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Summary

A prospective study was done from 01.04.1994 to 31.101994 to test the Lastrap bandage in 26 tennis players (age 19 to 55 years) with chronic epicondylitis. The bandage reduces vibrations and acceleration amplitude of the forearm by 50% using special shock absorbers. Damaging vibration and shock waves are supposed to be a main cause for epicondylitis. All patients were regularly examined over a period of 4 months. The pain-free range of movement of the forearm improved by an average of 28%, the pain on pressure at the epicondyle declined totally in 21 patients and partly in 5 patients. Pain during playing tennis (pain-scale 0 to 10) declined from 7,77 to 2,04. After 4 months, 22 of the patients were pain-free while playing tennis, 3 had slight pain, 1 had still severe pain.

Introduction

The epicondylitis radialis impairs the quality of life of many, especially active persons. Among these patients, the tennis players with the classic "tennis elbow" are in the minority. Equally affected are persons suffering high strain on their arms at their working place [2, 16, 19]. The mechanism of pathogenicity [18, 21, 24, 30] is as much disputed as the therapy [3, 4, 5, 6, 7, 8, 9, 10, 13, 20, 22, 23, 25, 29, 31, 33]. In the past few years numerous approaches to treatment have been published and discussed. However, the scientific value of most investigations has been classified as very questionable in a meta-analysis by Labelle et al. [17].

According to our own biomechanic analyses of the forearm, which have been confirmed by other authors [11, 15], acceleration forces acting on the hand and wrist, are absorbed by the wrist flexor and extensor muscles. The origin of the corresponding muscles at the epicondylus serves as a mechanical abutment. Great mechanical strain on the wrist inevitably leads to great strain on the muscular points of attachment. The reaction of the tissue to the constant overstrain histologically manifests itself as a degenerative change in the area of the tendinous insertion, which, among other things, could explain the unsatisfactory response of the symptoms to anti-inflammatory substances [24].

The essential factor of pathogenicity is less considered to be the total of forces taking effect on the epicondylus than the rapid change of load, as it is observed, for example, during a tennis match or work with building machines [16, 19]. It is known from the fields of acoustics, mechanics and biomechanics that acceleration forces and vibrations can be influenced and altered by absorbers. This consideration led to the development of the Lastrap Bandage, which is fitted to the forearm as an absorber and, through the mass inertia, causes the force impulse to be transmitted to the tendinous insertion in a measurably more even way. The objective of this study was to clinically verify the efficacy of the Lastrap Bandage in patients with recurrent epicondylitis.

Patients and Methods

To verify the efficacy of the bandage a controlled prospective study was carried out on 26 tennis players from April 01, 1994 to Oct. 31, 1994. The average age was 46.1 years (range: 19-55 years, for age distribution see Fig. 1). Sixteen women and ten men were included in the study.

Figure 1: Age distribution of patients

The criterion of inclusion was a minimum 3-year history of epicondylitis radialis. Another precondition was that the patient had been treated before with two different conventional concepts of therapy (drug therapy, physical therapy, bandages) that brought about no results (for pre-treatment see Table 1). During the study, no non-steroidal antiphlogistics were allowed, neither orally nor applied as an ointment or a cream. In addition to this, no treatment of the epicondylitis with other physical procedures was permitted. It was required that all patients played tennis in their club at least 4 hours/week. They were instructed to continue or resume training with undiminished intensity. After a first medical examination the patients were provided with the bandage and instructed to wear it as often as possible. The follow-up examinations took place at first weekly, then every other week. Each patient was observed for a total period of 4 months.

Table 1: Pre-treatment of the patients employed in this study

Subjective and objective parameters were ascertained at the regular examinations. The pain caused by pressure above the epicondylus was determined by the patients on the basis of a self-rating-scale ranging from 1 to 10. Another parameter was the middle finger extension test. For this test, the patient put his forearm in pronation on a table. The middle finger had to be lifted against a standardised resistance of 0.5 kg. The percentage of patients being able to perform the test without pain was determined. During the fist extension test the angle was measured which could be reached without pain by the patient in the position of pronation. The maximum pain-free position of supination and pronation were also measured. Muscular hardening on the forearm was determined by palpation and graded from 0 (no hardening) to 3 (severe hardening). The pain when playing tennis was rated by the patients on the basis of a scale ranging from 0 to 10. Finally, after a treatment period of 4 months, the patients were asked about their pain when playing tennis.

Results

At the start of the treatment all patients showed pronounced pain on pressure. On the pain scale ranging from 0 (pain-free) to 10 (maximum conceivable pain) the most frequent values stated were around 8 (mean value: 7.9). The pain on pressure distinctly declined in all patients in the course of the treatment (Fig. 2).

Figure 2: Pain on pressure at the epicondylus lateralis (pain scale 0-10)

The middle finger extension test designed as a provocative test showed that, in the beginning, no patient was able to lift the standard weight of 0.5 kg with his extended middle finger without feeling pain. After 8 weeks 22 patient were able to lift the weight.

The fist extension to be carried out without pain was initially 48.5° on average (range: 5° - 75°). After therapy of eight weeks, the mean value was 76.3° (range: 55° - 90°). At the start, supination possible without pain was 65° (range: 10° - 90°), pronation 61.3° (range: 20° - 90°). Supination improved to 88.3° (range: 80° - 90°), pronation to 87.7° (range: 80° - 90°) (Fig. 3).

Figure 3: Flexibility of the wrist (degrees)

The muscular hardening at the proximal forearm graded by palpation from 0 (no hardening) to 3 (severe hardening) was initially at 2.69 on average. This value improved to 0.35 (Fig. 4).

Figure 4: Muscular hardening (scale: 0-3)

At each examination the patients were requested to indicate their pain when playing tennis on the pain scale between 0 (no pain) and 10 (maximum pain). At the first examination the mean value was 7.77. After 8 weeks it had dropped to 2.04 (Fig. 5). After 4 months, 22 of the patients were free of pain when playing tennis, 3 had slight pain, 1 had still severe pain.

Figure 5: Pain when playing tennis (pain scale: 0-10)

Discussion

The prevalence of the epicondylitis in tennis players is 30-50% [11, 12, 26]. Altogether the percentage of tennis players among patients is only very small [28]. Epicondylitis is also found in 2% of the physically working population, in some trades the percentage is markedly higher [16, 19]. Both for the sportsman and for the person busy in his job, the epicondylitis, which is often extremely painful, means a marked impairment of their capabilities and thus of their quality of life.

All operative and conservative methods of treatment essentially aim at the reduction of pain and consequently the restoration of the person's capabilities. In achieving this aim, the patient should be exposed to as few risks and side-effects as possible. The treatment of the epicondylitis with bandages is the method involving the fewest risks and side-effects [6, 27].

New insight into the mechanism of pathogenicity of the epicondylitis has been published by Hennig et al. 1992 [11]. On the basis of biomechanical studies in tennis players conducted in vivo, the transmission of acceleration forces and vibrations have been analysed on their way from the racket through the hand and wrist to the elbow. At the wrist, the acceleration strain measured was up to 4.5 times higher than at the elbow joint. The extreme reduction of the vibrations from 6.8 - 20.3 g at the wrist to 1.5 - 4.5 g at the elbow joint (g = gravitational acceleration, 9.81 m/s2) is due to the counteraction of the neuromuscular control system [34]. The forearm mass has been described as another essential factor influencing the forearm vibrations. Persons with much forearm mass showed a markedly reduced acceleration amplitude compared with persons with little forearm mass. The acceleration values measured at the elbow of patients with epicondylitis were above the average.

The development of the Lastrap bandage is based on this knowledge. By changing the vibrating mass, especially of the vibrating extensor musculature, the acceleration at the elbow joint is reduced by about 50% (study of the author himself, not yet published). The bandage thus directly interferes with the mechanism of pathogenicity, which explains the good clinical results.

Every treatment of the epicondylitis lateralis has to be judged in comparison to the course the disease would take spontaneously. The peak of the morbidity rate is between the 40th and 50th year of life. In the case of acute appearance, 90% of the patients can expect spontaneous regression [12]. In the control group of another study spontaneous regression of acute epicondylitis within 2 weeks is reported for 9% of the patients [14]. If the disease has been chronic for more than one year, the percentage of spontaneous remissions is significantly smaller. In 1994 Almekinders et al [1] reported a remission rate of 28% for chronic overuse syndromes. In the other cases, unchanged condition or deterioration were observed. The prospects of recovery for these patients are only slight if they are treated with the conservative methods hitherto available.

The Lastrap bandage gives a new possibility of an efficacious conservative treatment of the epicondylitis by interfering directly with the mechanism of pathogenicity of the disease. The efficacy of this treatment concept is underlined by the high percentage of pain-free patients (85%) after a treatment period of 4 months.

In the case of those patients not responding to the treatment, the existence of nerve compression syndromes, subluxation, degeneration of the humeroradial joint as well as cervical causes should be ruled out by differential diagnosis [12, 32].

Surgical intervention (denervation operation according to Wilhelm, Hohmann's operation, Garden's operation) should be taken into consideration only when all conservative methods have failed repeatedly and all differential diagnoses have been excluded.

Although the results of the various operative techniques are altogether judged to be good, the essential problem here is that there is no relationship between the pre-operative finding and the operative success [33]. The long post-operative convalescent period of up to 8 months poses a big problem for the active sportsman [32].

Apart from its efficacy the Lastrap bandage satisfies the demand of active persons and sportsman for quick restitution of their full capabilities. In contrast to other treatment methods therapeutic components of which are rest and inactivity of the painful part, this investigation proved full efficacy in spite of unrestricted activities in sports. Thus, periods of absence from their place of employment or lost training time will be avoided. As with all new approaches to treatment it is certainly difficult to make a conclusive assessment. Further investigation of the bandage over a longer period of observation within the framework of a randomised, prospective study employing a larger group of patients has already been initiated.


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Priv. Doz. Dr. med. Rainer Wölfel
University Erlangen
Dept. of Trauma Surgery
Maximilinasplatz
91054 Erlangen
Germany
Tel.: +49 / 9131 / 853296