Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial

Ultrasound-Guided Subfascial Platelet-Rich Plasma Injections Versus Enthesis Needling for Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial

Background

Greater trochanteric pain syndrome (GTPS) is characterized by gluteal enthesopathy involving the peritrochanteric space and associated with chronic pain and functional impairment. A corticosteroid injection in the trochanteric bursa is the usual palliative treatment for pain. However, it is important to investigate treatment options that will relieve pain in the peritrochanteric space.

Purpose

To compare the clinical efficacy of subfascial platelet-rich plasma (PRP) injection and enthesis needling for GTPS.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A total of 92 patients (90% women; mean age, 55 years old; mean body mass index, 25.3 kg/m2) were randomly divided into a subfascial PRP injection group and an enthesis needling group. Descriptive data and radiographic measurements of the pelvis-including leg-length difference, pelvic width difference, and pelvic trochanteric index-were recorded. The primary outcome measures were the Hip Outcome Score (HOS) activities of daily living (HOS-ADL) and sports-specific (HOS-SS) subscales and the visual analog scale for pain at 3, 6, and 12 months posttreatment. In addition, we evaluated the presence or absence of ultrasound characteristics (fascia nodules, trochanteric bursa distension, and calcium deposits) over time in response to treatment.

Results

Baseline demographic and radiological characteristics were similar between the groups. The PRP group saw significantly greater improvement from baseline to 12 months posttreatment on the HOS-SS subscore compared with the needling group (32.09 [95% CI, 28.99-40.20] vs 20.52 [95% CI, 11.99-29.05]; P = .048). At 3 months, 60% of patients in the PRP group versus 33.3% in the needling group had a reduction in pain compared with a baseline of >20% (P = .040). After subfascial PRP injection, fewer patients had a fascia nodule over the trochanter and/or bursa distension (P = .006 and P = .004, respectively). The pelvic trochanteric index was predictive of HOS-ADL and HOS-SS outcomes (P = .011 and P = .022, respectively). The interaction between treatment modality and fascia nodule influenced HOS-ADL and HOS-SS outcomes (P = .021 and P = .023) as well as the interactions of treatment modality, fascia nodules, and calcifications (P = .027).

Conclusion

Both subfascial PRP injection and enthesis needling resulted in clinical improvements, but the improvement in the HOS-SS was greater in the PRP group.

Registration

NCT04231357 (ClinicalTrials.gov identifier).

Efficacy of trigger point dry needling on pain and function of the hip joint: a systematic review of randomized clinical trials

OBJECTIVE

The objective of this study was to assess the evidence for the impact of dry needling (DN) on hip pain and function.

METHODS

Medline/PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL databases were searched systematically through June 2022 for randomized clinical trials (RCTs) investigating the impact of DN on hip pain and function. Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess risk of bias. Descriptive analysis was conducted to explain the outcomes and adverse events of DN in hip joint diseases. Meta-analysis was not feasible due to significant heterogeneity.

RESULTS

A total of seven eligible studies (including 273 patients) were included out of 2152 screened records. Five studies were in participants with hip osteoarthritis (OA; n = 3), greater trochanteric pain syndrome (GTPS; n = 1) or piriformis syndrome (n = 1); the other two studies were conducted in healthy athletes (n = 2). Two articles assessed changes in participants' short-term visual analog scale (VAS) scores (<1 week), one of which showed that DN significantly reduced pain (P < 0.05). One-week VAS scores were analyzed in three studies, all of which demonstrated reduced scores following DN (P < 0.05). Hip range of motion (ROM) and muscle force were also improved following DN. No serious side effects were reported.

CONCLUSION

DN may be safe and effective at relieving hip pain and improving hip function. DN performs significantly better than several different types of control intervention (including sham DN, no treatment, corticosteroid injections and laser). Strong evidence (high degree of certainty around the results) is lacking, and future studies should ideally use longer follow-up periods and larger sample sizes.

REVIEW REGISTRATION NUMBER

CRD42022297845 (PROSPERO).

What factors influence pain scores following Corticosteroid injection in patients with Greater Trochanteric Pain Syndrome? A systematic review

BACKGROUND

Cortico-Steroid Injections (CSI) are commonly used to treat patients with Greater Trochanteric Pain Syndrome (GTPS) but it is unclear which patients will experience improvements in pain.

OBJECTIVES

To identify factors that influence improvements in pain for patients with GTPS treated with CSI.

DESIGN

Systematic review.

METHODS

A search was undertaken of AMED, CINAHL, Cochrane Library, EMBASE, Medline and PEDro databases. Studies were eligible for inclusion if they investigated factors that influenced changes in pain experienced by patients with GTPS who received a CSI. Studies needed to include relevant summary statistics and tests of clinical significance. Risk Of Bias in Non-randomised Trials Of Interventions (ROBINS-I) and Risk Of Bias 2 (ROB2) tools were used to assess bias.

RESULTS

The search identified 466 studies, 8 were included in the final review with a total of 643 participants. There was no association between demographic variables such as age, sex, symptom duration or obesity and pain outcomes post-CSI. Having a co-existing musculoskeletal (MSK) condition such as knee osteoarthritis or sacroiliac/lumbar spine pain was associated with less pain reduction post-CSI. Injections into the Trochanteric Bursa were associated with longer lasting pain reduction than Gluteus Medius Bursa or extra-bursal injections. Image guidance of CSI maintained lower pain scores at six months but did not increase the duration of the therapeutic effect past six months. The presence of specific ultrasound scan features was not associated with differences in pain scores.

CONCLUSIONS

Patients with co-existing MSK conditions may not respond to CSI as well as those without. Injections into the Greater Trochanteric Bursa may have longer lasting benefit. Further research is needed on the use of USS imaging findings and image guidance.

Comparing dry needling or local acupuncture to various wet needling injection types for musculoskeletal pain and disability. A systematic review of randomized clinical trials

PURPOSE

Systematically evaluate the comparative effectiveness of dry needling (DN) or local acupuncture to various types of wet needling (WN) for musculoskeletal pain disorders (MPD).

METHODS

Seven databases (PubMed, PEDro, SPORTDiscus, CINAHL, Scopus, Embase, and Cochrane Central Register of Controlled Trials) were searched following PROSPERO registration. Randomized clinical trials were included if they compared DN or local acupuncture with WN for MPD. Primary outcomes were pain and/or disability. The Revised Cochrane Collaboration tool (RoB 2.0) assessed the risk of bias.

RESULTS

Twenty-six studies were selected. Wet Needling types included cortisone (CSI) (N = 5), platelet-rich plasma (PRP) (N = 6), Botox (BoT) (N = 3), and local anesthetic injection (LAI) (N = 12). Evidence was rated as low to moderate quality. Results indicate DN produces similar effects to CSI in the short-medium term and superior outcomes in the long term. In addition, DN produces similar outcomes compared to PRP in the short and long term and similar outcomes as BoT in the short and medium term; however, LAI produces better pain outcomes in the short term.

CONCLUSION

Evidence suggests the effectiveness of DN to WN injections is variable depending on the injection type, outcome time frame, and diagnosis. In addition, adverse event data were similar but inconsistently reported. PROSPERO Registration: 2019 CRD42019131826Implications for rehabilitationDry needling produces similar effects for pain and disability in the short and medium term compared to cortisone, Botox, and platelet-rich plasma injections. Local anesthetic injection may be more effective at reducing short-term pain.Long-term effects on pain and disability are similar between dry needling and platelet-rich plasma injections, but dry needling may produce better long-term outcomes than cortisone injections.The available adverse event data is similar between dry and wet needling.The conclusions from this study may be beneficial for patients and clinicians for considering risk and cost benefit analyses.

Inertial Sensors and Pressure Pain Threshold to Evaluate People with Primary Adhesive Capsulitis: Comparison with Healthy Controls and Effects of a Physiotherapy Protocol

Inertial sensors (IMUs) have been recently widely used in exercise and rehabilitation science as they can provide reliable quantitative measures of range of motion (RoM). Moreover, the pressure pain threshold (PPT) evaluation provides an objective measure of pain sensation in different body areas. The aim of this study was to evaluate the efficacy of physiotherapy treatment in people with adhesive capsulitis in terms of RoM and pain improvement measured by IMUs and the PPT. A combined prospective cohort/cross-sectional study was conducted. Nineteen individuals with adhesive capsulitis (10/19 females, 54 ± 8 years) and nineteen healthy controls (10/19 females, 51 ± 6 years) were evaluated for active glenohumeral joint RoM and PPT on shoulder body areas. Then, individuals with adhesive capsulitis were invited to 20 sessions of a physiotherapy protocol, and the assessments were repeated within 1 week from the last session. The range of motion in the flexion (p = 0.001) and abduction (p < 0.001) of the shoulder increased significantly after the physiotherapy protocol. Similarly, the PPT was found to increase significantly in all the assessed shoulder body areas, leading to no significant differences compared to the healthy controls. IMU and PPT assessments could be used to evaluate the efficacy of physical therapy in people with adhesive capsulitis.

Acupuncture Treatment for Hip Pain: A Systematic Review and Meta-Analysis

Acupuncture treatment (AT) is an effective treatment for pain relief; however, there are few systematic reviews that have reported on the effectiveness of AT for hip pain. This systematic review aimed to evaluate the efficacy and safety of AT of hip pain. We searched eight databases for randomised controlled trials (RCTs) evaluating the effect of AT on hip pain until August 2022. Twelve RCTs (806 patients) were included: two reported a significant effect of AT compared with that of conventional medicine (CM) alone for hip pain; two reported significant effects of AT + CM compared with that of CM alone in terms of Visual Analogue Scale (VAS); two reported a significant effect of AT + CM compared with that of Sham AT + CM in terms of anaesthetic dosage; two reported a significant effect of AT + CM compared with that of Sham AT + CM in terms of the side effects associated with analgesic use; one study reported a significant effect of AT compared to that of no-treatment. No serious adverse events were reported. Our findings demonstrate the potential of AT in managing hip pain. Given the low quality and small sample sizes of the studies, the evidence supporting AT for hip pain management was weak. Further clinical trials and systematic reviews are required. The protocol of the current study was registered in the PROSPERO International prospective register of systematic reviews (CRD42017079586).

Dry needling in the management of tendinopathy: A systematic review of randomized control trials

INTRODUCTION

The objective of the study is to evaluate the best available evidence on the effectiveness of DN in the management of tendinopathy.

METHODS

Seven randomized control trials were selected following an electronic search in PubMed, Web of Science, Scopus, and SPORTDiscus databases. To be included in the current systematic review, the study had to be an RCT conducted on human participants, which investigated the effect of the DN technique on the management of tendinopathies. Only studies in the English language published in peer-reviewed journals between 1999 and 2020 were included. The methodological quality of the studies was assessed using the PEDro scale.

RESULTS

The PEDro score of the studies ranged from 5 to 9 with a mean score of 6.7 ± 1.2 (mean ± SD). A total of 357 participants were enrolled in the seven included studies, which were on greater trochanteric pain syndrome, lateral epicondylitis, supraspinatus tendinopathy and Achilles tendinopathy. DN was compared with various interventions, including platelet-rich plasma injection, autologous blood injection and non-steroidal anti-inflammatory medication. All the selected studies reported a significant positive effect of DN on pain intensity and other outcome measures, such as patient-specific functional score, disability index, range of motion and health-related quality of life.

CONCLUSION

The results indicate that DN appears to be as effective as other treatment methods at relieving pain and other symptoms of tendinopathy immediately after treatment and up to 6 months. DN can be considered among the many options available for the management of tendinopathy.

Local Corticosteroid Injection Versus Dry Needling in the Treatment of Lateral Epicondylitis

Background Lateral epicondylitis (LE) is an inflammation or micro-tearing of the tendons that join the forearm muscles on the lateral aspect of the elbow. Primary treatment of LE includes rest from offending activity and corticosteroid therapy for pain control. Dry needling (DN) is a relatively new therapy for LE. This study examined the results of DN therapy with corticosteroid injection. We aimed to compare pain relief and improvements in functional disability of LE patients treated via DN and corticosteroid injection in a tertiary care center. Methodology A prospective randomized control study was conducted among 54 patients in the Orthopaedics Department of R L Jalappa Hospital from January 2022 to May 2022. Patients received either DN or injectable corticosteroid therapy, and treatment groups were randomized using single-blinded randomization with sealed envelopes. Patients were evaluated using the Patient-Related Tennis Elbow Evaluation (PRTEE) score before the intervention and four and eight weeks after the intervention. Results A total of 54 patients were included in the final analysis. The mean age in the DN group was 43.96 ± 8.15 years and 44.74 ± 8.33 years in the corticosteroid group. In the DN group, 17 (62.96%) patients were male, and in the corticosteroid group, 16 (59.26%) patients were male. The differences in the PRTEE score at the fourth and eighth-week follow-up with baseline value (pre-injection) were statistically significant (p < 0.001). Conclusions DN is a low-cost, minimally invasive, and low-risk therapy whereas corticosteroid therapy is costly and produces systemic side effects in the long term. In this study, during the last follow-up visit, the PRTEE score improved in the DN group compared to the corticosteroid group.

Influence of Fatty Infiltration on Hip Abductor Repair Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Increasing evidence supports surgical intervention for hip abductor tears; however, the influence of fatty infiltration (FI) on outcomes after repair remains uncertain and has been addressed only in small case series.

PURPOSE

To clarify the relationship between FI and surgical outcomes for hip abductor tears.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. FI severity was assessed by Goutallier-Fuchs (G-F) grade. The relationship between FI and improvement in Harris Hip Score (HHS)/modified Harris Hip Score (mHHS) and visual analog scale (VAS) score for pain was examined with mixed-effects metaregression. Outcomes with open and endoscopic techniques were also compared.

RESULTS

A total of 4 studies (206 repairs in 201 patients) were eligible. High-grade FI was associated with significantly less improvement in HHS/mHHS than both no FI (6.761 less; 95% CI, 3.983-11.570; P = .002) and low-grade FI (7.776 less; 95% CI, 2.460-11.062; P < .001) but did not significantly influence VAS score (P > .05). Controlling for FI severity, we found no significant difference in HHS/mHHS improvement between open versus endoscopic repair (P > .05 at each level), but open repair resulted in significantly greater improvement in VAS score for every G-F grade (all P < .005).

CONCLUSION

Surgical intervention for symptomatic hip abductor tendon tears improved outcomes as reflected by change in HHS/mHHS; however, the presence of high-grade FI resulted in less improvement. FI severity did not influence VAS scores for pain. Although no differences were found between open and endoscopic repairs in terms of FI-adjusted improvement in HHS/mHHS, open repairs resulted in significantly greater pain relief at each FI level.

Acupuncture and Dry Needling for Sports Performance and Recovery

ABSTRACT

Acupuncture and dry needling share many similarities in their proposed mechanisms of action and their sports medicine-related applications. Pain is the most common indication for these needling treatments, but there also are some limited studies on their use for ergogenic purposes. Needling can likely improve muscular strength and power, including increasing jump height, and it also can increase flexibility. In terms of sports recovery, acupuncture can not only be used for pain relief after injury, but also can help with routine recovery, such as in delayed onset muscle soreness. There are numerous case reports of acupuncture and dry needling being used to treat athletes for various diagnoses and conditions, however more high quality studies are needed in order to make more specific evidence-based recommendations. Given the high degree of safety and limited adverse events associated with needling treatments, it can likely be promoted in athletes.

The effect of corticosteroid injection in the treatment of greater trochanter pain syndrome: a systematic review and meta-analysis of randomized controlled trials

Background

corticosteroid injection (CSI) has been used to treat greater trochanter pain syndrome (GTPS) for many years. However, so far, the efficacy of CSI in the treatment of GTPS is still controversial. Therefore, the aim of this review is to evaluate the effectiveness of CSI in comparison with sham intervention, nature history, usual care, platelet-rich plasma (PRP), physiotherapy/exercise therapy, dry needling, or other nonsurgical treatment for improvements in pain and function in GTPS.

Methods

PubMed (Medline), Embase, Cochrane Library were searched from their inception until April 2021. Randomized controlled trails (RCTs) comparing CSI to nonsurgical treatment were included. Data on the effect of CSI on pain and function were extracted and checked by two review authors independently. The treatment effect was analyzed in the short term, medium term, and long term.

Results

Eight RCTs (764 patients) were included. This review suggests CSI may be superior to usual care and ‘wait and see,’ ESWT, but may not be superior to exercise, PRP, dry needling, and sham intervention in short-term pain or function improvement. In terms of medium-term pain or function improvement, CSI may be superior to usual care and ‘wait and see,’ but may not be superior to PRP. In terms of long-term pain or function improvement, CSI may be inferior to PRP and ESWT, but it may be superior to usual care and ‘wait and see’ at 12 months.

Conclusions

Due to the small sample size and lack of sufficient clinical studies, current evidence is equivocal regarding the efficacy of CSI in the treatment of GTPS. Considering the limitations, more large-sample and high-quality RCTs are needed to prove the therapeutic effect of CSI on GTPS.

Trial registration

PROSPERO registration number: CRD42021247991. Registered 09 May 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03175-5.

Corticosteroid injection or dry needling for musculoskeletal pain and disability? A systematic review and GRADE evidence synthesis

Background

Corticosteroid injection and dry needling have been used in the treatment of musculoskeletal conditions, but it is unclear which intervention is the most effective. The purpose of this study was to compare the effects of corticosteroid injection and dry needling for musculoskeletal conditions at short-, medium-, and long-term follow-up.

Methods

Electronic databases were searched up to 31 October 2021. Two researchers independently screened titles, abstracts and full-text articles. Randomized clinical trials (RCTs) that investigated the effectiveness of dry needling compared to corticosteroid injection in patients over 18 years with a musculoskeletal condition were included in the review. The studies had to report pain and/or disability as outcome. Risk of bias was assessed by using the revised Cochrane Collaboration tool (RoB 2.0). Quality of evidence was evaluated by using the GRADE approach.

Results

Six studies were included (n = 384 participants). Four musculoskeletal conditions were investigated. There is very low-quality evidence that CSI is superior to DN for reducing heel pain (plantar fasciitis) and lateral elbow pain at short- and medium-term follow-up, but not for myofascial pain and greater trochanteric pain. There is very low-quality evidence that DN is more effective than CSI at long-term follow-up for reducing pain in people with plantar fasciitis and lateral epicondylitis. Very low-certainty evidence shows that there is no difference between DN and CSI for disability at short-term follow-up. One study showed that CSI is superior to DN at medium-term follow-up and another observed that DN is superior to CSI for reducing disability at long-term.

Conclusions

There are no differences between DN and CSI in pain or disability for myofascial pain and greater trochanteric pain syndrome. Very-low certainty evidence suggests that CSI is superior to DN at shorter follow-up periods, whereas DN seems to be more effective than CSI at longer follow-up durations for improving pain in plantar fasciitis and lateral epicondylitis. Large RCTs with higher methodological quality are needed in order to draw more incisive conclusions.

PROSPERO registration number

CRD42020148650.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00408-y.

Intramuscular Electrical Stimulation Combined with Therapeutic Exercises in Patients with Shoulder Adhesive Capsulitis: A Randomised Controlled Trial

Background:

Myofascial trigger points (MTrPs) precipitate the shoulder pain severity and disability in patients with shoulder adhesive capsulitis (SAC). This study aims to compare the effectiveness of intramuscular electrical stimulation (IMES) combined with therapeutic exercises versus dry needling (DN) combined with therapeutic exercises in improving the clinical outcomes in patients with SAC.

Methods and Materials:

In this randomized controlled trial, IMES (n = 45) and DN (43) groups had received respectively IMES, and DN twice weekly for three consecutive weeks. Both groups received therapeutic exercises 1520 minutes, five days in a week during the second and third week. Pain, disability, kinesiophobia, number of active and latent MTrPs, shoulder abduction and external rotation range of motion were assessed at baseline, week-1, week-2, week-3 and follow-up at 3 months. A repeated measures ANOVA performed to find out the significant differences in the clinical outcomes between the groups.

Results:

The results of repeated measures of ANOVA shows that the post intervention timelines assessment scores of VAS, DASH, shoulder abduction and external rotation ROM, number of active and latent MTrPs and kinesiophobia were significantly (p. < 0.05) improved in both groups. However, IMES group had achieved a greater improvement over DN group (p. < 0.05) on the shoulder pain severity and disability, shoulder range of motion, number of active and latent MTrPs and kinesiophobia. Despite the significant statistical differences between the groups, IMES group did not achieve the minimal clinically important differences of 1.5cm and 11-points respectively for the VAS and DASH scores. No serious adverse effects occurred during the three weeks of treatment.

Conclusion:

IMES combined with therapeutic exercises is an effective treatment to reduce the shoulder pain severity and upper limb disability by deactivating the active and latent MTrPs and improving the shoulder abduction and external rotation range of motion in patients with SAC.

Greater trochanteric pain syndrome: predicting who will respond to a local glucocorticoid injection

Objectives: This study aimed to explore whether certain clinical tests or a rapid improvement in lateral hip pain following periarticular injection are predictive of subsequent efficacy of local glucocorticoid (GC) injection in greater trochanteric pain syndrome (GTPS).Method: This secondary analysis of a randomized controlled trial of an injection of GC and local anaesthetic (LA) versus placebo included 44 patients with GTPS. Two subgroups of patients were defined: (i) 30 min responders, reporting a decrease of ≥ 50% of the initial pain at 30 min post-injection; and (ii) positive triple test, presenting a combination of three positive clinical tests (30-second single-leg stance, FABER, and Lequesne). Median level of numeric rating scale for pain at 1 month was the primary outcome. Interaction analysis of treatment effect in the subgroups was performed using a linear regression adjusting for pain at baseline.Results: Sixteen patients (36%) were 30 min responders. In this group, GC treatment was associated with a significant improvement in pain at 1 month compared to non-responders (p = 0.03). The 30 min response was not associated with the use of LA. Positive triple test (22% of patients) was associated with higher pain scores at baseline (p = 0.03). In this group, patients who received placebo had significantly more pain at 1 month than those with the cortisone injection (p = 0.04).Conclusion: Patients with GTPS who present a rapid decrease in pain after periarticular injection, and those who display a combination of three specific clinical tests, are more likely to benefit from an injection with GC and anaesthetic.

[Evidence in Infiltrative Pain Therapy of the Musculoskeletal System]

Musculoskeletal pain symptoms frequently generate limitations in daily work and life in many patients. Usually, symptomatic treatment is possible before clarifying the in depth diagnosis. A symptom-based infiltration therapy will never replace a thoroughly done physical examination and thoughtful collection of patient history, however, it can be of great benefit for the patient when done focused on the point of pain and executed with profound anatomical knowledge. Furthermore, the knowledge of the level of evidence of therapeutic infiltrations improves their outcomes and shapes realistic patients' expectations. Ultrasound-guided therapeutic infiltrations improve the outcome despite the use of lower amounts of active agents by pinpointed applications. This article provides an overview of the scientific evidence of effectiveness of (ultrasound-guided) infiltration techniques in diverse musculoskeletal regions.

Criteria Used for the Diagnosis of Myofascial Trigger Points in Clinical Trials on Physical Therapy: Updated Systematic Review

OBJECTIVE

The objective of this study was to conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019.

METHODS

MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points," "trigger point," "myofascial trigger point," "myofascial trigger points," "myofascial pain," and "myofascial pain syndrome." The MeSH keywords were combined by using Boolean operators "OR"/"AND." All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least 1 active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines.

RESULTS

Of 478 possibly relevant publications, 198 met the inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the 6 criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness," "referred pain," and "local twitch response" (n=28 studies, 22%).

CONCLUSIONS

A number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain, and local twitch response were the 3 most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature.

REGISTRY

This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.

Ultrasound-Guided Percutaneous Tenotomy for Gluteal Tendinopathy

Background:

Gluteal tendinopathy is a common cause of lateral hip pain. Percutaneous ultrasonic tenotomy (PUT) has been used successfully for the treatment of tendinopathy of the elbow, knee, and ankle, but its use in the hip has not been described.

Purpose:

To evaluate the efficacy of PUT in patients who did not respond to nonsurgical management of gluteal tendinopathy.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 29 patients with gluteal tendinopathy (mean age, 62 years) who did not respond to nonsurgical treatment were enrolled in this prospective study and underwent ultrasound-guided PUT in an outpatient setting. Patients with a history of ipsilateral hip surgery were excluded. All patients initially underwent magnetic resonance imaging or a computed tomography arthrogram demonstrating tendinopathy and/or partial tearing of the gluteus minimus or medius tendon or both tendons. Outcomes were assessed with a visual analog scale (VAS) for pain, the Harris Hip Score evaluation, and the 12-Item Short Form Health Survey (SF-12) before the procedure and at subsequent follow-up visits or by telephone interviews at 3 weeks, 3 months, 6 months, and final follow-up (range, 18-30 months).

Results:

The mean final follow-up was at 22 months postoperatively. At final follow-up, VAS scores had improved from a preprocedural mean ± SD of 5.86 ± 1.73 to 2.82 ± 2.22 (P < .01). Harris Hip Scores improved from a preprocedural mean of 60.03 ± 10.86 to 77.47 ± 14.34 (P < .01). Total SF-12 scores improved from a mean of 29.93 ± 5.39 (51% optimal) to 34.41 ± 4.88 (64% optimal) (P < .01). No complications were reported. At final follow-up, when asked whether they would have the procedure again, 15 patients replied “yes definitely,” 3 replied “yes probably,” 3 replied “maybe,” 1 replied “likely not,” and 2 replied “definitely not.” There were 3 patients who eventually had hip abductor tendon repair, and their PUT procedures were considered failures.

Conclusion:

PUT is an effective treatment, with good results for patients with gluteal tendinopathy.

Physiotherapy management of greater trochanteric pain syndrome (GTPS): an international survey of current physiotherapy practice

OBJECTIVES

This study aimed to establish and compare current physiotherapy management of GTPS in Australia, New Zealand (NZ) and Ireland.

DESIGN

Cross-sectional observational survey of physiotherapists.

METHODS

An online survey was distributed to registered musculoskeletal physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; median and interquartile ranges were calculated for numerical data. Inter-country comparisons were made using Chi-squared analyses for nominal/ordinal data and Kruskal-Wallis tests for numerical data. Statistical significance was set at P<0.05.

RESULTS/FINDINGS

Valid responses were received from 361 physiotherapists, 61% were female and 80% worked in private practice. Overall, consistency in treatment of GTPS was observed across the three countries. All physiotherapists used education and exercise (most commonly strengthening and neuromuscular control) primarily targeting the gluteal muscles. Other interventions included massage (90%), stretching (53%), range of motion (40%), thermal modalities (50%), taping (38%) and electrotherapy (25%), whilst 40% commonly recommended up to 2 to 3 corticosteroid injections per patient/per annum. Physiotherapists used pain severity scales as their primary outcome measure (79%). Single leg stance was the most common physical measure used (68%), and global rating scores or standardised physical measures were less commonly used.

CONCLUSION

This international survey established the physiotherapy management of GTPS. Education used in conjunction with exercise is in line with current evidence, but a proportion of clinicians use adjunct treatments without clear rationale or supporting evidence. Results indicate the need to further define optimal management of GTPS using robust methodologies such as randomised controlled trials.

How strong is the evidence that conservative treatment reduces pain and improves function in individuals with patellar tendinopathy? A systematic review of randomised controlled trials including GRADE recommendations

OBJECTIVE

To determine the effectiveness of conservative treatment (CT) on pain and function in patients with patellar tendinopathy (PT) compared with minimal intervention (MI) or other invasive intervention, or in addition to decline eccentric squat.

METHODS

Searches were performed in MEDLINE, Embase, Cochrane, PEDro, SPORTDiscus, CINAHL and AMED databases. All randomised trials that evaluated CT (any intervention not involving invasive procedures or medication) in individuals with PT were included. Two reviewers screened studies, extracted data and assessed risk of bias of all included studies. Where suitable, meta-analyses were conducted; we assessed certainty of the evidence using GRADE methodology.

RESULTS

When compared with MI, CT did not improve pain (weighted mean difference (WMD) -2.6, 95% CI -6.5 to 1.2) or function (WMD 1.8, 95% CI -2.4 to 6.1) in the short-term (up to 3 months) follow-up. When compared with invasive intervention, CT did not improve pain (WMD 0.7, 95% CI -0.1 to 1.4) or function (WMD -6.6, 95% CI -13.3 to 0.2) in the short-term follow-up. No overall effects were found for combined CT (when a conservative intervention was added to decline eccentric squat) on pain (WMD -0.5, 95% CI -1.4 to 0.4) or function (WMD -2.3, 95 % -9.1 to 4.6) at short-term follow-up. Single studies showed an effect on pain with iontophoresis at short-term follow-up (d = 2.42) or dry needling at medium/long-term follow-up (d = 1.17) and function with exercise intervention at medium/long-term follow-up (over 3 months) (d = 0.83).

SUMMARY/CONCLUSION

Our estimates of treatment effect have only low to very low certainty evidence to support them. This field of sports medicine/sports physiotherapy urgently needs larger, high-quality studies with pain and function among the potential primary outcomes.

Dry needling in addition to standard physical therapy treatment for sub-acromial pain syndrome: a randomized controlled trial protocol

BACKGROUND

Trigger point dry needling interventions are utilized by physical therapists to manage shoulder pain. Observational studies have shown positive short-term outcomes in patients with subacromial pain syndrome receiving trigger point dry needling. However, little research has been done to evaluate the long-term effectiveness of trigger point dry needling specifically as it compares to other commonly utilized interventions such as exercise and manual therapy. The purpose of this study is to assess the additive short and long-term effectiveness of trigger point dry needling to a standard physical therapy approach of manual therapy and exercise for patients with subacromial pain syndrome.

METHODS

This multicenter randomized trial with 3 arms was designed following the standard protocol items for randomized interventional trials. Results will be reported consistent with the consolidated standards of reporting trials guidelines. 130 participants will be randomized to receive standard PT interventions alone (manual therapy and exercise), standard PT and trigger point dry needling or standard PT and sham trigger point dry needling. The primary outcome measures will be the Shoulder Pain and Disability Index and Patient Reported Outcomes Measurement Information Systems (PROMIS-57) scores collected at baseline, 6-weeks, 6-months and one year. Healthcare utilization will be collected for 12 months following enrollment and groups analyzed for differences.

DISCUSSION

It is not known if trigger point dry needling provides long-term benefit for individuals with subacromial pain syndrome. This study will help determine if this intervention provides additive benefits over those observed with the commonly applied interventions of exercise and manual therapy.

TRIAL REGISTRATION

Identifier: NCT03442894 (https://clinicaltrials.gov/ct2/show/NCT03442894) on 22 February 2018.

Glucocorticoid injections for greater trochanteric pain syndrome: a randomised double-blind placebo-controlled (GLUTEAL) trial

Small observational studies suggest that local glucocorticoid (GC) injection may be effective in the management of the greater trochanteric pain syndrome (GTPS). The objective was to perform the first randomised double-blind placebo-controlled trial to investigate the efficacy of local GC injection in the management of GTPS. The trial was conducted between November 2011 and May 2015. Inclusion criteria included lateral hip pain (LHP) for greater than 1 month, a LHP score of ≥ 4/10 and typical LHP reproduced by palpation of the greater trochanter. Participants were randomised in a 1:1 ratio to injection with a combination of local anaesthetic and GC (intervention) or injection with normal saline solution (placebo). The primary outcome of interest was the difference in pain intensity at 4 weeks post-injection between the two groups. Patients were followed for 6 months. A total of 46 patients were included. There were no significant differences between the two groups in terms of pain reduction at 1 month (p = 0.23). When including all measures in the first 4 weeks and using multilevel regression, there was a trend towards improvement in pain scores in favour of the intervention group (p = 0.08). There were no significant differences in pain scores between groups at 3 and 6 months. In the management of GTPS, local glucocorticoid injections are of no greater efficacy than injection of normal saline solution. Given the lack of long-term improvement and the potential for cortisone-related side effects, this intervention is of limited benefit.

Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.

August 2017 Letters to the Editor-in-Chief

Letter to the Editor-in-Chief of JOSPT as follows: "Manual Therapy: More Than Elaborate Swordplay" with Authors' Response "Comparing Dry Needling to Corticosteroid Injection for Greater Trochanteric Pain Syndrome" with Authors' Response J Orthop Sports Phys Ther 2017;47(8):580-585. doi:10.2519/jospt.2017.0204.