CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2020; 55(05): 564-569
DOI: 10.1055/s-0039-3402465
Artigo Original
Ombro e Cotovelo

Comparative Study between Scales: Subjective Elbow Value and Patient-rated Tennis Elbow Evaluation Applied to Patients Affected by Lateral Epicondylitis

Article in several languages: português | English
1  Serviço de Ortopedia e Traumatologia, Hospital Ipiranga, São Paulo, SP, Brasil
,
Luiz Henrique Oliveira Almeida
1  Serviço de Ortopedia e Traumatologia, Hospital Ipiranga, São Paulo, SP, Brasil
,
Giovanna Galvão Braga Motta
1  Serviço de Ortopedia e Traumatologia, Hospital Ipiranga, São Paulo, SP, Brasil
,
Alexandre Se Moo Kim
1  Serviço de Ortopedia e Traumatologia, Hospital Ipiranga, São Paulo, SP, Brasil
,
Carlos Vitor Nunes Lial
1  Serviço de Ortopedia e Traumatologia, Hospital Ipiranga, São Paulo, SP, Brasil
,
Johny James Claros
1  Serviço de Ortopedia e Traumatologia, Hospital Ipiranga, São Paulo, SP, Brasil
› Author Affiliations
 

Abstract

Objective To verify if the subjective elbow value (SEV) scale presents similar results to those of the Patient-rated Tennis Elbow Evaluation (PRTEE) scale in the evaluation of patients with lateral elbow epicondylitis (LEE).

Methods Thirty-seven patients were diagnosed with LEE in the outpatient service of our hospital through clinical history, physical examination, X-ray, and ultrasonography. The SEV and PRTEE scales were used and their results were compared using a significance level ≥ 5% (p ≥0.05).

Results A statistically significant relationship was found between the values of SEV and PRTEE in the group of patients studied (p = 0.017).

Conclusion Subjective elbow value presented similar results to PRTEE in the evaluation of patients with diagnosis of LEE.


#

Introduction

Lateral elbow epicondylitis (LEE) is an orthopedic condition affecting the tendon of the extensor digitorum communis muscle. It is a very frequent condition, presenting with tendon degeneration and pain in the lateral region of the elbow.[1] The incidence of LEE is roughly 4/1,000 people per year, affecting a wide variety of workers and athletes who perform repetitive elbow and wrist movements. Its peak incidence is from the 4th to the 6th decades of life.[2]

Despite being called “tennis elbow”, LEE affects a large number of workers, ranging from office to industrial production line workers. In a study conducted in Washington, USA, between 1987 and 1995, LEE accounted for 11.7% of work-related injury complaints.[3]

The pathophysiology of LEE is not fully understood. Histopathological changes observed in the tendon include increased fibroblast concentration, vascular hyperplasia, and collagen fiber disorganization; as such, the condition can be defined as an elbow tendinopathy.[2]

Ultrasound (US) is the diagnostic method of choice to confirm LEE diagnosis, associated with physical examination and clinical history findings.[3]

The treatment of LEE remains challenging, with a high rate of poor outcomes.[2] Despite being a relatively common condition, there is little scientific evidence to support an algorithm for LEE treatment.[4] [5] [6]

The evaluation of LEE treatment outcomes is also challenging. There are several scales for elbow function analysis, such as: the Mayo elbow performance score (MEPS), disabilities of the arm, shoulder and hand (DASH) and upper extremity function scale (UEFS). These scales not only evaluate LEE-associated painful symptoms and associated functional loss, but also various trauma-related factors, such as stiffness and instability. As such, score values are increased, generating a false impression of discrete elbow involvement in LEE because the limiting factor for elbow functionality in this condition is pain with preserved range of motion and joint stability.[7] [8] [9] [10]

The Patient-rated Tennis Elbow Evaluation (PRTEE) scale was developed by MacDemid[7] and other authors[8] [9], in 1999, specifically to evaluate LEE cases. In 2005, it was modified to its current model by the same group of researchers. The PRTEE consists of 15 items, which are subdivided into 2 parts; the 1st part contains 5 items assessing pain, ranging from 0 to 10 according to pain intensity, whereas the second part has 10 items assessing elbow function in daily activities, in which 0 indicates total capacity and 10 refers to total incapacity. Results from the second part are divided by two and added to the results from the first part; the total score ranges from 0, indicating no involvement, to 100 points, referring to the maximum degree of limb involvement by LEE[10] [11]([Figure 1]).

Zoom Image
Fig. 1 Patient-Rated Tennis Elbow Evaluation (PRTEE) scale.

Subjective elbow value (SEV) is a single numerical value obtained by asking the patient the percentage of impaired functional activity in the affected elbow that can range from 0 to 100; in which 100 corresponds to an elbow with normal function and 0 to an elbow with total inability to perform daily routine and professional activities.[11]

The present study intended to verify if the SEV scale presented similar results to those of the PRTEE scale for the evaluation of patients with untreated LEE.


#

Materials and Methods

This study was conducted from July 2016 to March 2017. In total, 53 patients were evaluated at the shoulder and elbow outpatient facility with a diagnostic hypothesis of LEE; 37 subjects met the inclusion and exclusion criteria for this study ([Table 1]).

Table 1

PATIENTS

AGE

GENDER

OCCUPATION

AFFECTED SIDE

ROM

COZEN/MILLS/ GARDNER

PRTEE

SEV

(F/E; P/S)*

01

52

Female

HOUSEMAID

RIGHT

0-140; 75-80

POS/POS/POS

80

30%

02

56

Male

RETIRED

LEFT

0-140; 75-80

POS/POS/POS

77

20%

03

66

Male

COMMERCIAL REPRESENTATIVE

RIGHT

0-140; 90-90

POS/POS/NEG

60

30%

04

48

Female

HOUSEMAID

RIGHT

5-140; 75-85

POS/POS/NEG

63

50%

05

53

Female

TEACHER

RIGHT

0-130; 70-80

POS/POS/POS

74

40%

06

50

Female

HAIRDRESSER

RIGHT

0-120; 65-80

POS/POS/NEG

87

30%

07

46

Female

CLEANING ATTENDANT

RIGHT

0-140; 75-80

POS/POS/NEG

93

50%

08

49

Female

CLEANING ATTENDANT

RIGHT

0-120; 70-80

POS/POS/POS

75

45%

09

51

Female

UNEMPLOYED

RIGHT

0-130; 65-75

POS/POS/POS

76

30%

10

44

Female

HOUSEMAID

RIGHT

0-120; 60-80

POS/POS/NEG

77

60%

11

48

Female

RADIOLOGY TECHNICIAN

RIGHT

0-140; 70-85

POS/NEG/NEG

68

70%

12

57

Male

TEACHER

RIGHT

0-120; 75-80

POS/POS/NEG

69

50%

13

45

Female

MANICURIST

RIGHT

0-130; 70-85

POS/POS/NEG

74

30%

14

49

Female

FINANCIAL EXECUTIVE

RIGHT

0-140; 75-85

POS/POS/POS

85

90%

15

59

Male

TAXI DRIVER

RIGHT

0-140;90-90

NEG/POS/POS

73

60%

16

55

Male

LAWYER

RIGHT

0-140;90-90

POS/POS/POS

66

30%

17

60

Female

HOUSEKEEPER

RIGHT

0-140;90-90

POS/POS/POS

72

30%

18

40

Female

ELDERLY CAREGIVER

RIGHT

0-140;90-90

NEG/NEG/POS

71

25%

19

51

Male

HAIRDRESSER

LEFT

0-140;80-80

NEG/NEG/POS

74

50%

20

43

Male

DOORMAN

RIGHT

0-130;80-80

POS/POS/POS

73

70%

21

39

Female

SEAMSTRESS

RIGHT

0-140;90-90

POS/POS/POS

78

35%

22

44

Female

HOUSEMAID

RIGHT

0-140;90-90

POS/POS/POS

70

55%

23

45

Male

DRIVER

LEFT

0-140;90-90

POS/POS/POS

60

45%

24

46

Female

CLEANING ATTENDANT

LEFT

0-140; 80-90

POS/NEG/POS

75

40%

25

56

Male

TEACHER

RIGHT

0-130; 75-80

POS/POS/POS

68

30%

26

42

Female

RADIOLOGY TECHNICIAN

LEFT

0-140; 80-90

POS/POS/NEG

62

50%

27

54

Female

NURSE ASSISTANT

LEFT

0-140; 90-90

POS/NEG/NEG

60

50%

28

45

Male

RETIRED

RIGHT

0-140; 80-90

POS/POS/NEG

65

30%

29

33

Female

HAIRDRESSER

RIGHT

0-130;80-80

POS/POS/POS

81

70%

30

47

Female

HOUSEMAID

RIGHT

0-140;80-90

POS/POS/POS

63

60%

31

45

Female

COMMERCIAL REPRESENTATIVE

RIGHT

0-140;90-90

POS/POS/POS

76

80%

32

40

Female

HOUSEKEEPER

RIGHT

0-140;90-90

POS/POS/POS

70

60%

33

54

Female

HAIRDRESSER

RIGHT

0-140;90-90

NEG/POS/POS

82

80%

34

37

Female

HAIRDRESSER

RIGHT

0-140;90-90

NEG/NEG/POS

60

80%

35

47

Female

LAUNDRY WORKER

RIGHT

0-130;80-80

POS/POS/POS

66

60%

36

36

Male

BRICKLAYER ASSISTANT

LEFT

0-130;90-90

POS/POS/POS

67

70%

37

38

Male

MECHANIC

RIGHT

0-140;90-90

POS/NEG/NEG

68

60%

The inclusion criteria were: compatible findings at clinical history and physical examination, complemented by ultrasound findings, normal results at elbow radiographs, and lack of any previous treatment.

Clinical criteria used for diagnosis included chronic pain at the lateral aspect of the elbow, defined as pain for more than 12 weeks, pain during lateral epicondyle palpation and positivity in at least two of the following physical examination tests: pain during wrist or finger extension against resistance with the elbow at 90 degrees of flexion (Cozen test),[12] pain with the elbow in extension and passive wrist extension (Mills test),[12] pain during elevation from chair with pronated and semiflexed wrist (Gardner test),[12] pain at resistive supination,[12] and pain during passive stretch of the supinator muscle[12] ([Figure 2A-B]). All photos belong to the authors' archives and pictures of all physical examination tests would exceed the maximum number of pictures allowed by this journal.

Zoom Image
Fig. 2 (A) Cozen test, (B) Mills test.

The exclusion criteria were: previous history of rheumatologic disease and/or arthritis, orthopedic disorders affecting the elbow other than LEE, acute elbow pain, diabetes mellitus, pregnancy, neurological diseases, peripheral neuropathies, recent acute upper limb trauma, previous surgery on the affected limb, and chronic polyarthralgia.

The clinical diagnosis was made and then confirmed by an ultrasound examination; an x-ray of the affected elbow was also performed to exclude other orthopedic joint conditions.[11]

The research project was duly approved by the research ethics committee of the institution. All patients participating in this study signed an informed consent form.

The 37 patients diagnosed with lateral epicondylitis were evaluated using the PRTEE and SEV scales during an outpatient visit at our hospital.[8] [9] [10] [11]

An Excel spreadsheet (Microsoft Corp., Redmond, WA, USA) was used for data organization. The IBM SPSS statistical package, version 23.0 (IBM Corp., Armonk, NY, USA) was used for results analysis. The Mann-Whitney test was used to verify possible differences between genders and to analyze the relationship between laterality and SEV.

The Spearman's correlation analysis was used to evaluate the degree of relationship between SEV and PRTEE. Values were considered statistically significant when p- value was greater than or equal to 5% (p ≥0.05).


#

Results

In total, 25 patients were female (67.6%); the mean patients' age was 47 years, 10 months-old, and 27 (79.4%) subjects performed activities associated with repetitive elbow or wrist movements. At the physical examination tests, 86.4%, 81%, and 67.5% of the patients presented positive results at the Cozen, Mills, and Gardner tests, respectively.

The Mann-Whitney test was used to evaluate whether gender and laterality represented important factors in SEV results and found no statistically significant differences. Therefore, the fact that the patient affected by LEE was male or female did not influence the degree of elbow involvement (p = 0.179); similarly, whether the affected side was the right or left one did not represent a statistically significant factor (p = 0.433) ([Table 2]).

Table 2

Variable

Gender

n

Average

Standard deviation

Minimum

Maximum

25th percentile

50th percentile (Median)

75th percentile

Significance (p)

SEV

Female

25

54.80%

18.62%

30.00%

100.00%

40.00%

50.00%

70.00%

0.179

Male

12

45.42%

17.25%

20.00%

70.00%

30.00%

47.50%

60.00%

Total

37

51.76%

18.49%

20.00%

100.00%

32.50%

50.00%

65.00%

Variable

Gender

n

Average

Standard deviation

Minimum

Maximum

25th percentile

50th percentile (Median)

75th percentile

Significance (p)

SEV

Right

30

53.00%

19.24%

30.00%

100.00%

30.00%

52.50%

70.00%

0.1433

Left

7

46.43%

14.92%

20.00%

70.00%

40.00%

50.00%

50.00%

Total

37

51.76%

18.49%

20.00%

100.00%

32.50%

50.00%

65.00%

The Spearman correlation analysis evaluated if there was a statistically significant relationship between the results obtained with the SEV and PRTEE scales; since this relationship actually existed, results were equivalent when both scales were applied (p = 0.017) ([Table 3]).

Table 3

Variable

Statistical Analysis

SEV

AGE

Coefficient of correlation (r)

-0.409

Calculated significance (p)

0.012

n

37

PRTEE

Coefficient of correlation (r)

+0.391

Calculated significance (p)

0.017

n

37


#

Discussion

Previous researches have shown that the PRTEE scale is a satisfactory method for evaluating LEE patients, since it was created specifically for the study of these subjects. The PRTEE scale presents a good correlation with clinical complaints in subjects with LEE-associated functional limitations.[7] [13] In several case series, the PRTEE scale demonstrated a good sensitivity in the evaluation of LEE patients, but it is very extensive and difficult for the examiner to memorize; these are its main limitations for its use in clinical practice. The PRTEE had good sensitivity and specificity in the evaluation of both acute and chronic LEE cases.[7] [13] [14]

Consistent with the literature, our study also demonstrated that SEV is a simple and easy-to-use scale for the clinical investigation of the degree of functional impairment in patients with elbow conditions, being easily understood by the subject and rapidly memorized by the physician. In addition, SEV was developed to evaluate any elbow condition.[15]

A study conducted in 2014 observed that there was a moderate statistical relationship between SEV and MEPS in the evaluation of patients with elbow tendon conditions; this paper showed that, despite being simple, SEV is as good as a more complex scale, such as MEPS, in evaluating these diseases.[16]

In 2017, Ernstbrunner observed similar results in the postoperative evaluation of patients undergoing total elbow arthroplasty using MEPS or SEV scales.[17]

A 2011 study demonstrated similar results between SEV and MEPS in the evaluation of patients submitted to an anconeus graft at the elbow for chronic posterior skin defect with no joint involvement; this finding confirmed information from the previous study that SEV is a very appropriate scale for elbow conditions.[18]

Our study observed a statistically significant relationship between results obtained with the SEV and PRTEE scales in the evaluation of patients diagnosed with LEE.


#

Conclusion

Subjective elbow value is a functional scale with statistically similar results to those of PRTEE in the evaluation of untreated LEE patients.


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Conflitos de Interesse

Os autores declaram não haver conflitos de interesse.


Endereço para correspondência

Luiz Henrique Oliveira Almeida
Av. Nazaré
28, Vila Monumento, São Paulo, SP, 04262-000
Brasil   

Publication History

Received: 01 February 2018

Accepted: 28 March 2019

Publication Date:
20 October 2020 (online)

© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Sociedade Brasileira de Ortopedia e Traumatologia. Published by Thieme Revinter Publicações Ltda
Rio de Janeiro, Brazil


Zoom Image
Fig. 1 Escala de Patient-Rated Tennis Elbow Evaluation (PRTEE).
Zoom Image
Fig. 1 Patient-Rated Tennis Elbow Evaluation (PRTEE) scale.
Zoom Image
Fig. 2 (A) Teste de Cozen, (B) Teste de Mills.
Zoom Image
Fig. 2 (A) Cozen test, (B) Mills test.