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It’s time to change perspective! New diagnostic tools for lateral elbow pain

Abstract

Purpose

The presence of intra-articular findings that may complement the extra-articular pathology in lateral epicondilytis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated. This study was designed to describe two new clinical tests, aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance.

Methods

Ten patients suffering of atraumatic lateral elbow pain unresponsive to conservative treatment were considered in this study. Two clinical tests were developed and administrated prior to arthroscopy: Supination and Antero-Lateral pain Test (SALT); Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER). Sensitivity, specificity, predictive values and accuracy of SALT and PEPPER as diagnostic tests for seven intra-articular findings were calculated.

Results

In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity or intra-articular abnormal findings had a positive response to at least one of the two tests. SALT proved to have a high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis. PEPPER test was sensible, specific and accurate in the detection of radial head chondropathy.

Conclusions

Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition.

Level of evidence

Diagnostic study, development of diagnostic criteria on basis of consecutive patients, level II.

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Author information

Correspondence to D. Cucchi.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Video 1: Supination and Antero-Lateral pain Test (SALT). The examiner positions own thumb at the level of the anterolateral aspect of the radial head. The thumb is progressively slid anteriorly over the radial head combined with supination of the radius. Muscles of the anterolateral compartment are pushed away to keep contact between finger and bone. The test is positive if the patient experiences anterolateral pain with forearm supination (MP4 9875 kb)

Video 2: Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER). The examiner positions his own thumb at the level of the posterior aspect of the radiocapitellar joint. The test is positive if the patient experiences pain while extending the elbow (MP4 7956 kb)

Video 1: Supination and Antero-Lateral pain Test (SALT). The examiner positions own thumb at the level of the anterolateral aspect of the radial head. The thumb is progressively slid anteriorly over the radial head combined with supination of the radius. Muscles of the anterolateral compartment are pushed away to keep contact between finger and bone. The test is positive if the patient experiences anterolateral pain with forearm supination (MP4 9875 kb)

Video 2: Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER). The examiner positions his own thumb at the level of the posterior aspect of the radiocapitellar joint. The test is positive if the patient experiences pain while extending the elbow (MP4 7956 kb)

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Arrigoni, P., Cucchi, D., Menon, A. et al. It’s time to change perspective! New diagnostic tools for lateral elbow pain. Musculoskelet Surg 101, 175–179 (2017) doi:10.1007/s12306-017-0486-8

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Keywords

  • Elbow arthroscopy
  • Lateral epicondylitis
  • Tennis elbow
  • SMILE
  • Minor instability
  • Diagnostic test