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Merkel MFR, Hellsten Y, Magnusson SP, Kjaer M. Tendon blood flow, angiogenesis, and tendinopathy pathogenesis. TRANSLATIONAL SPORTS MEDICINE 2021. [DOI: 10.1002/tsm2.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Max Flemming Ravn Merkel
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Stig Peter Magnusson
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Center for Healthy Aging Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Center for Healthy Aging Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Bayat M, Raeissadat SA, Mortazavian Babaki M, Rahimi-Dehgolan S. Is Dextrose Prolotherapy Superior To Corticosteroid Injection In Patients With Chronic Lateral Epicondylitis?: A Randomized Clinical Trial. Orthop Res Rev 2019; 11:167-175. [PMID: 31819675 PMCID: PMC6847986 DOI: 10.2147/orr.s218698] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/08/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare the efficacy of dextrose prolotherapy versus steroid injection in the treatment of patients with chronic lateral epicondylitis. Methods Thirty subjects with chronic lateral epicondylitis were randomly assigned into two groups of hypertonic dextrose or methylprednisolone injection. Participants were assessed through Quick DASH and VAS scores, once before injection, and then after 1- and 3-months follow-up. Two patients were excluded due to not completing the follow-up timepoints. Results In both groups VAS scores revealed significant improvement during the first month follow-up [mean difference (MD) = 1.9±3.3, versus 1.5±1.9 for the prolotherapy and steroid groups, respectively]. This declining trajectory continued at the third month visit in the prolotherapy group and MD reached 4.4±2.9, while it did not change remarkably in the steroid group (MD=1.9±3.4). In fact, comparing VAS scores between the 1st- and 3rd-month time points did not reveal a significant improvement in the steroid group (p=0.6). Also, the Quick DASH index showed a similar pattern and improved remarkably in both groups during the first visit. However, only the efficacy in the prolotherapy group persisted after 3-month follow-up (MD = 9.5±21.6, p=0.044). One month after injections no preference between the two interventions was observed (p=0.74 for VAS and 0.14 for Quick DASH score). However, the 3rd-month follow-up revealed a meaningful superiority (p=0.03 for VAS and p=0.01 for Quick DASH score) favoring the prolotherapy method. Conclusion Both methods were proven to be effective in the short-term treatment of chronic lateral epicondylitis, but dextrose prolotherapy seems to be slightly more efficacious than steroid injection over a longer period.Clinical trial registration: Iranian Registry of Clinical Trials Database: IRCT20170311033000N3.
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Affiliation(s)
- Masume Bayat
- Physical Medicine and Rehabilitation Department of Mahdiyeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Raeissadat
- Clinical Development Research Center of Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Mortazavian Babaki
- Physical Medicine and Rehabilitation Department & Research Center, Shohada-E-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahram Rahimi-Dehgolan
- Physical Medicine and Rehabilitation Department of Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Keijsers R, Kuijer PPFM, Koenraadt KLM, van den Bekerom MPJ, Gerritsma-Bleeker CLE, Beumer A, Frings-Dresen MHW, Eygendaal D. Effectiveness of standardized ultrasound guided percutaneous treatment of lateral epicondylitis with application of autologous blood, dextrose or perforation only on pain: a study protocol for a multi-center, blinded, randomized controlled trial with a 1 year follow up. BMC Musculoskelet Disord 2019; 20:351. [PMID: 31366332 PMCID: PMC6668105 DOI: 10.1186/s12891-019-2711-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 07/09/2019] [Indexed: 11/25/2022] Open
Abstract
Background In the treatment of Lateral Epicondylitis (LE) no single intervention concerning injection therapies has been proven to be the most effective with regard to pain reduction. In this trial 3 injection therapies (perforation with application of autologous blood, perforation with application of dextrose and perforation only) will be compared in a standardized and ultrasound guided way. The objective is to assess the effectiveness of these 3 injection therapies on pain, quality of life and functional recovery. By conducting this study, we hope to make a statement on the effectiveness of injection therapy in the treatment of LE. Hereby, unnecessary treatments can be avoided, a more universal method of treatment can be established and the quality of the treatment can be improved. Methods/design A multicenter, randomized controlled trial with a superiority design and 12 months follow-up will be conducted in four Dutch hospitals. One hundred sixty five patients will be recruited in the age of 18 to 65 years, with chronic symptomatic lateral epicondylitis lasting longer than 6 weeks, which have concordant pain during physical examination. Patients will be randomized by block randomization to one of the three treatment arms. The treatment will be blinded for patients and outcome assessors. The following three injection therapies are compared: perforation with application of autologous blood, perforation with application of dextrose and perforation only. Injections will be performed ultrasound guided in a standardized and automated way. The primary endpoint is: pain (change in ‘Visual Analogue Scale’). Secondary endpoints are quality of life and functional recovery. These measurements are collected at baseline, 8 weeks, 5 months and 1 year after treatment. Discussion When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. In current literature proper comparison of the effectiveness of injectables for LE is questionable, due to the lack of standardization of the treatment. This study will overcome bias due to manually performed injection therapy. Trial registration This study is registered in the Trial Register (www.trialregister.nl) of the Dutch Cochrane centre. Trial ID; NTR4569. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4569
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Affiliation(s)
- Renée Keijsers
- Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, P.O. Box 90158, 4800, RK, Breda, The Netherlands. .,Department of Orthopaedic Surgery, Amsterdam University Medical Centers, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands.
| | - P Paul F M Kuijer
- Amsterdam University Medical Centers, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Koen L M Koenraadt
- Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, P.O. Box 90158, 4800, RK, Breda, The Netherlands
| | - Michel P J van den Bekerom
- Department of Orthopaedic Surgery, O.L.V.G, Oosterpark 9, P.O. Box 95500, 1090, HM, Amsterdam, The Netherlands
| | | | - Annechien Beumer
- Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, P.O. Box 90158, 4800, RK, Breda, The Netherlands.,Amsterdam University Medical Centers, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Monique H W Frings-Dresen
- Amsterdam University Medical Centers, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, P.O. Box 90158, 4800, RK, Breda, The Netherlands.,Department of Orthopaedic Surgery, Amsterdam University Medical Centers, Meibergdreef 9, Amsterdam, AZ, 1105, The Netherlands
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Injection of tennis elbow: Hit and miss? A cadaveric study of injection accuracy. Knee Surg Sports Traumatol Arthrosc 2017; 25:2289-2292. [PMID: 27372804 DOI: 10.1007/s00167-016-4212-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 06/14/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Different injection therapies are used in the treatment of lateral epicondylitis (LE). Usually, the extensor carpi radialis brevis (ECRB) tendon is affected. Therefore, an injection should be aimed at the origin of this tendon. This study demonstrates the accuracy of manual injections in the treatment of LE. METHODS Ten surgeons have injected a cadaver elbow with acrylic paint, using the same injection technique (i.e. number of perforations, amount of injected fluid) that they in daily practice would use in the treatment of LE. After the injection, an arthroscopy and dissection of the elbow were performed. The injection technique and localization of acrylic paint were reported. RESULTS Only a third of the injections were (partially) localized in the ECRB tendon; 60 % were localized intra-articular. CONCLUSION Injections carried out manually for the treatment of LE are not accurate, resulting in the majority being localized intra-articular. For future research to the effect of injection therapy in the treatment of LE, it is important that injections should be performed in a reproducible and standardized way.
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Abstract
BACKGROUND Tendinopathies of the shoulder and elbow joint are a common problem. According to the current state of knowledge tendinopathies can be separated into acute and chronic tendinitis as well as degenerative tendinosis. ORIGIN The causes of tendinopathy can be intrinsic, extrinsic or a combination of both. A false straining or overuse with repetitive microtrauma is often the cause. Particularly affected are tendons of the rotator cuff, the long biceps tendons and lower arm extensors. TREATMENT Priority is given to conservative appproaches for these disease processes. Following appropriate diagnostics the pain can be reduced and function can be improved by specific training. When conservative treatment is unsuccessful and in the presence of certain indications, a surgical approach should be considered. In these cases a structural damage of the tendon often already exists, which could have resulted from the tendinopathy. The structural damage must be considered as a separate entity and differentiated from the tendinopathy.
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Affiliation(s)
- Nael Hawi
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Emmanouil Liodakis
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Maximilian Petri
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Christian Krettek
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Rupert Meller
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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Branson R, Naidu K, du Toit C, Rotstein AH, Kiss R, McMillan D, Fooks L, Coombes BK, Vicenzino B. Comparison of corticosteroid, autologous blood or sclerosant injections for chronic tennis elbow. J Sci Med Sport 2017; 20:528-533. [PMID: 28089102 DOI: 10.1016/j.jsams.2016.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 09/26/2016] [Accepted: 10/21/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To compare three different ultrasound-guided injections for chronic tennis elbow. DESIGN Assessor-blinded, randomized controlled comparative trial. METHODS 44 patients with clinically diagnosed tennis elbow, confirmed by Doppler ultrasound, received under ultrasound guidance, a single corticosteroid injection (n=14), or two injections (separated by 4 weeks) of either autologous blood (n=14) or polidocanol (n=16). Clinical and ultrasound examination was performed at baseline, 4, 12 and 26 weeks. RESULTS Complete recovery or much improvement was greater for corticosteroid injection than autologous blood and polidocanol at 4 weeks (p<0.001, number needed to treat 1 (95% CI 1-2)). In contrast, at 26 weeks corticosteroid was significantly worse than polidocanol (p=0.004, number needed to harm 2 (1-6)). Recurrence after corticosteroid injection was significantly higher than autologous blood or polidocanol (p=0.007, number needed to harm 2 (1-4)). Corticosteroid injection produced greater reduction in tendon thickness and vascularity than autologous blood at 4 weeks only. Compared to autologous blood, polidocanol reduced tendon thickness at 4 and 12 weeks and reduced echogenicity and hyperaemia after 12 or 26 weeks respectively. CONCLUSIONS Injections of corticosteroid cannot be recommended over polidocanol or autologous blood, because despite beneficial short-term effect there were inferior long-term effects. Whether polidocanol or autologous blood injections are effective is unknown, especially as their global effect profiles are not unlike previously reported for wait-and-see.
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Affiliation(s)
- R Branson
- Olympic Park Sports Medicine Centre, Australia
| | - K Naidu
- Olympic Park Sports Medicine Centre, Australia
| | - C du Toit
- Olympic Park Sports Medicine Centre, Australia
| | - A H Rotstein
- Victoria House Medical Imaging, MIA Radiology, Australia
| | - R Kiss
- Victoria House Medical Imaging, MIA Radiology, Australia
| | - D McMillan
- Olympic Park Sports Medicine Centre, Australia
| | - L Fooks
- Olympic Park Sports Medicine Centre, Australia
| | - B K Coombes
- University of Queensland, School of Health and Rehabilitation Sciences, Physiotherapy, Australia; School of Biomedical Sciences, University of Queensland, Australia
| | - B Vicenzino
- School of Biomedical Sciences, University of Queensland, Australia.
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Claessen FMAP, Heesters BA, Chan JJ, Kachooei AR, Ring D. A Meta-Analysis of the Effect of Corticosteroid Injection for Enthesopathy of the Extensor Carpi Radialis Brevis Origin. J Hand Surg Am 2016; 41:988-998.e2. [PMID: 27546443 DOI: 10.1016/j.jhsa.2016.07.097] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/01/2016] [Accepted: 07/12/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The null hypothesis that there is no effect of corticosteroid injection on visual analog scale for pain in patients with enthesopathy of the extensor carpi radialis brevis (eECRB) origin 6 months after treatment was tested. Our secondary hypotheses were that there is no effect of corticosteroid injection on pain intensity at 1 and 3 months after treatment; that there is no effect of corticosteroid injection on grip strength at 1, 3, and 6 months after treatment; and that there is no effect of corticosteroid injection on Disabilities of the Arm, Shoulder, and Hand scores at 1, 3 and 6 months after treatment. METHODS EMBASE, PubMed Publisher, MEDLINE, OvidSP, Web of Science, Google Scholar, and the Cochrane Central were searched for relevant studies. Studies were eligible if there was (1) a description of corticosteroid injection treatment for eECRB; (2) randomized placebo injection-controlled trials with at least 10 adults included with eECRB; (3) a full-text article available with data describing the mean differences between the corticosteroid and the control groups and the outcome measures used; and (4) follow-up of at least 1 month. In total, 7 randomized controlled trials comparing the effect of corticosteroid injection with a placebo injection on symptoms of eECRB were included in our meta-analysis. RESULTS We found no difference in pain intensity 6 months after injection of corticosteroids or placebo. Pain intensity was slightly, but significantly, lower 1 month, but not 3 months, after steroid injection. There were no significant differences in grip strength or Disabilities of the Arm, Shoulder, and Hand score at any time point. CONCLUSIONS This meta-analysis showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection. We interpret the weight of evidence to date as suggesting that corticosteroid injections are neither meaningfully palliative nor disease modifying when used to treat eECRB. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.
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Affiliation(s)
- Femke M A P Claessen
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Balthasar A Heesters
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA
| | - Jimmy J Chan
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Amir Reza Kachooei
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - David Ring
- Department of Hand Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA.
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Abstract
High-resolution ultrasonography can help clinicians visualize key anatomic structures of the elbow and guide periarticular and intra-articular injections. Historically, most procedures done around the elbow have been done using landmark guidance, and few studies have reported the accuracy of ultrasonography-guided injections in the elbow region. This article reviews common musculoskeletal disorders about the elbow that can be evaluated with ultrasonography, reviews the literature on ultrasonography-guided injections of the elbow region, and describes the senior author's preferred approach for the most commonly performed elbow region injections.
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Affiliation(s)
- Walter I Sussman
- Department of Physical Medicine and Rehabilitation, Emory University, 1441 Clifton Road, NE Atlanta, GA 30322, USA; Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Christopher J Williams
- Department of Physical Medicine and Rehabilitation, Emory University, 1441 Clifton Road, NE Atlanta, GA 30322, USA
| | - Ken Mautner
- Department of Physical Medicine and Rehabilitation, Emory University, 1441 Clifton Road, NE Atlanta, GA 30322, USA; Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA.
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Intratendinous Injection of Hyaluronate Induces Acute Inflammation: A Possible Detrimental Effect. PLoS One 2016; 11:e0155424. [PMID: 27176485 PMCID: PMC4866702 DOI: 10.1371/journal.pone.0155424] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/28/2016] [Indexed: 11/19/2022] Open
Abstract
Hyaluronate (HA) is therapeutic for tendinopathy, but an intratendinous HA injection is usually painful; thus, it is not suggested for clinical practice. However, there are no studies on the histopathological changes after an intratendinous HA injection. We hypothesized that an HA injection would induce more-acute inflammation than that induced by an injection of phosphate buffered saline (PBS). Thirty-two rats were randomly divided into 4 post-injection groups (n = 8): day 3, day 7, day 28, and day 42. HA (0.1 c.c.) was, using ultrasound guidance, intratendinously injected into each left Achilles tendon, and PBS (0.1 c.c.) into each right one. For each group, both Achilles tendons of 3 control-group rats (n = 6) were given only needle punctures. The histopathological score, ED1+ and ED2+ macrophage densities, interleukin (IL)-1β expression, and the extent of neovascularization were evaluated. In both experimental groups, each Achilles tendon showed significant histopathological changes and inflammation compatible with acute tendon injury until day 42. The HA group showed more-significant (p < 0.05) histopathological changes, higher ED1+ and ED2+ macrophage density, and higher IL-1β expression than did the PBS group. The neovascularization area was also significantly (p < 0.05) greater in the HA group, except on day 3. Both HA and PBS induced acute tendon injury and inflammation, sequential histopathological changes, ED1+ and ED2+ macrophage accumulation, IL-1β expression, and neovascularization until post-injection day 42.HA induced more-severe injury than did PBS. Therefore, an intratendinous HA injection should be avoided.
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Kachooei AR, Talaei-Khoei M, Faghfouri A, Ring D. Factors associated with operative treatment of enthesopathy of the extensor carpi radialis brevis origin. J Shoulder Elbow Surg 2016; 25:666-70. [PMID: 26995457 DOI: 10.1016/j.jse.2015.12.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 12/16/2015] [Accepted: 12/25/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study investigated the factors associated with variation in the rate of surgery for enthesopathy of the extensor carpi radialis brevis (eECRB). METHODS We used a large database from 3 academic hospitals including 5964 patients with the diagnosis of eECRB from 2001 to 2007. Of those, 244 patients (4%) had surgery for eECRB. We used the date of the first encounter as the date of diagnosis. We also recorded the date of the first cortisone injection and surgery for eECRB. We used Cox multivariable regression analysis to find factors associated with surgery. We considered the following explanatory factors: age, sex, race, diabetes, a diagnosis of major depression, a diagnosis of an anxiety disorder, hospital, provider (surgeon vs. nonsurgeon), corticosteroid injection, and the time from diagnosis to the first cortisone injection. RESULTS The hazard ratio of having surgery was 12-times greater if the initial provider was an orthopedic surgeon rather a nonsurgeon and 1.7-times greater at 1 of the 2 hospitals. The rate of surgery varied substantially, ranging from 0% to 22%. Corticosteroid injection delayed the time to surgery but was ultimately associated with a higher rate of surgery. The majority (86%) of surgeries were done within 1 year of the first documented office visit. CONCLUSIONS It seems likely that an emphasis on the preferences and values of the patient rather than the surgeon would decrease the variation in surgery rates for eECRB observed in this study. Methods for optimizing the influence of patient preferences and values on decision making (eg, decision aids) merit additional study.
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Affiliation(s)
- Amir Reza Kachooei
- Orthopedic Hand and Upper Extremity Department, Massachusetts General Hospital, Harvard Medical School, Boston, USA; Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mojtaba Talaei-Khoei
- Orthopedic Hand and Upper Extremity Department, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Aram Faghfouri
- Orthopedic Hand and Upper Extremity Department, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - David Ring
- Orthopedic Hand and Upper Extremity Department, Massachusetts General Hospital, Harvard Medical School, Boston, USA; Comprehensive Care Dell Medical School University of Texas, Austin, TX, USA.
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Long L, Briscoe S, Cooper C, Hyde C, Crathorne L. What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations. Health Technol Assess 2015; 19:1-134. [PMID: 25629427 DOI: 10.3310/hta19080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Lateral elbow tendinopathy (LET) is a common complaint causing characteristic pain in the lateral elbow and upper forearm, and tenderness of the forearm extensor muscles. It is thought to be an overuse injury and can have a major impact on the patient's social and professional life. The condition is challenging to treat and prone to recurrent episodes. The average duration of a typical episode ranges from 6 to 24 months, with most (89%) reporting recovery by 1 year. OBJECTIVES This systematic review aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for LET. DATA SOURCES A comprehensive search was conducted from database inception to 2012 in a range of databases including MEDLINE, EMBASE and Cochrane Databases. METHODS AND OUTCOMES We conducted an overview of systematic reviews to summarise the current evidence concerning the clinical effectiveness and a systematic review for the cost-effectiveness of conservative interventions for LET. We identified additional randomised controlled trials (RCTs) that could contribute further evidence to existing systematic reviews. We searched MEDLINE, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Web of Science, The Cochrane Library and other important databases from inception to January 2013. RESULTS A total of 29 systematic reviews published since 2003 matched our inclusion criteria. These were quality appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist; five were considered high quality and evaluated using a Grading of Recommendations, Assessment, Development and Evaluation approach. A total of 36 RCTs were identified that were not included in a systematic review and 29 RCTs were identified that had only been evaluated in an included systematic review of intermediate/low quality. These were then mapped to existing systematic reviews where further evidence could provide updates. Two economic evaluations were identified. LIMITATIONS The summary of findings from the review was based only on high-quality evidence (scoring of > 5 AMSTAR). Other limitations were that identified RCTs were not quality appraised and dichotomous outcomes were also not considered. Economic evaluations took effectiveness estimates from trials that had small sample sizes leading to uncertainty surrounding the effect sizes reported. This, in turn, led to uncertainty of the reported cost-effectiveness and, as such, no robust recommendations could be made in this respect. CONCLUSIONS Clinical effectiveness evidence from the high-quality systematic reviews identified in this overview continues to suggest uncertainty as to the effectiveness of many conservative interventions for the treatment of LET. Although new RCT evidence has been identified with either placebo or active controls, there is uncertainty as to the size of effects reported within them because of the small sample size. Conclusions regarding cost-effectiveness are also unclear. We consider that, although updated or new systematic reviews may also be of value, the primary focus of future work should be on conducting large-scale, good-quality clinical trials using a core set of outcome measures (for defined time points) and appropriate follow-up. Subgroup analysis of existing RCT data may be beneficial to ascertain whether or not certain patient groups are more likely to respond to treatments. STUDY REGISTRATION This study is registered as PROSPERO CRD42013003593. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Linda Long
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis and Modelling for Health Improvement (ESMI), University of Exeter Medical School, Exeter, UK
| | - Simon Briscoe
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis and Modelling for Health Improvement (ESMI), University of Exeter Medical School, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis and Modelling for Health Improvement (ESMI), University of Exeter Medical School, Exeter, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis and Modelling for Health Improvement (ESMI), University of Exeter Medical School, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis and Modelling for Health Improvement (ESMI), University of Exeter Medical School, Exeter, UK
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Somford MP, van Deurzen DFP, Ostendorf M, Eygendaal D, van den Bekerom MPJ. Quality of research and quality of reporting in elbow surgery trials. J Shoulder Elbow Surg 2015; 24:1619-26. [PMID: 25958211 DOI: 10.1016/j.jse.2015.03.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 03/12/2015] [Accepted: 03/18/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Randomized controlled trials (RCTs) are high in the hierarchy of scientific evidence, but possible sources of bias should be identified or even excluded. This systematic review assessed the methodologic quality and the quality of reporting of the RCTs on the treatment of elbow pathology. METHODS A systematic review of RCTs was performed on the treatment of elbow pathology. PubMed/MEDLINE, Embase, and the Cochrane Library were searched for relevant trials. Thirty-five of the initial 540 articles being an (pseudo) RCT on invasive treatment of elbow pathology in humans were included. These were scored with the use of an adapted Checklists to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). To assess quality of reporting, points were administered to the articles based on the results from CLEAR-NPT list. The highest possible score for quality is 26 points. RESULTS The average quality score was 18.1 points (range, 10-25 points). The mean scores were 19.5 for trials published in the American Journal of Sports Medicine, 19.8 for those published in the Journal of Bone and Joint Surgery, and 20.3 for those published in the Journal of Shoulder and Elbow Surgery. CONCLUSIONS The most important finding was that the overall quality and the quality of reporting has not improved over the years and that the overall quality of the selected studies and the quality of reporting in these trials is not related to the journal they are published in.
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Affiliation(s)
- Matthijs P Somford
- Department of Orthopedic Surgery, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Derek F P van Deurzen
- Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Marieke Ostendorf
- Department of Orthopedic Surgery, St Maartenskliniek Woerden, Woerden, The Netherlands
| | - Denise Eygendaal
- Upper Limb Unit, Department of Orthopedic Surgery, Amphia Hospital, Breda, The Netherlands
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Sorani A, Campbell R. Image-guided elbow interventions: a literature review of interventional treatment options. Br J Radiol 2015. [PMID: 26206415 DOI: 10.1259/bjr.20150368] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Over the years, a wide range of image-guided interventional therapies have been used in treating different elbow pathologies, many of which are predominantly based on anecdotal and low-level study findings. This article critically assesses the existing literature and discusses the efficacy of the most commonly utilized interventional procedures for elbow pathology.
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Affiliation(s)
- Alan Sorani
- Department of Radiology, Royal Liverpool University Hospital, Liverpool, UK
| | - Robert Campbell
- Department of Radiology, Royal Liverpool University Hospital, Liverpool, UK
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Lee SY, Kim W, Lim C, Chung SG. Treatment of Lateral Epicondylosis by Using Allogeneic Adipose-Derived Mesenchymal Stem Cells: A Pilot Study. Stem Cells 2015. [PMID: 26202898 DOI: 10.1002/stem.2110] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Mesenchymal stem cell therapy is a novel regenerative approach for treating tendinopathy. Here, we evaluated the safety and efficacy of allogeneic adipose-derived mesenchymal stem cells (allo-ASC) in treating lateral epicondylosis (LE). Under ultrasound guidance, allo-ASCs mixed with fibrin glue were injected into the hypoechoic common extensor tendon lesions of 12 participants with chronic LE; 6 subjects each were administered 10(6) or 10(7) cells in 1 ml. Safety was evaluated at day 3 and weeks 2, 6, 12, 26, and 52 post-injection. Efficacy was assessed by measuring patients' visual analog scale (VAS) score for elbow pain, modified Mayo clinic performance index for the elbow, and by evaluating longitudinal and transverse ultrasound images of tendon defect areas after 6, 12, 26, and 52 weeks. No significant adverse effects of allo-ASC injection were observed through 52 weeks of follow-up. From baseline through 52 weeks of periodic follow-up, VAS scores progressively decreased from 66.8 ± 14.5 mm to 14.8 ± 13.1 mm and elbow performance scores improved from 64.0 ± 13.5 to 90.6 ± 5.8. Tendon defects also significantly decreased through this period. Allo-ASC therapy was thus safe and effective in improving elbow pain, performance, and structural defects for 52 weeks. This clinical study is the first to reveal therapeutic value of mesenchymal stem cell injection for treating chronic tendinopathy.
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Affiliation(s)
- Sang Yoon Lee
- Department of Physical Medicine & Rehabilitation, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Won Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chaiyoung Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sun G Chung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Institute of Aging, Medical Research Center, Seoul National University, Seoul, South Korea.,Rheumatism Research Institute, Medical Research Center, Seoul National University, Seoul, South Korea
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Teggeler M, Schmitz M, Fink A, Jansen JACG, Pisters MF. Reliability and agreement of ultrasonographic thickness measurements of the common lateral extensors of the elbow. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:1592-1598. [PMID: 25748525 DOI: 10.1016/j.ultrasmedbio.2015.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 01/10/2015] [Accepted: 01/21/2015] [Indexed: 06/04/2023]
Abstract
In individuals with lateral elbow tendinopathy, the thickness of the common lateral extensors tendon can be evaluated by musculoskeletal ultrasonography (MSU) for diagnostic and evaluative purposes. The reproducibility of these thickness measurements should be established before integrating it into daily practice. A test-retest design was used to determine the reproducibility of these measurements in the longitudinal and transverse planes. Seventy-three healthy participants were measured two times by two raters. Intra-class correlation coefficient values for inter-rater reliability for the longitudinal and transverse planes were 0.67 and 0.49. Intra-class correlation coefficient values for intra-rater reliability varied between 0.73 and 0.92. The smallest detectable change ranged from 0.50 to 0.78 mm and comprised 9.8%-16.3% of the mean thickness. MSU thickness measurement of the common lateral extensors tendon of the elbow has fair to excellent intra- and inter-rater reliability. Additionally, agreement is acceptable, which makes MSU a valuable tool for the evaluation of tendon thickness over time.
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Affiliation(s)
- Marlijn Teggeler
- Physical Therapy Science, Program in Clinical Health Sciences and Department of Rehabilitation, Nursing Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands; Physical Therapy Practice Emmastraat, Enschede, The Netherlands.
| | - Marc Schmitz
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, The Netherlands
| | - Alexandra Fink
- Physical Therapy Science, Program in Clinical Health Sciences and Department of Rehabilitation, Nursing Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands; Hand Therapy Center, Enschede, The Netherlands
| | - Jaap A C G Jansen
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, The Netherlands
| | - Martijn F Pisters
- Physical Therapy Science, Program in Clinical Health Sciences and Department of Rehabilitation, Nursing Science and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Health Innovation and Technology, Fontys University of Applied Sciences, Eindhoven, The Netherlands; Center for Physical Therapy Research and Innovation in Primary Care, Leidsche Rijn Julius Health Care Centers, Utrecht, The Netherlands
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Evidence-based treatment of common extensor tendinopathy. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2014. [DOI: 10.1007/s40141-014-0070-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Sims SEG, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (N Y) 2014; 9:419-46. [PMID: 25414603 PMCID: PMC4235906 DOI: 10.1007/s11552-014-9642-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Non-surgical approaches to treatment of lateral epicondylitis are numerous. The aim of this systematic review is to examine randomized, controlled trials of these treatments. METHODS Numerous databases were systematically searched from earliest records to February 2013. Search terms included "lateral epicondylitis," "lateral elbow pain," "tennis elbow," "lateral epicondylalgia," and "elbow tendinopathy" combined with "randomized controlled trial." Two reviewers examined the literature for eligibility via article abstract and full text. RESULTS Fifty-eight articles met eligibility criteria: (1) a target population of patients with symptoms of lateral epicondylitis; (2) evaluation of treatment of lateral epicondylitis with the following non-surgical techniques: corticosteroid injection, injection technique, iontophoresis, botulinum toxin A injection, prolotherapy, platelet-rich plasma or autologous blood injection, bracing, physical therapy, shockwave therapy, or laser therapy; and (3) a randomized controlled trial design. Lateral epicondylitis is a condition that is usually self-limited. There may be a short-term pain relief advantage found with the application of corticosteroids, but no demonstrable long-term pain relief. Injection of botulinum toxin A and prolotherapy are superior to placebo but not to corticosteroids, and botulinum toxin A is likely to produce concomitant extensor weakness. Platelet-rich plasma or autologous blood injections have been found to be both more and less effective than corticosteroid injections. Non-invasive treatment methods such as bracing, physical therapy, and extracorporeal shockwave therapy do not appear to provide definitive benefit regarding pain relief. Some studies of low-level laser therapy show superiority to placebo whereas others do not. CONCLUSIONS There are multiple randomized controlled trials for non-surgical management of lateral epicondylitis, but the existing literature does not provide conclusive evidence that there is one preferred method of non-surgical treatment for this condition. Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions to Authors for a complete description of level of evidence.
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Affiliation(s)
- Susan E. G. Sims
- />Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
| | - Katherine Miller
- />University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 601, Rochester, NY 14642 USA
| | - John C. Elfar
- />Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
| | - Warren C. Hammert
- />Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA
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Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard P, Arbogast G, Wilson JJ, Balzano JF. Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective Open-label Study. Glob Adv Health Med 2014; 2:26-31. [PMID: 24416661 PMCID: PMC3833522 DOI: 10.7453/gahmj.2012.054] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Objective: Assess platelet rich plasma (PRP) injection for rotator cuff tendinopathy (RCT). Design: Prospective open label study with 1-year follow-up. Methods: Participants recruited from an outpatient sports medicine clinic had clinically and magnetic resonance image (MRI)—demonstrated RCT refractory to physical therapy and corticosteroid injection. They received one ultrasound-guided injection of 3.0 mL of 1% xylocaine followed by 3.5 mL of PRP at the lesion and surrounding tendon. Primary outcome: 0–10 visual analog scale (VAS; baseline, 8, 12, and 52 weeks). Secondary outcomes: functional shoulder tests assessing rotator cuff strength and endurance (at baseline and 8 and 12 weeks), MRI severity (1–5 points [at baseline and 4 and 8 weeks]), and patient satisfaction (52 weeks). Results: Eighteen participants with 19 assessed shoulders reported VAS pain score improvement from 7.5 ± 0.3 points to 0.5 ± 0.3 points by week 12 and 0.4 ± 0.2 (P = .0001) points at week 52. Functional outcomes significantly improved; the largest effect was seen in the external rotation test: 33.5 ± 5.7 seconds to 62.6 ± 7.2 seconds at week 12 (P = .0001). MRI appearance improved by 1 to 3 points in 16 of 18 assessed shoulders. Seventeen participants were “completely satisfied” (12) or “satisfied” (5). One participant was “unsatisfied.” Conclusions: A single ultrasound-guided, intralesional injection of PRP resulted in safe, significant, sustained improvement of pain, function, and MRI outcomes in participants with refractory RCT. Randomized multidisciplinary effectiveness trials that add ultrasound and validated clinical outcome measures are needed to further assess PRP for RCT.
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Affiliation(s)
- Michael Scarpone
- Department of Orthopedics, Drexel University College of Medicine; Philadelphia, Pennsylvania, United States
| | - David Rabago
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, Madison, United States
| | - Edward Snell
- Department of Orthopedics, Drexel University College of Medicine; Philadelphia, Pennsylvania; United States
| | - Patrick Demeo
- Department of Orthopedic Surgery and Division of Sports Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania; Orthopedic Surgery, Drexel University College of Medicine, United States
| | - Kristine Ruppert
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, United States
| | - Perry Pritchard
- Riverside Sports, Spine, and Fitness Center, Wintersville, Ohio, United States
| | - Gennie Arbogast
- Riverside Sports, Spine, and Fitness Center, Wintersville, Ohio, United States
| | - John J Wilson
- Departments of Family Medicine and Orthopedics, Division of Sports Medicine, Madison, Wisconsin, United States
| | - John F Balzano
- Images Interpretation Services, Ltd, and Open MRI of Steubenville and Weirton, Lifeline Hospital, Mingo Junction, Ohio, United States
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Wilde B, Havill A, Priestley L, Lewis J, Kitchen S. The efficacy of sclerosing injections in the treatment of painful tendinopathy. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/1743288x11y.0000000025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
Lateral epicondylitis has several different treatment methods, with no single agreed upon therapy. This article summarizes the current literature on injection therapies for lateral epicondylitis. Glucocorticoid, botulinum toxin, autologous blood, platelet-rich plasma, hyaluronic acid, polidocanol, glycosaminoglycan, and prolotherapy injections are discussed.
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Affiliation(s)
- Christopher H Judson
- Department of Orthopaedic Surgery, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA
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Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, Bliddal H, Christensen R. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med 2013; 41:1435-46. [PMID: 22972856 DOI: 10.1177/0363546512458237] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injection therapy with glucocorticoids has been used since the 1950s as a treatment strategy for lateral epicondylitis (tennis elbow). Lately, several novel injection therapies have become available. PURPOSE To assess the comparative effectiveness and safety of injection therapies in patients with lateral epicondylitis. STUDY DESIGN Systematic review and meta-analysis. METHODS Randomized controlled trials comparing different injection therapies for lateral epicondylitis were included provided they contained data for change in pain intensity (primary outcome). Trials were assessed using the Cochrane risk of bias tool. Network (random effects) meta-analysis was applied to combine direct and indirect evidence within and across trial data using the final end point reported in the trials, and results for the arm-based network analyses are reported as standardized mean differences (SMDs). RESULTS Seventeen trials (1381 participants; 3 [18%] at low risk of bias) assessing injection with 8 different treatments-glucocorticoid (10 trials), botulinum toxin (4 trials), autologous blood (3 trials), platelet-rich plasma (2 trials), and polidocanol, glycosaminoglycan, prolotherapy, and hyaluronic acid (1 trial each)-were included. Pooled results (SMD [95% confidence interval]) showed that beyond 8 weeks, glucocorticoid injection was no more effective than placebo (-0.04 [-0.45 to 0.35]), but only 1 trial (which did not include a placebo arm) was at low risk of bias. Although botulinum toxin showed marginal benefit (-0.50 [-0.91 to -0.08]), it caused temporary paresis of finger extension, and all trials were at high risk of bias. Both autologous blood (-1.43 [-2.15 to -0.71]) and platelet-rich plasma (-1.13 [-1.77 to -0.49]) were also statistically superior to placebo, but only 1 trial was at low risk of bias. Prolotherapy (-2.71 [-4.60 to -0.82]) and hyaluronic acid (-5.58 [-6.35 to -4.82]) were both more efficacious than placebo, whereas polidocanol (0.39 [-0.42 to 1.20]) and glycosaminoglycan (-0.32 [-1.02 to 0.38]) showed no effect compared with placebo. The criteria for low risk of bias were only met by the prolotherapy and polidocanol trials. CONCLUSION This systematic review and network meta-analysis of randomized controlled trials found a paucity of evidence from unbiased trials on which to base treatment recommendations regarding injection therapies for lateral epicondylitis.
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Bell KJ, Fulcher ML, Rowlands DS, Kerse N. Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial. BMJ 2013; 346:f2310. [PMID: 23599320 PMCID: PMC3629924 DOI: 10.1136/bmj.f2310] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the effectiveness of two peritendinous autologous blood injections in addition to a standardised eccentric calf strengthening programme in improving pain and function in patients with mid-portion Achilles tendinopathy. DESIGN Single centre, participant and single assessor blinded, parallel group, randomised, controlled trial. SETTING Single sports medicine clinic in New Zealand. PARTICIPANTS 53 adults (mean age 49, 53% men) with symptoms of unilateral mid-portion Achilles tendinopathy for at least three months. Participants were excluded if they had a history of previous Achilles tendon rupture or surgery or had undergone previous adjuvant treatments such as injectable therapies, glyceryl trinitrate patches, or extracorporeal shockwave therapy. INTERVENTIONS All participants underwent two unguided peritendinous injections one month apart with a standardised protocol. The treatment group had 3 mL of their own whole blood injected while the control group had no substance injected (needling only). Participants in both groups carried out a standardised and monitored 12 week eccentric calf training programme. Follow-up was at one, two, three and six months. MAIN OUTCOME MEASURES The primary outcome measure was the change in symptoms and function from baseline to six months with the Victorian Institute of Sport Assessment-Achilles (VISA-A) score. Secondary outcomes were the participant's perceived rehabilitation and their ability to return to sport. RESULTS 26 participants were randomly assigned to the treatment group and 27 to the control group. In total, 50 (94%) completed the six month study, with 25 in each group. Clear and clinically worthwhile improvements in the VISA-A score were evident at six months in both the treatment (change in score 18.7, 95% confidence interval 12.3 to 25.1) and control (19.9, 13.6 to 26.2) groups. The overall effect of treatment was not significant (P=0.689) and the 95% confidence intervals at all points precluded clinically meaningful benefit or harm. There was no significant difference between groups in secondary outcomes or in the levels of compliance with the eccentric calf strengthening programme. No adverse events were reported. CONCLUSION The administration of two unguided peritendinous autologous blood injections one month apart, in addition to a standardised eccentric training programme, provides no additional benefit in the treatment of mid-portion Achilles tendinopathy. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12610000824066, WHO U1111-1117-2641.
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Affiliation(s)
- Kevin J Bell
- Sydney Sports Medicine Centre, Sydney Olympic Park, NSW 2127, Australia
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Ustuner E, Toprak U, Baskan B, Oztuna D. Sonographic examination of the common extensor tendon of the forearm at three different locations in the normal asymptomatic population. Surg Radiol Anat 2013; 35:547-52. [DOI: 10.1007/s00276-013-1084-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 02/04/2013] [Indexed: 11/24/2022]
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Abstract
Tendinopathy is a common and debilitating condition that results in significant deficits in performance and prolonged time away from activity. For this reason, much effort has been placed in defining beneficial and cost-effective treatments. This review has outlined the current literature on some of the most widely used therapies for cases of tendinopathy. As such, recommendations remain limited by the evidence available. The variability in both quantity and quality of research into tendinopathy treatments makes it difficult to make definitive treatment recommendations. In general, however, a reasonable first line of treatment for tendinopathy should include a course of NSAIDs and eccentric exercise-based physical therapy. Corticosteroid injections seem to offer excellent short-term pain relief but lack long term efficacy. Alternative injections, such as PRP, have shown short-term efficacy for tendinopathy sufferers; data are lacking to support sclerosing agents and proteinase inhibitors. Operative management seems to offer some benefit in symptomatic relief but carries a higher complication rate than other treatment options and should be reserved only for patients recalcitrant to other more conservative options. Although the inability to make definitive therapeutic recommendations in some instances is discouraging, it is important to note that a lack of high-quality evidence supporting specific treatments does not necessarily imply that they are inherently ineffective. Given the growing prevalence of tendinopathy and the impact it has on the general public, it is more important now than ever to continue the search for the most effective and accessible treatment modalities.
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Hoksrud A, Torgalsen T, Harstad H, Haugen S, Andersen TE, Risberg MA, Bahr R. Ultrasound-guided sclerosis of neovessels in patellar tendinopathy: a prospective study of 101 patients. Am J Sports Med 2012; 40:542-7. [PMID: 22238058 DOI: 10.1177/0363546511433012] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A randomized controlled study has shown promising clinical results after treatment with sclerosing injections in a group of patients with patellar tendinopathy, but no study has investigated medium- or long-term outcome in a large and unselected group of patients. PURPOSE To investigate if sclerosing treatment would affect the level of patellar tendon pain and knee function after 24 months in a large group of patients with patellar tendinopathy. STUDY DESIGN Case series; Level of evidence, 4. METHODS This prospective study recruited patients with a clinical diagnosis of jumper's knee and visible neovascularization corresponding to the painful area on power Doppler ultrasound. They received up to a maximum of 5 ultrasound-guided sclerosing injections using polidocanol at 4- to 6-week intervals. Knee pain and function were recorded using the Victorian Institute of Sport Assessment-Patella (VISA-P) score before treatment and 6, 12, and 24 months after the first injection. RESULTS In total, 101 patients (15 women and 86 men) with 120 tendons were included and given from 1 to 5 sclerosing injections (mean [SD], 2.5 [0.9]). The patients reported a significantly improved VISA-P score from baseline (mean, 39; 95% confidence interval [CI], 36-42) to the 24-month follow-up (mean, 65; 95% CI, 60-70) (range, 21-100; P < .001, paired t test). However, a VISA-P score of >95 points was reported in only 22 cases (20%), whereas 37 cases (36%) reported a VISA-P score of <50 at 24 months. CONCLUSION Sclerosing treatment with polidocanol resulted in a moderate improvement in knee function and reduced pain in a heterogeneous group of patients with patellar tendinopathy. Nevertheless, few of the patients were cured, and the majority still had reduced function and substantial pain after 24 months of follow-up.
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Affiliation(s)
- Aasne Hoksrud
- Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, PO Box 4014 Ullevaal Stadion, 0806 Oslo, Norway.
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Backman LJ, Andersson G, Fong G, Alfredson H, Scott A, Danielson P. Alpha-2 adrenergic stimulation triggers Achilles tenocyte hypercellularity: Comparison between two model systems. Scand J Med Sci Sports 2012; 23:687-96. [PMID: 22292987 PMCID: PMC3933766 DOI: 10.1111/j.1600-0838.2011.01442.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2011] [Indexed: 11/29/2022]
Abstract
The histopathology of tendons with painful tendinopathy is often tendinosis, a fibrosis-like condition of unclear pathogenesis characterized by tissue changes including hypercellularity. The primary tendon cells (tenocytes) have been shown to express adrenoreceptors (mainly alpha-2A) as well as markers of catecholamine production, particularly in tendinosis. It is known that adrenergic stimulation can induce proliferation in other cells. The present study investigated the effects of an exogenously administered alpha-2 adrenergic agonist in an established in vivo Achilles tendinosis model (rabbit) and also in an in vitro human tendon cell culture model. The catecholamine producing enzyme tyrosine hydroxylase and the alpha-2A-adrenoreceptor (α2A AR) were expressed by tenocytes, and alpha-2 adrenergic stimulation had a proliferative effect on these cells, in both models. The proliferation was inhibited by administration of an α2A AR antagonist, and the in vitro model further showed that the proliferative alpha-2A effect was mediated via a mitogenic cell signaling pathway involving phosphorylation of extracellular-signal-regulated kinases 1 and 2. The results indicate that catecholamines produced by tenocytes in tendinosis might contribute to the proliferative nature of the pathology through stimulation of the α2A AR, pointing to a novel target for future therapies. The study furthermore shows that animal models are not necessarily required for all aspects of this research.
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Affiliation(s)
- L J Backman
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
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Reliability of sonographic assessment of tendinopathy in tennis elbow. Skeletal Radiol 2012; 41:83-9. [PMID: 21384199 DOI: 10.1007/s00256-011-1132-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/25/2011] [Accepted: 02/13/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the reliability and compute the minimum detectable change using sonographic scales to quantify the extent of pathology and hyperaemia in the common extensor tendon in people with tennis elbow. MATERIALS AND METHODS The lateral elbows of 19 people with tennis elbow were assessed sonographically twice, 1-2 weeks apart. Greyscale and power Doppler images were recorded for subsequent rating of abnormalities. Tendon thickening, hypoechogenicity, fibrillar disruption and calcification were each rated on four-point scales, and scores were summed to provide an overall rating of structural abnormality; hyperaemia was scored on a five point scale. Inter-rater reliability was established using the intraclass correlation coefficient (ICC) to compare scores assigned independently to the same set of images by a radiologist and a physiotherapist with training in musculoskeletal imaging. Test-retest reliability was assessed by comparing scores assigned by the physiotherapist to images recorded at the two sessions. The minimum detectable change (MDC) was calculated from the test-retest reliability data. RESULTS ICC values for inter-rater reliability ranged from 0.35 (95% CI: 0.05, 0.60) for fibrillar disruption to 0.77 (0.55, 0.88) for overall greyscale score, and 0.89 (0.79, 0.95) for hyperaemia. Test-retest reliability ranged from 0.70 (0.48, 0.84) for tendon thickening to 0.82 (0.66, 0.90) for overall greyscale score and 0.86 (0.73, 0.93) for calcification. The MDC for the greyscale total score was 2.0/12 and for the hyperaemia score was 1.1/5. CONCLUSION The sonographic scoring system used in this study may be used reliably to quantify tendon abnormalities and change over time. A relatively inexperienced imager can conduct the assessment and use the rating scales reliably.
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Nilsson P, Lindgren EC, Månsson J. Lateral epicondylalgia. A quantitative and qualitative analysis of interdisciplinary cooperation and treatment choice in the Swedish health care system. Scand J Caring Sci 2011; 26:28-37. [PMID: 21649686 DOI: 10.1111/j.1471-6712.2011.00899.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE AND AIM Interdisciplinary cooperation is essential to develop a broad range of knowledge and skills. The aim of this study was to describe health care professionals' treatment choices, their cooperation with other professionals and their perceptions of potential risks regarding treatments of acute lateral epicondylalgia (LE). DESIGN A quantitative descriptive study design with a summative approach to qualitative analysis. ETHICAL ISSUES The ethical committee was asked verbally for approval but, as this study was performed to develop an organised way to treat LE, it did not require approval. The four ethical aspects information, consent, confidentiality and the use of the study materials were all addressed. SUBJECTS All orthopaedic surgeons, general practitioners, physiotherapists and occupational therapists in a county. METHODS Questionnaire with 18 dichotomous, multiple-response, multiple-choice questions and three open-ended questions were analysed using quantitative cross-tab and qualitative content analysis with summative approach. RESULTS The most common treatment choices were Non Steroidal Anti Inflammatory Drugs (NSAID), corticosteroid injections, training programmes, braces and ergonomics. Advantages from interdisciplinary cooperation were higher rated than disadvantages. The qualitative findings dealt with perceptions of interdisciplinary cooperation and resulted in three categories; right level of care, increased quality of care and decreased quality of care. Almost half of the physicians felt potential risks associated with their treatment methods. The qualitative findings dealt with perceptions of the potential risks and resulted in two categories: side effects and inadequate treatment. STUDY LIMITATIONS The number of responses varied because some of the respondents did not answered all of the questions. CONCLUSION Interdisciplinary cooperation in the treatment of patients with acute LE benefits the patients by shortening the rehabilitation period and provides health care professionals the opportunity for an improved learning and exchanging experiences. These basic conditions must be met to improve health care quality.
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Affiliation(s)
- Pia Nilsson
- Research and Development Unit, Primary Health Care, General Practice and Public Health, Falkenberg, Sweden.
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Abstract
CLINICAL QUESTION What is the best treatment for tennis elbow? RESULTS Despite a wealth of research, there is no true consensus on the most efficacious management of tennis elbow especially for effective long-term outcomes. Corticosteroid injections do show large pain-relieving effects in the short term but are associated with risks of adverse events and long-term reoccurrence. Advice with a "wait and see" approach is recommended as the first-line treatment in primary care for most cases. In the medium term physiotherapy and or low-level laser therapy may be effective. IMPLEMENTATION Rule out alternative diagnosis. Onward referral may be indicated if the condition does not resolve after 12 months.
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Affiliation(s)
- Linda S Chesterton
- Arthritis research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, UK
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Abstract
Chronic lateral epicondylitis is a common painful condition affecting the elbow. Many treatments have been proposed to alleviate the pain. Surgical treatment options include open, arthroscopic, and percutaneous debridement techniques, while nonoperative modalities have traditionally included physical therapy, bracing, and cortisone injections. Platelet-rich plasma injections have recently gained popularity as an additional treatment option, with early reports of success in elite athletes. The largest study of platelet-rich plasma injections for treatment of lateral epicondylitis showed improvement by platelet-rich plasma compared to corticosteroid injections. This article presents a case of a 55-year-old right-hand-dominant woman with bilateral lateral epicondylitis refractory to multiple corticosteroid injections and physical therapy, treated with platelet-rich plasma injection in the right elbow and concomitant arthroscopic extensor carpi radialis brevis tendon release and debridement in the left elbow. At 4-month follow-up, her visual analog scale was 80/100 in the elbow receiving platelet-rich plasma compared to 10/100 on her operative side, and platelet-rich plasma treatment was considered a failure. The patient then underwent arthroscopic debridement of the right elbow for recalcitrant pain. At 1-year follow-up, both elbows were improved after operative treatment (visual analog scale 10/100 right and 0/100 left), consistent with several studies that have reported improvements from arthroscopic extensor carpi radialis brevis debridement as high as 95%. In our experience, arthroscopic extensor carpi radialis brevis debridement is a safe and efficacious method for treating chronic lateral epicondylitis. Further studies are required to define the role of platelet-rich plasma injections in the treatment of this condition.
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Affiliation(s)
- Steve B Behrens
- Department of Orthopedic Surgery, Division of Shoulder and Eblow Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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Davidson J, Jayaraman S. Guided interventions in musculoskeletal ultrasound: what’s the evidence? Clin Radiol 2011; 66:140-52. [PMID: 21216330 DOI: 10.1016/j.crad.2010.09.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 08/13/2010] [Accepted: 09/21/2010] [Indexed: 11/26/2022]
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The elbow. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00071-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010; 376:1751-67. [PMID: 20970844 DOI: 10.1016/s0140-6736(10)61160-9] [Citation(s) in RCA: 487] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection. METHODS We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0-12), intermediate term (26 weeks, 13-26), or long term (52 weeks, ≥52). Adverse events were also reported. FINDINGS 3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17-1·71, p<0·0001), but no intervention was favoured at intermediate term (-0·40, -0·67 to -0·14, p<0·003) and long term (-0·31, -0·61 to -0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise. INTERPRETATION Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy. FUNDING None.
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Affiliation(s)
- Brooke K Coombes
- Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Queensland, Australia
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37
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Lento PH, Strakowski JA. The Use of Ultrasound in Guiding Musculoskeletal Interventional Procedures. Phys Med Rehabil Clin N Am 2010; 21:559-83. [DOI: 10.1016/j.pmr.2010.04.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Clarke AW, Ahmad M, Curtis M, Connell DA. Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability. Am J Sports Med 2010; 38:1209-14. [PMID: 20335508 DOI: 10.1177/0363546509359066] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lateral elbow tendinopathy is a common condition often diagnosed by ultrasound. Debate exists regarding which ultrasound findings correlate with disease severity and prognosis. HYPOTHESIS Sonographic predictors for tendon healing in patients with lateral elbow tendinopathy can be found by correlating initial ultrasound findings with subsequent changes in pain and functional disability scores after a period of nonoperative management. STUDY DESIGN Cohort study (prognosis); Level of evidence, 2. METHODS Sixty-two elbows (34 right, 28 left) in 62 patients (30 male, 32 female) with a clinical diagnosis of lateral elbow tendinopathy underwent sonographic evaluation of the common extensor origin after assessment with a validated outcome measure, the Patient-Rated Tennis Elbow Evaluation (PRTEE). After 6 months of nonoperative standardized treatment (physiotherapy with eccentric loading), the PRTEE questionnaire was repeated. RESULTS The mean pretreatment PRTEE was 78 (range, 51-97) and posttreatment score was 29 (range, 0-91). This difference in means was found to be significant (P < .0001). A positive correlation was identified between the presence of a lateral collateral ligament tear (P < .0001) and the size of the largest intrasubstance tear (P < .0001) and poor outcome. A negative correlation was identified with amount of hypoechogenicity (P = .0009). No correlation was found with age, sex, side, duration of symptoms, thickness of tendon, or amount of neovascularity. CONCLUSION The size of intrasubstance tears and presence of a lateral collateral ligament tear on ultrasound can be used to assess lateral elbow tendinopathy severity, indicate those who may not respond to nonoperative therapy, and potentially guide more invasive treatment. Those patients with a large intrasubstance tear or tears identified on ultrasound are less likely to respond to nonoperative treatment. Presence of neovascularity has little correlation with change in pain severity or functional disability and may be a poor predictor of prognosis.
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Affiliation(s)
- Andrew W Clarke
- Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, London, UK.
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Poltawski L, Jayaram V, Watson T. Measurement issues in the sonographic assessment of tennis elbow. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:196-204. [PMID: 20186762 DOI: 10.1002/jcu.20676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Sonography is increasingly being used for assessment in tennis elbow research and clinical practice, but there are a lack of data regarding its validity, reliability, and responsiveness to change for this application. Studies using the modality were reviewed to establish current levels of evidence for these measurement properties. There is reasonable evidence regarding its validity for identifying tennis elbow tendinopathy, but a lack of data addressing its reliability and responsiveness. Practical issues affecting image quality are discussed, and recommendations for further investigation are suggested, to enhance the credible use of sonography with this debilitating condition.
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Affiliation(s)
- Leon Poltawski
- School of Health and Emergency Professions, University of Hertfordshire, Hatfield, AL10 9AB, UK
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40
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Abstract
Prolotherapy is an injection-based complementary and alternative medical therapy for chronic musculoskeletal pain. Prolotherapy techniques and injected solutions vary by condition, clinical severity, and practitioner preferences; over several treatment sessions, a fairly small volume of an irritant or sclerosing solution is injected at sites on painful ligament and tendon insertions and in adjacent joint space during several treatment sessions. Prolotherapy is becoming increasingly popular in the United States and internationally and is actively used in clinical practice. Prolotherapy has been assessed as a treatment for various painful chronic musculoskeletal conditions that are refractory to "standard of care" therapies. Although anecdotal clinical success guides the use of prolotherapy for many conditions, clinical trial literature supporting evidence-based decision-making for the use of prolotherapy exists for low back pain, several tendinopathies, and osteoarthritis.
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Affiliation(s)
- David Rabago
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, 777 South Mills Street, Madison, WI 53715, USA.
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41
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Lewis JS, Raza SA, Pilcher J, Heron C, Poloniecki JD. The prevalence of neovascularity in patients clinically diagnosed with rotator cuff tendinopathy. BMC Musculoskelet Disord 2009; 10:163. [PMID: 20025761 PMCID: PMC2813234 DOI: 10.1186/1471-2474-10-163] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 12/21/2009] [Indexed: 11/18/2022] Open
Abstract
Background Shoulder dysfunction is common and pathology of the rotator cuff tendons and subacromial bursa are considered to be a major cause of pain and morbidity. Although many hypotheses exist there is no definitive understanding as to the origin of the pain arising from these structures. Research investigations from other tendons have placed intra-tendinous neovascularity as a potential mechanism of pain production. The prevalence of neovascularity in patients with a clinical diagnosis of rotator cuff tendinopathy is unknown. As such the primary aim of this pilot study was to investigate if neovascularity could be identified and to determine the prevalence of neovascularity in the rotator cuff tendons and subacromial bursa in subjects with unilateral shoulder pain clinically assessed to be rotator cuff tendinopathy. The secondary aims were to investigate the association between the presence of neovascularity and pain, duration of symptoms, and, neovascularity and shoulder function. Methods Patients with a clinical diagnosis of unilateral rotator cuff tendinopathy referred for a routine diagnostic ultrasound (US) scan in a major London teaching hospital formed the study population. At referral patients were provided with an information document. On the day of the scan (on average, at least one week later) the patients agreeing to participate were taken through the consent process and underwent an additional clinical examination prior to undergoing a bilateral grey scale and colour Doppler US examination (symptomatic and asymptomatic shoulder) using a Philips HDI 5000 Sono CT US machine. The ultrasound scans were performed by one of two radiologists who recorded their findings and the final assessment was made by a third radiologist blinded both to the clinical examination and the ultrasound examination. The findings of the radiologists who performed the scans and the blinded radiologist were compared and any disagreements were resolved by consensus. Results Twenty-six patients agreed to participate and formed the study population. Of these, 6 subjects were not included in the final assessment following the pre-scan clinical investigation. This is because one subject had complete cessation of symptoms between the time of the referral and entry into the trial. Another five had developed bilateral shoulder pain during the same period. The mean age of the 20 subjects forming the study population was 50.2 (range 32-69) years (SD = 10.9) and the mean duration of symptoms was 22.6 (range .75 to 132) months (SD = 40.1). Of the 20 subjects included in the formal analysis, 13 subjects (65%) demonstrated neovascularity in the symptomatic shoulder and 5 subjects (25%) demonstrated neovascularity in the asymptomatic shoulder. The subject withdrawn due to complete cessation of symptoms was not found to have neovascularity in either shoulder and of the 5 withdrawn due to bilateral symptoms; two subjects were found to have signs of bilateral neovascularity, one subject demonstrated neovascularity in one shoulder and two subjects in neither shoulder. Conclusions This study demonstrated that neovascularity does occur in subjects with a clinical diagnosis of rotator cuff tendinopathy and to a lesser extent in asymptomatic shoulders. In addition, the findings of this investigation did not identify an association between the presence of neovascularity; and pain, duration of symptoms or shoulder function. Future research is required to determine the relevance of these findings.
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Affiliation(s)
- Jeremy S Lewis
- Therapy Department, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
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Housner JA, Jacobson JA, Misko R. Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:1187-1192. [PMID: 19710216 DOI: 10.7863/jum.2009.28.9.1187] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Initial reports have shown percutaneous sonographically guided needle tenotomy without corticosteroid injection to be effective for the treatment of tennis elbow. The purpose of this study was to determine the effectiveness of this procedure with various tendons throughout the body. METHODS Fourteen tendons in 13 patients were identified as having a greater than 6-month history of clinical presentation consistent with tendinopathy that had failed treatment with physical therapy. All patients were treated with sonographically guided percutaneous tenotomy using a 22-gauge needle and a local anesthetic. A visual analog scale (VAS) pain score measurement was obtained before the procedure and at 4- and 12-week follow-up appointments. All complications were recorded. RESULTS The 14 tendons in this study included patellar (5), Achilles (4), proximal gluteus medius (1), proximal iliotibial tract (1), proximal hamstring (1), common extensor elbow (1), and proximal rectus femoris (1). The composite VAS score was significantly lower at both 4 weeks (mean +/- SEM, 2.4 +/- 0.7) and 12 weeks (2.2 +/- 0.7) compared with the baseline (5.8 +/- 0.6; P < .001). No complications or morbidity occurred. CONCLUSIONS Sonographically guided percutaneous tenotomy of tendinosis was effective in improving patient symptoms without complications. Further investigation with additional patients and comparisons to alternative treatments is needed to validate these preliminary results.
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Affiliation(s)
- Jeffrey A Housner
- Department of Orthopedic Surgery, University of Michigan MedSport, Ann Arbor, 48105-9755, USA.
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Rabago D, Best TM, Zgierska AE, Zeisig E, Ryan M, Crane D. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. Br J Sports Med 2009; 43:471-81. [PMID: 19028733 PMCID: PMC2755040 DOI: 10.1136/bjsm.2008.052761] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To appraise existing evidence for prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injection therapies for lateral epicondylosis (LE). DESIGN Systematic review. DATA SOURCES Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine. SEARCH STRATEGY names and descriptors of the therapies and LE. STUDY SELECTION All human studies assessing the four therapies for LE. MAIN RESULTS Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. In follow-up periods ranging from 9 to 108 weeks, studies reported sustained, statistically significant (p<0.05) improvement in visual analogue scale primary outcome pain score measures and disease-specific questionnaires; relative effect sizes ranged from 51% to 94%; Cohen's d ranged from 0.68 to 6.68. Secondary outcomes also improved, including biomechanical elbow function assessment (polidocanol and prolotherapy), presence of abnormalities and increased vascularity on ultrasound (autologous whole blood and polidocanol). Subjects reported satisfaction with therapies on single-item assessments. All studies were limited by small sample size. CONCLUSIONS There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.
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Affiliation(s)
- D Rabago
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, 777 S. Mills St, Madison WI 53715, USA.
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Abstract
Plantar fasciitis is a painful condition affecting many athletes. Anatomic and biomechanical factors combined with overuse can contribute to its genesis. Correction of gait disturbances, changes in footwear, use of tension night splints, and stretching of tight calf and plantar tissues have all be proven to relieve symptoms. Anti-inflammatory modalities, including medications, iontophoresis, and corticosteroid injection generally provide temporary improvement. Recent studies on the efficacy of extracorporeal shock wave therapy are conflicting. Injections with platelet-rich plasma or sclerotic agents are currently under investigation for use in this and other similar conditions. A small percentage of patients with refractory symptoms may benefit from surgical release of the plantar fascia. Diagnosis and correction of biomechanical factors leading to this condition should be a mainstay of treatment and may prevent recurrences.
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Affiliation(s)
- James L Glazer
- Division of Sports Medicine, Department of Family Medicine, Maine Medical Center, 272 Congress Street, Portland, ME 04103, USA.
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Knobloch K. Does the dosage matter in sclerosing polidocanol injections in Achilles tendinopathy? Knee Surg Sports Traumatol Arthrosc 2009; 17:111-2; author reply 113-4. [PMID: 19099292 DOI: 10.1007/s00167-008-0687-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Accepted: 11/11/2008] [Indexed: 10/21/2022]
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Knobloch K. The role of tendon microcirculation in Achilles and patellar tendinopathy. J Orthop Surg Res 2008; 3:18. [PMID: 18447938 PMCID: PMC2397381 DOI: 10.1186/1749-799x-3-18] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Accepted: 04/30/2008] [Indexed: 12/11/2022] Open
Abstract
Tendinopathy is of distinct interest as it describes a painful tendon disease with local tenderness, swelling and pain associated with sonographic features such as hypoechogenic texture and diameter enlargement. Recent research elucidated microcirculatory changes in tendinopathy using laser Doppler flowmetry and spectrophotometry such as at the Achilles tendon, the patellar tendon as well as at the elbow and the wrist level. Tendon capillary blood flow is increased at the point of pain. Tendon oxygen saturation as well as tendon postcapillary venous filling pressures, determined non-invasively using combined Laser Doppler flowmetry and spectrophotometry, can quantify, in real-time, how tendon microcirculation changes over with pathology or in response to a given therapy. Tendon oxygen saturation can be increased by repetitive, intermittent short-term ice applications in Achilles tendons; this corresponds to 'ischemic preconditioning', a method used to train tissue to sustain ischemic damage. On the other hand, decreasing tendon oxygenation may reflect local acidosis and deteriorating tendon metabolism. Painful eccentric training, a common therapy for Achilles, patellar, supraspinatus and wrist tendinopathy decreases abnormal capillary tendon flow without compromising local tendon oxygenation. Combining an Achilles pneumatic wrap with eccentric training changes tendon microcirculation in a different way than does eccentric training alone; both approaches reduce pain in Achilles tendinopathy. The microcirculatory effects of measures such as extracorporeal shock wave therapy as well as topical nitroglycerine application are to be studied in tendinopathy as well as the critical question of dosage and maintenance. Interestingly it seems that injection therapy using color Doppler for targeting the area of neovascularisation yields to good clinical results with polidocanol sclerosing therapy, but also with a combination of epinephrine and lidocaine.
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Affiliation(s)
- Karsten Knobloch
- Plastic, Hand and Reconstructive surgery, Hannover Medical School, Germany.
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