrated electromyography of forearm

1019 extensor musculature proximal to the bands. Am J Sports Med 17:278281 Meyer NJ, Walter F, Haines B et al (2003) Modeled evidence of force reduction at the extensor carpi radialis brevis origin with the forearm support band. J Hand Surg 28A:279287 Jansen CW, Olson SL, Hasson SM (1997) The effect of use of a wrist orthosis during functional activities on surface electromyography of the wrist extensors in normal subjects. J Hand Ther 10:283289 Derebery VJ, Devenport JN, Giang GM et al (2005) The effects of splinting on outcomes for epicondylitis. Arch Phys Med Rehabil 86:10811088 Labelle H, Guibert R, Joncas J et al (1992) Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. J Bone Joint Surg Br 74:646651 Van de Streek MD, Van der Schans CP, de Greef MH et al (2004) The effect of a forearm/hand splint compared with an elbow band as a treatment for lateral epicondylitis. Prosthet Orthot Int 28:183 189

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