Prevalence of Lateral Epicondylitis among Housewives in Lahore: A Cross-sectional Study

Prevalence of Lateral Epicondylitis among Housewives in Lahore: A Cross-sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence of Lateral Epicondylitis among Housewives in Lahore: A Cross-sectional Study Hira Akbar, Seher Akbar, Muhammad Nabeel Saddique This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4744814/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Oct, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 13 You are reading this latest preprint version Abstract Background Lateral epicondylitis (LE) is characterized by pain, inflammation and local tenderness over the bony prominence of lateral epicondyle and is exacerbated under stressful and repetitive movements such as prolonged supination and pronation movements, twisting and rolling activities. Lateral Epicondylitis ranks as the second most commonly diagnosed musculoskeletal condition. Females, especially housewives, are more affected by LE. It can lead to persistent elbow pain, reduced grip strength, limited arm movement, and difficulty performing daily tasks Results All of our 150 participants were women aged 25–50 years. We found that 17% (26 of 150) housewives have severe type of pain, 43% (65 of 150) have moderate pain, 30% (45 of 150) have mild pain, 9% (14 of 150) reported no pain at all according to PRTEE questionnaire. We also found that most affected part of body by pain was arm (68%) (102 of 150) while 26% (39 of 150) reported pain in both arms. Only 30.7% of women (46 of 150) reported functional limitations during specific activities, 26% (29 of 150) during usual activities, while the remaining 43.3% (65 of 150) were pain-free. Conclusion We found a high prevalence of patient-reported lateral epicondylitis among housewives with arms affected by pain most hindering functional mobility of body. Robust studies with larger sample size are needed to establish conclusive evidence. Cross-sectional study epicondylitis Tennis elbow elbow pain repetitive stress Figures Figure 1 Figure 2 Figure 3 1. BACKGROUND Lateral epicondylitis, which is also known as tennis elbow, lateral epicondylalgia, and calcareous tendinitis, is an unpleasant painful condition caused by repetitive strain on the forearm extensor tendons, leading to pain and tenderness on the outer elbow [ 1 ]. Lateral epicondylitis (LE) is a very prevalent condition affecting 1.6–23.1% of workers who engage in repetitive upper-limb activities. The prevalence of tennis elbow in tennis players ranges from 40 to 50%, although it is less common in general and only affects 1.3 percent of the population [ 2 ]. It is more common is middle to old age (35–55 years) women.[ 3 ] Lack of rest, repetitive wrist and elbow movements, high handgrip force activities, vibrating tools, heavy lifting, diabetes, soft tissue issues, and psychological factors like depression can increase the risk of tennis elbow. (7) Carpenters, teachers, housewives, shopkeepers, cooks, and painters are at risk of LE. In housewives, it is mostly due to their work routine, which includes frequent pronation or supination movements, repetitive stress, workload, and pin-rolling activities. Washing of clothes and cooking is also a major cause of having lateral epicondylitis.[ 4 ] Limited evidence backs a single effective treatment for LE patients. LE treatments range from NSAIDs, physiotherapy, corticosteroids, PRP, operative treatment, Mulligan and Cyriax techniques, and non-pharmacological options such lifestyle changes, elbow bands, heat, etc.[ 3 , 5 ] Only 30% of all patients with LE refer to physiotherapy.[ 6 ] Physical therapy is essential for treating lateral epicondylitis in individuals who use their elbow, wrist, or hand extensively. It aids in muscle healing, and pain reduction, and enhances recovery for those with tennis elbow. [ 1 , 5 ] There was plenty of literature on pathology, risk factors, prevalence, and treatment, but there was little on tennis elbow awareness and prevalence in housewives. If it persists, it can significantly affect their daily activities. The continuous pain, limited arm mobility, and difficulty in performing tasks can lead to decreased quality of life. It may hinder work, household chores, and recreational activities, impacting overall well-being. Timely treatment and proper management strategies are crucial to alleviate symptoms and prevent further complications. Persistent lateral epicondylitis can not only cause physical discomfort but also emotional distress due to the limitations it imposes on daily life. It is essential to address and manage the condition. This cross-sectional study will contribute to enrich the limited pool of data we have in Pakistan concerning the prevalence, awareness, and impact of lateral epicondylitis. Additionally, the study aims to raise awareness among women about the significance of this condition, empowering them to manage their work and implement preventive measures effectively. 2. METHODS 2.1. Study design and setting This study utilized a cross-sectional design and involved 150 housewives. The sample size was determined using Epitool with a 95% confidence interval, resulting in a calculated sample size of 150. Convenient sampling was employed to collect the sample. Participants were selected from 3 different location i.e. Kamahan , and Chungi Amar Saddu, Thoka r in Lahore, Pakistan. All participants were admitted only after signing an informed consent form linked to the questionnaire. This study was approved by Ethical Review Board. 2.2. Data measurement and variable The Patient-Rated Tennis Elbow Evaluation (PTREE) questionnaire used for the evaluation of tennis elbow, comprises 15 questions: the first five concerning the pain in the elbow, and the remaining 10 questions concerning the function of the elbow. The survey was filled out in person by reaching out to the housewives, and some were shared online using Google Forms (via WhatsApp) to gather maximum responses. The patient consent form and questionnaire are presented in “Supplementary files.” 2.3. Participants selection criteria The study included housewives aged 25–50, excluding elderly housewives, those with elbow fractures, rheumatoid arthritis, cubital tunnel syndrome (CBTS), thoracic outlet syndrome, or a history of corticosteroid use. Housewives experiencing lateral epicondylitis for less than 6 months were included. The responses were gathered from March 2022 to August 2022. 2.4. Statistical methods Data analysis was conducted using IBM SPSS Statistics version 25. Descriptive statistics such as mean, median, mode, standard deviation, frequency, and percentage were calculated for age, gender, height, and weight. Pearson's chi-square test was applied to determine the prevalence of tennis elbow among housewives. A significance level of p < 0.05 was considered statistically significant in the analysis. 3. RESULTS 3.1. Participant demographics This study involved 150 housewives aged 25–50. The data reveals that the highest percentage of participants falls within the age range of 25–30, accounting for 36%, followed by the 45–50 age group at 22.6%. In contrast, the participation rates are lower in other age groups, with 30-35-year-olds making up 14%, 35-40-year-olds at 14.6%, and only 12% from the 40–45 age group in the entire population. ( Table 1 ) displays demographic information about the housewife participants. Table 1 Descriptive statistics of demographic characteristics of participants Variable Years Frequency (N) Percentage (%) Age 25–30 30–35 35–40 40–45 45–50 55 21 22 18 34 36% 14% 14.6% 12% 22.6% Gender Female 150 100% 3.2. Outcomes Prevalence of pain among housewives with lateral epicondylitis We found that the majority of housewives with lateral epicondylitis had pain in their right elbow 48% (72 out of 150). While 20% (30 of 150) housewives experienced pain in the left elbow, and only 26% (29 of 150) had pain in both elbows. This data highlights the high prevalence of right elbow pain among housewives with lateral epicondylitis ( Fig. 1 ) Severity of lateral epicondylitis pain among housewives We found that about 43% (65 of 150) housewives reported moderate pain, 30% (45 of 150) experienced mild pain, while 17.3% (26 of 150) reported severe pain, and only 14 pain-free. This data sheds light on the pain experiences of housewives, with a notable portion facing moderate pain levels. ( Fig. 2 ) Functional disability with specific and usual activities We found a high prevalence of pain and functional disability experienced by housewives in various activities like turning doorknobs, carrying bags, and more. We found that 30.7% (46 of 150) individuals, faced challenges in specific tasks, 26% (39 of 150) encountered difficulties in usual activities, while 43.3% (65 of 150) reported no issues. These stats show how pain and disability affect daily life, stressing the need for personalized support to boost well-being and independence. ( Fig. 3 ) 4. DISCUSSION Lateral epicondylitis (tennis elbow) pain is the major problem to visit the clinical specialist. Tennis is a painful, unpleasant condition that affects young, physically active individuals with sedentary lifestyles. Tennis elbow affects 1%-3% of the world population. And it counts 40–50% of tennis players.[ 7 ] Lateral epicondylitis pain is characterized by pain, inflammation, and local tenderness over the bony prominence of the lateral epicondyle and is exacerbated under stressful and repetitive movements. Some activities like prolonged supination and pronation movements, and twisting and rolling activities of the hand can interrupt the normal routine of the forearm. The cause of tennis elbow is somehow clear with a multi-factorial nature and develops secondary to functional and structural mal-alignment of the elbow joint. It has been documented that a degenerative process is the underlying cause of the condition of LE, not inflammation. Nirschl and Pettrone pathologically demonstrated that LE is a chronic enthesopathy triggered by repetitive small injuries at the ECRB’s origin.[ 8 ] Moreover, in cadaveric studies, it was observed that degeneration at the origin of the Extensor Carpi Radialis Brevis (ECRB) worsens with age. This finding suggests a possible explanation for the higher prevalence of Lateral Epicondylitis (tennis elbow) in middle-aged and elderly individuals compared to younger population. Management of tennis elbow is somehow clear with the multiple therapeutic effects but still challenging in some patients.[ 9 ] A sum of our cross-sectional study had the overall high incidence in women especially housewives as they work remotely, frequently in their homes, even after adjusting pain and tenderness during rest. As an epidemiological study was observed indicating that the majority of patients arrested with tennis elbow were housewives. [ 10 ] This finding is consistent with the previous cross-sectional study which was conducted for the determination of most common repetitive stress injuries among housewives. [ 1 ] That shows tennis elbow is the major RSI that the housewife faces. However, many studies investigated its incidence among tennis players, cooks, neurosurgeons, wheelchair users, and also in military people. Further prospective studies are needed to confirm the cause and risk factor of tennis elbow in housewives and its consequence on their health and quality of life.[ 7 ] This cross-sectional study was conducted to explore the sociodemographic and clinical profiles of patients with lateral epicondylitis. The PTREE questionnaire was used in this study. Sixty participants were included, and the majority of the patients with LE were aged 20–40 years. All participants had positive results, which showed the incidence of lateral epicondylitis with pain, swelling (13.3%), joint temperature (8.3%), and tenderness (95%).[ 11 ] Another study was similar to our study in which two groups were included. One of the men and the other of women. Incidence rates (IR) and rate ratios (RR) among various demographic groups were determined using multivariate Poisson regression. There were 2.98 and 0.82 cases of lateral and medial epicondylitis per 1,000 people per year, respectively. It was noticed that females were at great risk of getting lateral epicondylitis but not medial epicondylitis.[ 12 ] Furthermore, another study was carried out for the diagnosis and current management of tennis elbow 97 patients of age 41–50 years suffering from tennis elbow were included. It was seen that housewives (32%) were mostly affected. Pharmacological and non-pharmacological treatments were applied. It was found that one of the treatments is efficient for long-term management of LE. [ 4 ] Limitations The current investigation faced certain limitations. Firstly, it employed a cross-sectional design, which may not yield definitive insights into causal relationships. Secondly, although the diagnosis of lateral epicondylitis (LE) was based on a Patient-Rated Tennis Elbow Evaluation (PRTEE), other physiological and radiological assessments were omitted. Furthermore, the study did not explore the impact of workload on LE. We also didn't balance the groups to study the link between age and tennis elbow pain, focusing on housewives' percentage of LE. Our results were limited by the age range of 25–50 years; different age groups may show varying tennis elbow pain patterns. Lastly, the lack of prior studies on housewives was a limitation for my research. Conclusion We found that a significant portion (86%) of participants reported some level of pain using the PRTEE questionnaire, with 17% experiencing severe pain. The most commonly affected body part was the arm, and pain severity impacted daily activities for over half the participants. These findings suggest a high prevalence of lateral epicondylitis among housewives in Lahore. Further research with larger sample sizes is warranted to confirm these results. Abbreviations PRTEE Patient rated tennis elbow evaluation TE Tennis elbow LE Lateral epicondylitis RSI Repetitive stress injuries CT Computed tomography MRI Magnetic resonance imaging ECRB Extensor carpi radialis brevis TENS Transcutaneous electrical nerve stimulation NSAID non-steroidal anti-inflammatory drug ME Medial epicondylitis Declarations Ethics approval and consent to participate The study protocol was approved by the Ethical Review Board of Govt. College University Faisalabad, Pakistan. The study was conducted in accordance with the principles of the Declaration of Helsinki. A written consent form was signed by each participant. ( Supplementary files ) Consent for publication A written informed consent was obtained from each patient for publication of the data. Availability of data and material The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available. Competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding The authors received no funding. Guarantor H.A. Authors' contributions H.A : Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing. S.A: Data curation, Formal analysis, Writing – original draft, Writing – review & editing. M.N.S: Writing – original draft, Writing – review & editing. Acknowledgements We are grateful to Ms. Nadia Bashir, Ms. Kainaat Shoukat and Ms. Widiya Yonus, for their invaluable guidance and support. We also extend thanks Mr. and Mrs. Akbar Ali, Fahad Akbar and Abdul Ahad. References Rasel AH. Functional Outcome of Lateral Epicondylitis Patients After Physiotherapy Interventions-A Pretest & Posttest Study From Bangladesh. J Adv Sport Phys Edu. 2021;4:193–7. Abbas S, Riaz R, Khan A, Javed A, Raza S. Effects of mulligan and cyriax approach in patients with subacute lateral epicondylitis: Soi: 21-2017/re-trjvol03iss02p107. Rehabil J. 2019;3:107–15. Dhakal S, Acharya T, Gautam S, Upadhyay N, Dhakal S. Diagnosis and management pattern of lateral epicondylitis in a tertiary care center. Age. 2015;29:34. Afzal M, Zakaullah S, Memon SI, Nisar A, Touqeer H, Shabir H. Prevalence and risk factors of lateral epicondylitis among restaurant cooks at district Gujranwala: A cross-sectional study. Rawal Med J. 2021;46:338–338. Ahmed A, Ibrar M, Arsh A, Wali S, Hayat S, Abass S. Comparing the effectiveness of Mulligan mobilization versus Cyriax approach in the management of patients with subacute lateral epicondylitis. J Pak Med Assoc. 2021;71:12–12. Cutts S, Gangoo S, Modi N, Pasapula C. Tennis elbow: A clinical review article. J Orthop. 2020;17:203–7. Keijsers R, de Vos R-J, Kuijer PPF, van den Bekerom MP, van der Woude H-J, Eygendaal D. Tennis elbow. Shoulder Elb. 2019;11:384–92. Mukhtar T, Bashir MS, Noor R. Prevalence of Lateral Epicondylitis Among Computer Users n.d. Polat O, Tuncer C, Kati YA, Uckun OM, Er U. Investigation of lateral epicondylitis in neurosurgeons. Turk Neurosurg. 2019;29:414–9. Kitai E, Itay S, Ruder A, Engel J, Modan M. An epidemiological study of lateral epicondylitis (tennis elbow) in amateur male players. Ann Chir Main Organe Off Soc Chir Main. 1986;5:113–21. https://doi.org/10.1016/s0753-9053(86)80023-0 . Bazancir Z, Fırat T. A potential factor in the pathophysiology of lateral epicondylitis: The long sarcomere length of the extensor carpi radialis brevis muscle and implications for physiotherapy. Med Hypotheses. 2019;130:109278. https://doi.org/10.1016/j.mehy.2019.109278 . Tajika T, Kobayashi T, Yamamoto A, Kaneko T, Takagishi K. Prevalence and Risk Factors of Lateral Epicondylitis in a Mountain Village in Japan. J Orthop Surg. 2014;22:240–3. https://doi.org/10.1177/230949901402200227 . Additional Declarations No competing interests reported. Supplementary Files Supplementaryfiles.docx Cite Share Download PDF Status: Published Journal Publication published 15 Oct, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 12 Aug, 2024 Reviews received at journal 11 Aug, 2024 Reviews received at journal 06 Aug, 2024 Reviews received at journal 01 Aug, 2024 Reviews received at journal 31 Jul, 2024 Reviewers agreed at journal 31 Jul, 2024 Reviewers agreed at journal 27 Jul, 2024 Reviewers agreed at journal 25 Jul, 2024 Reviewers agreed at journal 24 Jul, 2024 Reviewers invited by journal 24 Jul, 2024 Editor assigned by journal 18 Jul, 2024 Submission checks completed at journal 18 Jul, 2024 First submitted to journal 15 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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BACKGROUND","content":"\u003cp\u003eLateral epicondylitis, which is also known as tennis elbow, lateral epicondylalgia, and calcareous tendinitis, is an unpleasant painful condition caused by repetitive strain on the forearm extensor tendons, leading to pain and tenderness on the outer elbow [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Lateral epicondylitis (LE) is a very prevalent condition affecting 1.6\u0026ndash;23.1% of workers who engage in repetitive upper-limb activities. The prevalence of tennis elbow in tennis players ranges from 40 to 50%, although it is less common in general and only affects 1.3 percent of the population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is more common is middle to old age (35\u0026ndash;55 years) women.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLack of rest, repetitive wrist and elbow movements, high handgrip force activities, vibrating tools, heavy lifting, diabetes, soft tissue issues, and psychological factors like depression can increase the risk of tennis elbow. (7) Carpenters, teachers, housewives, shopkeepers, cooks, and painters are at risk of LE. In housewives, it is mostly due to their work routine, which includes frequent pronation or supination movements, repetitive stress, workload, and pin-rolling activities. Washing of clothes and cooking is also a major cause of having lateral epicondylitis.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLimited evidence backs a single effective treatment for LE patients. LE treatments range from NSAIDs, physiotherapy, corticosteroids, PRP, operative treatment, Mulligan and Cyriax techniques, and non-pharmacological options such lifestyle changes, elbow bands, heat, etc.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Only 30% of all patients with LE refer to physiotherapy.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Physical therapy is essential for treating lateral epicondylitis in individuals who use their elbow, wrist, or hand extensively. It aids in muscle healing, and pain reduction, and enhances recovery for those with tennis elbow. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThere was plenty of literature on pathology, risk factors, prevalence, and treatment, but there was little on tennis elbow awareness and prevalence in housewives. If it persists, it can significantly affect their daily activities. The continuous pain, limited arm mobility, and difficulty in performing tasks can lead to decreased quality of life. It may hinder work, household chores, and recreational activities, impacting overall well-being. Timely treatment and proper management strategies are crucial to alleviate symptoms and prevent further complications. Persistent lateral epicondylitis can not only cause physical discomfort but also emotional distress due to the limitations it imposes on daily life. It is essential to address and manage the condition.\u003c/p\u003e \u003cp\u003eThis cross-sectional study will contribute to enrich the limited pool of data we have in Pakistan concerning the prevalence, awareness, and impact of lateral epicondylitis. Additionally, the study aims to raise awareness among women about the significance of this condition, empowering them to manage their work and implement preventive measures effectively.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design and setting\u003c/h2\u003e \u003cp\u003eThis study utilized a cross-sectional design and involved 150 housewives. The sample size was determined using \u003cem\u003eEpitool\u003c/em\u003e with a 95% confidence interval, resulting in a calculated sample size of 150. Convenient sampling was employed to collect the sample. Participants were selected from 3 different location i.e. \u003cem\u003eKamahan\u003c/em\u003e, and \u003cem\u003eChungi Amar Saddu, Thoka\u003c/em\u003er in Lahore, Pakistan. All participants were admitted only after signing an informed consent form linked to the questionnaire.\u003c/p\u003e \u003cp\u003e This study was approved by Ethical Review Board.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Data measurement and variable\u003c/h2\u003e \u003cp\u003eThe Patient-Rated Tennis Elbow Evaluation (PTREE) questionnaire used for the evaluation of tennis elbow, comprises 15 questions: the first five concerning the pain in the elbow, and the remaining 10 questions concerning the function of the elbow. The survey was filled out in person by reaching out to the housewives, and some were shared online using Google Forms (via WhatsApp) to gather maximum responses. The patient consent form and questionnaire are presented in \u003cb\u003e\u0026ldquo;Supplementary files.\u0026rdquo;\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Participants selection criteria\u003c/h2\u003e \u003cp\u003eThe study included housewives aged 25\u0026ndash;50, excluding elderly housewives, those with elbow fractures, rheumatoid arthritis, cubital tunnel syndrome (CBTS), thoracic outlet syndrome, or a history of corticosteroid use. Housewives experiencing lateral epicondylitis for less than 6 months were included. The responses were gathered from March 2022 to August 2022.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Statistical methods\u003c/h2\u003e \u003cp\u003eData analysis was conducted using IBM SPSS Statistics version 25. Descriptive statistics such as mean, median, mode, standard deviation, frequency, and percentage were calculated for age, gender, height, and weight. Pearson's chi-square test was applied to determine the prevalence of tennis elbow among housewives. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant in the analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Participant demographics\u003c/h2\u003e \u003cp\u003eThis study involved 150 housewives aged 25\u0026ndash;50. The data reveals that the highest percentage of participants falls within the age range of 25\u0026ndash;30, accounting for 36%, followed by the 45\u0026ndash;50 age group at 22.6%. In contrast, the participation rates are lower in other age groups, with 30-35-year-olds making up 14%, 35-40-year-olds at 14.6%, and only 12% from the 40\u0026ndash;45 age group in the entire population. \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e displays demographic information about the housewife participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of demographic characteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYears\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (N)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;30\u003c/p\u003e \u003cp\u003e30\u0026ndash;35\u003c/p\u003e \u003cp\u003e35\u0026ndash;40\u003c/p\u003e \u003cp\u003e40\u0026ndash;45\u003c/p\u003e \u003cp\u003e45\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e22\u003c/p\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36%\u003c/p\u003e \u003cp\u003e14%\u003c/p\u003e \u003cp\u003e14.6%\u003c/p\u003e \u003cp\u003e12%\u003c/p\u003e \u003cp\u003e22.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Outcomes\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePrevalence of pain among housewives with lateral epicondylitis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe found that the majority of housewives with lateral epicondylitis had pain in their right elbow 48% (72 out of 150). While 20% (30 of 150) housewives experienced pain in the left elbow, and only 26% (29 of 150) had pain in both elbows. This data highlights the high prevalence of right elbow pain among housewives with lateral epicondylitis \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSeverity of lateral epicondylitis pain among housewives\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe found that about 43% (65 of 150) housewives reported moderate pain, 30% (45 of 150) experienced mild pain, while 17.3% (26 of 150) reported severe pain, and only 14 pain-free. This data sheds light on the pain experiences of housewives, with a notable portion facing moderate pain levels. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eFunctional disability with specific and usual activities\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe found a high prevalence of pain and functional disability experienced by housewives in various activities like turning doorknobs, carrying bags, and more. We found that 30.7% (46 of 150) individuals, faced challenges in specific tasks, 26% (39 of 150) encountered difficulties in usual activities, while 43.3% (65 of 150) reported no issues. These stats show how pain and disability affect daily life, stressing the need for personalized support to boost well-being and independence. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eLateral epicondylitis (tennis elbow) pain is the major problem to visit the clinical specialist. Tennis is a painful, unpleasant condition that affects young, physically active individuals with sedentary lifestyles. Tennis elbow affects 1%-3% of the world population. And it counts 40\u0026ndash;50% of tennis players.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLateral epicondylitis pain is characterized by pain, inflammation, and local tenderness over the bony prominence of the lateral epicondyle and is exacerbated under stressful and repetitive movements. Some activities like prolonged supination and pronation movements, and twisting and rolling activities of the hand can interrupt the normal routine of the forearm. The cause of tennis elbow is somehow clear with a multi-factorial nature and develops secondary to functional and structural mal-alignment of the elbow joint. It has been documented that a degenerative process is the underlying cause of the condition of LE, not inflammation. Nirschl and Pettrone pathologically demonstrated that LE is a chronic enthesopathy triggered by repetitive small injuries at the ECRB\u0026rsquo;s origin.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Moreover, in cadaveric studies, it was observed that degeneration at the origin of the Extensor Carpi Radialis Brevis (ECRB) worsens with age. This finding suggests a possible explanation for the higher prevalence of Lateral Epicondylitis (tennis elbow) in middle-aged and elderly individuals compared to younger population. Management of tennis elbow is somehow clear with the multiple therapeutic effects but still challenging in some patients.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eA sum of our cross-sectional study had the overall high incidence in women especially housewives as they work remotely, frequently in their homes, even after adjusting pain and tenderness during rest.\u003c/p\u003e \u003cp\u003eAs an epidemiological study was observed indicating that the majority of patients arrested with tennis elbow were housewives. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] This finding is consistent with the previous cross-sectional study which was conducted for the determination of most common repetitive stress injuries among housewives. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] That shows tennis elbow is the major RSI that the housewife faces. However, many studies investigated its incidence among tennis players, cooks, neurosurgeons, wheelchair users, and also in military people. Further prospective studies are needed to confirm the cause and risk factor of tennis elbow in housewives and its consequence on their health and quality of life.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis cross-sectional study was conducted to explore the sociodemographic and clinical profiles of patients with lateral epicondylitis. The PTREE questionnaire was used in this study. Sixty participants were included, and the majority of the patients with LE were aged 20\u0026ndash;40 years. All participants had positive results, which showed the incidence of lateral epicondylitis with pain, swelling (13.3%), joint temperature (8.3%), and tenderness (95%).[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAnother study was similar to our study in which two groups were included. One of the men and the other of women. Incidence rates (IR) and rate ratios (RR) among various demographic groups were determined using multivariate Poisson regression. There were 2.98 and 0.82 cases of lateral and medial epicondylitis per 1,000 people per year, respectively. It was noticed that females were at great risk of getting lateral epicondylitis but not medial epicondylitis.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFurthermore, another study was carried out for the diagnosis and current management of tennis elbow 97 patients of age 41\u0026ndash;50 years suffering from tennis elbow were included. It was seen that housewives (32%) were mostly affected. Pharmacological and non-pharmacological treatments were applied. It was found that one of the treatments is efficient for long-term management of LE. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe current investigation faced certain limitations. Firstly, it employed a cross-sectional design, which may not yield definitive insights into causal relationships. Secondly, although the diagnosis of lateral epicondylitis (LE) was based on a Patient-Rated Tennis Elbow Evaluation (PRTEE), other physiological and radiological assessments were omitted. Furthermore, the study did not explore the impact of workload on LE. We also didn't balance the groups to study the link between age and tennis elbow pain, focusing on housewives' percentage of LE. Our results were limited by the age range of 25\u0026ndash;50 years; different age groups may show varying tennis elbow pain patterns. Lastly, the lack of prior studies on housewives was a limitation for my research.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eWe found that a significant portion (86%) of participants reported some level of pain using the PRTEE questionnaire, with 17% experiencing severe pain. The most commonly affected body part was the arm, and pain severity impacted daily activities for over half the participants. These findings suggest a high prevalence of lateral epicondylitis among housewives in Lahore. Further research with larger sample sizes is warranted to confirm these results.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePRTEE Patient rated tennis elbow evaluation\u003c/p\u003e \u003cp\u003eTE Tennis elbow\u003c/p\u003e \u003cp\u003eLE Lateral epicondylitis\u003c/p\u003e \u003cp\u003eRSI Repetitive stress injuries\u003c/p\u003e \u003cp\u003eCT Computed tomography\u003c/p\u003e \u003cp\u003eMRI Magnetic resonance imaging\u003c/p\u003e \u003cp\u003eECRB Extensor carpi radialis brevis\u003c/p\u003e \u003cp\u003eTENS Transcutaneous electrical nerve stimulation\u003c/p\u003e \u003cp\u003eNSAID non-steroidal anti-inflammatory drug\u003c/p\u003e \u003cp\u003eME Medial epicondylitis\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethical Review Board of Govt. College University Faisalabad, Pakistan. The study was conducted in accordance with the principles of the Declaration of Helsinki. A written consent form was signed by each participant. (\u003cstrong\u003eSupplementary files\u003c/strong\u003e)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA written informed consent was obtained from each patient for publication of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuarantor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH.A.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eH.A\u003c/strong\u003e: Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eS.A:\u0026nbsp;\u003c/strong\u003eData curation, Formal analysis, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eM.N.S:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to Ms. Nadia Bashir, Ms. Kainaat Shoukat and Ms. Widiya Yonus, for their invaluable guidance and support. We also extend thanks Mr. and Mrs. Akbar Ali, Fahad Akbar and Abdul Ahad.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRasel AH. Functional Outcome of Lateral Epicondylitis Patients After Physiotherapy Interventions-A Pretest \u0026amp; Posttest Study From Bangladesh. J Adv Sport Phys Edu. 2021;4:193\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbbas S, Riaz R, Khan A, Javed A, Raza S. Effects of mulligan and cyriax approach in patients with subacute lateral epicondylitis: Soi: 21-2017/re-trjvol03iss02p107. Rehabil J. 2019;3:107\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhakal S, Acharya T, Gautam S, Upadhyay N, Dhakal S. Diagnosis and management pattern of lateral epicondylitis in a tertiary care center. Age. 2015;29:34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfzal M, Zakaullah S, Memon SI, Nisar A, Touqeer H, Shabir H. Prevalence and risk factors of lateral epicondylitis among restaurant cooks at district Gujranwala: A cross-sectional study. Rawal Med J. 2021;46:338\u0026ndash;338.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed A, Ibrar M, Arsh A, Wali S, Hayat S, Abass S. Comparing the effectiveness of Mulligan mobilization versus Cyriax approach in the management of patients with subacute lateral epicondylitis. J Pak Med Assoc. 2021;71:12\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCutts S, Gangoo S, Modi N, Pasapula C. Tennis elbow: A clinical review article. J Orthop. 2020;17:203\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeijsers R, de Vos R-J, Kuijer PPF, van den Bekerom MP, van der Woude H-J, Eygendaal D. Tennis elbow. Shoulder Elb. 2019;11:384\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukhtar T, Bashir MS, Noor R. Prevalence of Lateral Epicondylitis Among Computer Users n.d.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePolat O, Tuncer C, Kati YA, Uckun OM, Er U. Investigation of lateral epicondylitis in neurosurgeons. Turk Neurosurg. 2019;29:414\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKitai E, Itay S, Ruder A, Engel J, Modan M. An epidemiological study of lateral epicondylitis (tennis elbow) in amateur male players. Ann Chir Main Organe Off Soc Chir Main. 1986;5:113\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0753-9053(86)80023-0\u003c/span\u003e\u003cspan address=\"10.1016/s0753-9053(86)80023-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBazancir Z, Fırat T. A potential factor in the pathophysiology of lateral epicondylitis: The long sarcomere length of the extensor carpi radialis brevis muscle and implications for physiotherapy. Med Hypotheses. 2019;130:109278. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.mehy.2019.109278\u003c/span\u003e\u003cspan address=\"10.1016/j.mehy.2019.109278\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTajika T, Kobayashi T, Yamamoto A, Kaneko T, Takagishi K. Prevalence and Risk Factors of Lateral Epicondylitis in a Mountain Village in Japan. J Orthop Surg. 2014;22:240\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/230949901402200227\u003c/span\u003e\u003cspan address=\"10.1177/230949901402200227\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cross-sectional study, epicondylitis, Tennis elbow, elbow pain, repetitive stress","lastPublishedDoi":"10.21203/rs.3.rs-4744814/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4744814/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLateral epicondylitis (LE) is characterized by pain, inflammation and local tenderness over the bony prominence of lateral epicondyle and is exacerbated under stressful and repetitive movements such as prolonged supination and pronation movements, twisting and rolling activities. Lateral Epicondylitis ranks as the second most commonly diagnosed musculoskeletal condition. Females, especially housewives, are more affected by LE. It can lead to persistent elbow pain, reduced grip strength, limited arm movement, and difficulty performing daily tasks\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e All of our 150 participants were women aged 25\u0026ndash;50 years. We found that 17% (26 of 150) housewives have severe type of pain, 43% (65 of 150) have moderate pain, 30% (45 of 150) have mild pain, 9% (14 of 150) reported no pain at all according to PRTEE questionnaire. We also found that most affected part of body by pain was arm (68%) (102 of 150) while 26% (39 of 150) reported pain in both arms. Only 30.7% of women (46 of 150) reported functional limitations during specific activities, 26% (29 of 150) during usual activities, while the remaining 43.3% (65 of 150) were pain-free.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe found a high prevalence of patient-reported lateral epicondylitis among housewives with arms affected by pain most hindering functional mobility of body. Robust studies with larger sample size are needed to establish conclusive evidence.\u003c/p\u003e","manuscriptTitle":"Prevalence of Lateral Epicondylitis among Housewives in Lahore: A Cross-sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-17 02:28:28","doi":"10.21203/rs.3.rs-4744814/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-12T10:35:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-11T10:37:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-06T09:00:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-02T01:48:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-31T14:00:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7479744325765005474937306296508423664","date":"2024-07-31T10:41:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110907095959351771862701069297811958365","date":"2024-07-27T05:25:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146754139738055289386958964123788340742","date":"2024-07-25T14:15:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282954172247518685327144790288127459407","date":"2024-07-24T23:31:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-24T20:52:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-18T11:17:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-18T11:16:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-07-15T18:29:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab430356-9030-4c7b-921d-ef4222e05c62","owner":[],"postedDate":"August 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:08:26+00:00","versionOfRecord":{"articleIdentity":"rs-4744814","link":"https://doi.org/10.1186/s12891-024-07889-x","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2024-10-15 15:57:48","publishedOnDateReadable":"October 15th, 2024"},"versionCreatedAt":"2024-08-17 02:28:28","video":"","vorDoi":"10.1186/s12891-024-07889-x","vorDoiUrl":"https://doi.org/10.1186/s12891-024-07889-x","workflowStages":[]},"version":"v1","identity":"rs-4744814","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4744814","identity":"rs-4744814","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}