Report on Hands from Doctors Demystify, March 2012
CONTENTS
DD Courses, again
Best treatment for lateral epicondylitis
Tennis player returns from arm amputation to reach state finals
A plea for helping DD go green
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JOURNAL ARTICLE REVIEW Physical therapy, corticosteroid injection,
and extracorporeal shock wave treatment in lateral epicondylitis
This study was just published in Clinical Rheumatology. The authors studied 59 patients
who had tennis elbow symptoms for less than 3 months that were interfering with ADL.
The investigators performed baseline grip and pinch strength measurements, visual
analog score pain assessments, and ultrasound imaging of the lateral elbow region. They
then randomized the patients into 3 treatment regimens: (1) 1 cortisone injection; (2) 10
therapy sessions consisting of hot packs, ultrasound, and friction massage; and (3) 10
sessions of extracorporeal shock wave treatment (ESWT). They then repeated the clinical
assessments at 1, 3, and 6 months and the ultrasound imaging at 6 months. For all of the
follow-up assessments, the examiner did not know the treatment that the patient had
received.
The groups were evenly matched for age, sex, BMI, side involved, dominant hand, and
duration of symptoms. No patients dropped out.
At 1 month, all groups had significantly less pain and had significantly improved grip
strength. These changes were sustained or in some instances improved slightly at the 3
and 6 month marks. Pinch strength and ultrasound imaging did not change over baseline
at 1, 3, or 6 months.
The authors conclude that the 3 treatments had similar and favorable benefits on pain and
grip strength, yet these improvements were not reflected on ultrasound imaging.
Comment: Readers could conclude pretty much whatever they wished from this study.
One position would be that therapy is as good as the more invasive injection or the more
expensive ESWT. Another position would be that a single injection on a single visit is as
good as the more prolonged and expensive hand therapy or ESWT. This well-executed
study, however, has a serious flaw in its design—it did not include a control group where
nothing was done.
Lateral epicondylitis is a lifestyle issue of individuals 40-60 years old and may be the
patient’s first indication of middle age with its progressive limitations of strength,
endurance, and resiliency. The authors of the current study do cite a 2002 study that
compared injection vs. therapy vs. no treatment. At 6 weeks the injection group was more
comfortable and stronger than the other 2 groups. At a year, the therapy and control
groups were similar to each other and better than the injection group. In other words,
lifestyle modification and time are likely to succeed. This has certainly been the
experience with my patients and with my own elbow (onset after 3 days of unaccustomed
wood chopping followed by toting a heavy suitcase too far). Advising patience, activity
modification, and insight is likely the most important aspect of our treatment for this
annoying condition. Remember what the commander told Tom Cruise in Top Gun. “Your
ego’s writing checks your body can’t cash.” I don’t see how ESWT could help that.
Perhaps gently suggesting to you tennis player patients that they learn to play with their
nondominant hand. It can be done…
TENNIS STAR RETURNS FROM ARM AMPUTATION TO REACH STATE
FINALS
A PLEA FOR HELPING DD GO GREEN
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Roy A. Meals, MD
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