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Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023; 27:1-389. [PMID: 37929629 PMCID: PMC10641714 DOI: 10.3310/tfws2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy. Review questions (i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies? Methods A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021. Results Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship. Limitations Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made. Conclusion The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence. Future work There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes. Study registration This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review). Funding This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kay Cooper
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Lyndsay Alexander
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - David Brandie
- Sportscotland Institute of Sport, Airthrey Road, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Isabelle Harrison
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Colin MacLean
- Library Services, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Laura Mitchell
- NHS Grampian, Physiotherapy Department, Ellon Health Centre, Schoolhill, Ellon, Aberdeenshire, UK
| | - Dylan Morrissey
- William Harvey Research Institute, School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, UK
| | - Rachel Ann Moss
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | | | - Joanna Shim
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
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Barker-Davies RM, Baker P, Watson J, Goodall D, Wheeler PC, Nicol AM, Fong DT, Lewis MP, Bennett AN. High-Volume Image-Guided Injections in Achilles and Patellar Tendinopathy in a Young Active Military Population: A Double-Blind Randomized Controlled Trial. Orthop J Sports Med 2022; 10:23259671221088326. [PMID: 35425844 PMCID: PMC9003662 DOI: 10.1177/23259671221088326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Chronic Achilles and patellar tendinopathy are a significant burden in physically active populations. High-volume image-guided injection (HVIGI) proposes to strip away associated neovascularity, disrupt painful nerve ingrowth, and facilitate rehabilitation. Purpose: To investigate the efficacy of HVIGI with and without steroid relative to placebo. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 62 participants were recruited between May 25, 2016, and March 5, 2020. Participants were men aged 18 to 55 years with Achilles or patellar tendinopathy of at least 6-month chronicity that had not improved with nonoperative management (including physical therapy and shockwave therapy), with ultrasound evidence of neovascularization, tendon thickening, and echogenic changes. They were assigned to the following groups: control (3 mL of subcutaneous 0.5% bupivacaine), HVIGI (10 mL of 0.5% bupivacaine and 30 mL of normal saline, ultrasound-guided between tendon and underlying fat pad), or HVIGI with steroid (HVIGIwSteroid; 0.25 mL of 100 mg/mL hydrocortisone). Clinicians and assessors were blinded. All participants were supervised through a pain-guided progressive loading program for 6 months postinjection. The main outcome measures were the Victoria Institute of Sport Assessments (VISA) for Achilles and patellar tendinopathy and the visual analog scale (VAS) for pain at 6 months postinjection. Results: The VISA score improved by a mean of 22.8 points (95% CI, 10.4-35.3 points; effect size [ES], 1.51) in the control group (n = 21), 18.6 points (95% CI, 9.1-28.0 points; ES, 1.31) in the HVIGI group (n = 21), and 18.5 points (95% CI, 3.4-33.6 points; ES, 0.88) in the HVIGIwSteroid group (n = 20). VAS pain improved by a mean of 15 points (interquartile range [IQR], –38.75, 8 points; ES, 0.39) in controls, 13 points (IQR,–34.0, 3.75 points; ES, 0.47) in the HVIGI group, and 27 points (IQR,–38.0, –1.0 points; ES, 0.54) in the HVIGIwSteroid group. The main effects were significant for time (P < .001) but not group (P ≥ .48), with no group × time interaction (P = .71). One participant was lost to follow-up from each group, multiple imputation was used for missing data points. No adverse events occurred. Conclusion: Study findings did not demonstrate superiority of HVIGI over control injection. Registration: EU Clinical Trials Register (EudraCT: 2015-003587-36).
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Affiliation(s)
- Robert M. Barker-Davies
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Polly Baker
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
| | - James Watson
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
| | - Duncan Goodall
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
| | - Patrick C. Wheeler
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Alastair M. Nicol
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Daniel T.P. Fong
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Mark P. Lewis
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Alexander N. Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Nottinghamshire, UK
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, Loughborough, UK
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3
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Butt A, Umaskanth N, Sahu A. Image-guided intervention in the management of chronic patellar tendinopathy with calcification: a three-pronged approach. BMJ Case Rep 2021; 14:14/6/e240553. [PMID: 34116988 DOI: 10.1136/bcr-2020-240553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patellar tendinopathy is a common cause of knee pain and functional impairment in athletes. It is commonly managed using conservative measures such as physiotherapy, but cases that are refractory to such treatment may require a more invasive approach. Various forms of image-guided injection therapy have been described in the literature. We present a case of successful treatment of chronic patellar tendinopathy with calcification with the first reported use of a three-pronged image-guided approach, consisting of dry needling, high volume image-guided injection (but at a reduced dose) and barbotage applied in a single sitting. The patient reported resolution of symptoms persisting to 1 year postprocedure. We suggest that this management option, if supported by further positive research findings, could be used in the future in the management of certain cases of patellar tendinopathy with calcification where conservative measures have failed.
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Affiliation(s)
- Aqeel Butt
- Medicine, London North West University Healthcare NHS Trust, London, UK
| | - Neelan Umaskanth
- Medicine, London North West University Healthcare NHS Trust, London, UK
| | - Ajay Sahu
- Radiology, London North West University Healthcare NHS Trust, London, UK
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4
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Nielsen TG, Miller LL, Mygind-Klavsen B, Lind M. High-volume image-guided injection in the chronic recalcitrant non-insertional patellar tendinopathy: a retrospective case series. J Exp Orthop 2020; 7:80. [PMID: 33037952 PMCID: PMC7547937 DOI: 10.1186/s40634-020-00299-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To evaluate if High-volume Image-guided Injection (HVIGI)-treatment for chronic Patellar tendinopathy (PT) improve function and reduce pain at 16-months follow-up. Methods Patients with resistant PT who failed to improve after a three-month eccentric loading program were included in the study. Maximal tendon thickness was assessed with ultrasound. All patients were injected with 10 mL of 0.5% Marcaine, 0.5 mL Triamcinolonacetonid (40 mg/mL) and 40 mL of 0.9% NaCl saline solution under real-time ultrasound-guidance and high pressure. All outcome measures were recorded at baseline and at 16 months. A standardised Heavy Slow Resistance rehabilitation protocol was prescribed after HVIGI-treatment. Clinical outcome was assessed with the Victorian Institute of Sports Assessment-Patella tendon questionnaire (VISA-P) and statistically analyses were performed. Results The study included 28 single treatment HVIGI procedures in PT in 23 patients (19 men, 4 women) with a mean age of 30.3 (range 19–52). The mean duration of symptoms before HVIGI was 33 months. The baseline VISA-P score of 43 ± 17 (range 15–76) improved to 76 ± 16 (range 42–95) after 16 months (p < 0.01). Of the 28 HVIGI procedures 12 patients (15 PT) were not satisfied after the initial HVIGI procedure. Of these, 5 patients (5 PT) had additional HVIGI, 2 patients (2 PT) had corticoid injection and 6 patients (8 PT) needed surgery. Of the remaining 11 patients (13 PT), 9 patients had more than a 13-point improvement in the VISA-P score after 16 months. Conclusions In this retrospective case-study, only 9 patients (32%) did benefit of a single HVIGI treatment at 16-months and a 33-point significant improvement was seen on the VISA-P score.
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Affiliation(s)
- Torsten Grønbech Nielsen
- Aarhus University Hospital, Orthopedic Department, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Lene Lindberg Miller
- Aarhus University Hospital, Orthopedic Department, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Bjarne Mygind-Klavsen
- Aarhus University Hospital, Orthopedic Department, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Martin Lind
- Aarhus University Hospital, Orthopedic Department, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Masci L, Alfredson H, Neal B, Wynter Bee W. Ultrasound-guided tendon debridement improves pain, function and structure in persistent patellar tendinopathy: short term follow-up of a case series. BMJ Open Sport Exerc Med 2020; 6:e000803. [PMID: 32789022 PMCID: PMC7380954 DOI: 10.1136/bmjsem-2020-000803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 01/17/2023] Open
Abstract
There is a need for effective therapeutic options for resistant patellar tendinopathy. Ultrasound (US)-guided arthroscopic debridement has demonstrated promising clinical results.
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Affiliation(s)
- Lorenzo Masci
- Department of Sports and Execise Medicine, Queen Mary University of London, London, UK.,Department of Sports and Exercise Medicine, ISEH, London, UK
| | - Hakan Alfredson
- Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umea, Sweden.,Clinical Research, Pure Sports Medicine, London, UK
| | - Brad Neal
- Department of Sports and Execise Medicine, Queen Mary University of London, London, UK.,Clinical Research, Pure Sports Medicine, London, UK
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6
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Aicale R, Bisaccia RD, Oliviero A, Oliva F, Maffulli N. Current pharmacological approaches to the treatment of tendinopathy. Expert Opin Pharmacother 2020; 21:1467-1477. [DOI: 10.1080/14656566.2020.1763306] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Rocco Domenico Bisaccia
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Department of Pharmacology, School of Medicine and Surgery, University of Salerno , Baronissi, Italy
| | - Antonio Oliviero
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno , Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona , Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London , London, UK
- Keele University, Faculty of Medicine, School of Pharmacology and Bioengineering, Guy Hilton Research Centre , Stoke-on-Trent, UK
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7
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Moura JL, Abreu FG, Queirós CM, Pisanu G, Clechet J, Vieira TD, Sonnery-Cottet B. Ultrasound-Guided Electrocoagulation of Neovessels for Chronic Patellar Tendinopathy. Arthrosc Tech 2020; 9:e803-e807. [PMID: 32577355 PMCID: PMC7301331 DOI: 10.1016/j.eats.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/13/2020] [Indexed: 02/03/2023] Open
Abstract
Chronic patellar tendinopathy remains a challenging problem. The first line of treatment is conservative; when this fails, surgical treatment is indicated. Several open and arthroscopic techniques have been described. We describe an alternative technique using ultrasound-guided electrocoagulation of neovessels that leaves the patellar tendon intact.
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Affiliation(s)
| | | | | | | | | | | | - Bertrand Sonnery-Cottet
- Address correspondence to Bertrand Sonnery-Cottet, M.D., Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Hôpital Privé Jean Mermoz, Groupe Ramsay GDS, 69008 Lyon, France.
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8
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Abstract
Patellar tendinopathy, or jumper's knee is a common musculoskeletal condition characterized by progressive activity-related pain on the anterior aspect of the knee and tenderness on the patellar tendon. A conservative method is often the first choice of treatment, which can include anti-inflammatory medication, injection therapies, physiotherapy, eccentric exercises, extra corporeal shock wave therapy, orthosis, etc. Although there are several treatment options available, the management of patellar tendinopathy is still controversial. The literature reveals many different injection methods are being used by clinicians for the treatment of patellar tendinopathy. Platelet rich plasma, corticosteroids, autologous blood, and aprotinin are the most commonly used injection treatments. Injection therapies give promising results in the management of Patellar tendinopathy. However, due to low quality research and variation in the protocol and population it is difficult to provide a firm conclusion on its effectiveness. More high-quality clinical studies are recommended to determine the effectiveness of injections and at which stage of Patellar tendinopathy they are the most effective. This review can provide insight to clinicians involved in the management of this condition.
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Affiliation(s)
- Shibili Nuhmani
- Department of Physical Therapy, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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9
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Kaplan K, Olivencia O, Dreger M, Hanney WJ, Kolber MJ. Achilles Tendinopathy: An Evidence-Based Overview for the Sports Medicine Professional. Strength Cond J 2019. [DOI: 10.1519/ssc.0000000000000485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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10
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Boesen AP, Langberg H, Hansen R, Malliaras P, Boesen MI. High volume injection with and without corticosteroid in chronic midportion achilles tendinopathy. Scand J Med Sci Sports 2019; 29:1223-1231. [PMID: 31044450 DOI: 10.1111/sms.13450] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 04/06/2019] [Accepted: 04/25/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND High volume injection (HVI) shows promising results in the treatment of chronic midportion Achilles tendinopathy (AT). HVI consists of a large volume of saline with a small amount of corticosteroid and local anesthetic. OBJECTIVE To determine the effect of corticosteroid in HVI in AT. METHODS A total of 28 men (18-59 years) with chronic (>3 months) AT were included in a double-blinded RCT and followed for 24 weeks. All performed eccentric training and randomized to either (a) HVI injection with corticosteroid or (b) HVI injection without corticosteroid. Outcomes included self-reported function (VISA-A score) and pain (VAS score) and ultrasound imaging (tendon thickness, Doppler flow). RESULTS VISA-A and VAS score improved in both groups at all time-points (P < 0.05). VISA-A improvement was significantly greater in HVI with corticosteroid (mean ± SEM; 6-weeks = 31 ± 3 points; 12-weeks = 32 ± 5 points) vs HVI without corticosteroid (6 weeks = 14 ± 3; 12-weeks = 17 ± 3) at 6 and 12 weeks (P < 0.05), but not at 24 weeks. Decrease in VAS scores was significantly greater in HVI with corticosteroid (6 weeks = 55 ± 3 mm; 12 weeks = 53 ± 5 mm) vs HVI without corticosteroid (6 weeks = 16 ± 3 mm; 12 weeks = 25 ± 5 mm) at 6 and 12 weeks (P < 0.05) but not at 24 weeks. Tendon thickness decreased significantly in both groups at all time-points (P < 0.05), but more in the HVI with corticosteroid vs HVI without corticosteroid at 6 and 12 weeks (P < 0.05) but not at 24 weeks. CONCLUSION High volume injection with or without corticosteroid in combination with eccentric training seems effective in AT. HVI with corticosteroid showed a better short-term improvement than HVI without corticosteroid indicating a short-term effect of corticosteroid in HVI treatment of AT.
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Affiliation(s)
- Anders P Boesen
- Ortopaedic Surgery M, Bispebjerg Hospital, Institute of Sports Medicine Copenhagen, Copenhagen, Denmark.,Arthroscopic Center and Sports Orthopaedic Research Center- Copenhagen (SORC-C), Hvidovre, Denmark
| | - Henning Langberg
- Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, CopenRehab, Institute of Social Medicine, Copenhagen, Denmark
| | - Rudi Hansen
- Ortopaedic Surgery M, Bispebjerg Hospital, Institute of Sports Medicine Copenhagen, Copenhagen, Denmark
| | - Peter Malliaras
- Department of Physiotherapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Morten I Boesen
- Department of Orthopedic Surgery, Sjaelland University Hospital, Køge, Denmark
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Andriolo L, Altamura SA, Reale D, Candrian C, Zaffagnini S, Filardo G. Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. Am J Sports Med 2019; 47:1001-1018. [PMID: 29601207 DOI: 10.1177/0363546518759674] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patellar tendinopathy is a condition characterized by anterior knee activity-related pain. It has a high incidence among athletes engaged in jumping sports and may become a chronic condition. Nonoperative management is the first choice in these patients, and several nonsurgical treatment options have been proposed. Nonetheless, clear indications on the most effective approach to address patellar tendinopathy are still lacking. PURPOSE To analyze the evidence on nonoperative options to treat chronic patellar tendinopathy through a systematic review of the literature and to perform a meta-analysis to identify the most effective nonsurgical option. STUDY DESIGN Systematic review and meta-analysis. METHODS The search was conducted with the PubMed and Cochrane databases on January 4, 2017. All clinical English-language reports of any level of evidence on nonsurgical treatment of patellar tendinopathy were included. The quality of each article was assessed by use of the Coleman score. A meta-analysis was performed on all articles reporting the Victorian Institute of Sport Assessment scale for patellar tendinopathy to evaluate the results of the most described treatments. RESULTS A total of 70 studies involving 2530 patients were included in the qualitative data synthesis. The Coleman score showed an overall poor study quality. The most described treatment groups that could be included in the meta-analysis were reported in 22 studies on eccentric exercise, extracorporeal shockwave therapy (ESWT), and platelet-rich plasma (PRP). Single and multiple PRP injections were evaluated separately. Eccentric exercise therapies obtained the best results ( P < .05) at short-term (<6 months, mean 2.7 ± 0.7 months). However, multiple injections of PRP obtained the best results ( P < .05), followed by ESWT and eccentric exercise, at long-term follow-up (≥6 months, mean 15.1 ± 11.3 months). CONCLUSION The literature documents several nonsurgical approaches for the treatment of chronic patellar tendinopathy with important limitations in terms of study quality. The available evidence showed an overall positive outcome, but some differences have been highlighted. Eccentric exercises may seem the strategy of choice in the short-term, but multiple PRP injections may offer more satisfactory results at long-term follow-up and can be therefore considered a suitable option for the treatment of patellar tendinopathy.
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Affiliation(s)
- Luca Andriolo
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
| | - Sante Alessandro Altamura
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
| | - Davide Reale
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
| | | | - Stefano Zaffagnini
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
| | - Giuseppe Filardo
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
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Abate M, Di Carlo L, Verna S, Di Gregorio P, Schiavone C, Salini V. Synergistic activity of platelet rich plasma and high volume image guided injection for patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc 2018; 26:3645-3651. [PMID: 29605861 DOI: 10.1007/s00167-018-4930-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 03/26/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Platelet rich plasma and high volume image guided injections of saline have been used in the treatment of patellar tendinopathy with positive results. As the different mechanisms of action do not interfere each other, it can be hypothesized that they can be used in combination. Aim of this study was twofold: first, to evaluate the efficacy of these two treatments in the management of patellar tendinopathy; second, to verify whether the combination of these therapies could provide further advantages. METHODS Fifty-four patients suffering from patellar tendinopathy were enrolled. After clinical (VAS and VISA-P) and sonographic evaluation, two ultrasound guided injections (2 weeks apart) of platelet rich plasma, high-volume image-guided injections of saline, or both in association were performed. The VAS and VISA-P scores obtained from the three treatments groups (18 patients in each group) were compared across the different follow-up times (3 and 6 months). RESULTS In the short term both treatments showed comparable efficacy, whereas in the medium term the positive effects of high-volume image-guided injections gradually diminished and platelet rich plasma showed greater efficacy. Better results (reduced pain, improved function and increased number of subjects who exhibited optimal recovery [> 20 points in VISA-P score]) were observed when both procedures were associated. CONCLUSIONS The contemporaneous administration of platelet rich plasma and high volume image guided injections of saline treatments, which influence tendon repair by means of different mechanisms, grants a greater improvement for patellar tendinopathy. This finding has clinical relevance, given that this condition has a substantial impact on sports and work performance. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michele Abate
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy.
| | - Luigi Di Carlo
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
| | - Sandra Verna
- Immunohaematology and Transfusional Medicine Service, "SS. Annunziata" Hospital, Chieti Scalo, Chieti, Italy
| | - Patrizia Di Gregorio
- Immunohaematology and Transfusional Medicine Service, "SS. Annunziata" Hospital, Chieti Scalo, Chieti, Italy
| | - Cosima Schiavone
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
| | - Vincenzo Salini
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
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Abdelbary MH, Bassiouny A. Ultrasound guided injection in patellar tendinopathy; clinical outcomes of platelet-rich plasma compared to high-volume injection. The Egyptian Journal of Radiology and Nuclear Medicine 2018; 49:1159-62. [DOI: 10.1016/j.ejrnm.2018.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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de Cesar Netto C, da Fonseca LF, Simeone Nascimento F, O'Daley AE, Tan EW, Dein EJ, Godoy-Santos AL, Schon LC. ☆Diagnostic and therapeutic injections of the foot and ankle-An overview. Foot Ankle Surg 2018; 24:99-106. [PMID: 29409219 DOI: 10.1016/j.fas.2017.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 01/17/2017] [Accepted: 02/02/2017] [Indexed: 02/04/2023]
Abstract
Foot and ankle injections are useful diagnostic and therapeutic tools, particularly when the pain etiology is uncertain. A variety of foot and ankle injuries and pathologies, including degenerative joint disease, plantar fasciitis and different tendinopathies are amenable to injections. Understanding the foot and ankle anatomical landmarks, a thorough physical exam and knowledge of the different injection techniques is key for a successful approach to different pathologies. The objective of this study is to review the use of foot and ankle injections in the orthopaedic literature, present the readers with the senior author's experience and provide a comprehensive clinical guideline to the most common foot and ankle diagnostic and therapeutic injections.
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Affiliation(s)
- Cesar de Cesar Netto
- Medstar Union Memorial Hospital - 3333 Calvert Street, Baltimore, MD, 21218, USA; University of Alabama at Birmingham (UAB) - 1313 13th Street South, Birmingham, Alabama, 35205, USA.
| | | | | | - Andres Eduardo O'Daley
- University of Alabama at Birmingham (UAB) - 1313 13th Street South, Birmingham, Alabama, 35205, USA
| | - Eric W Tan
- University of Southern California (USC), Keck School of Medicine, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA
| | - Eric J Dein
- Johns Hopkins University, School of Medicine, 601 N Caroline Street, Baltimore, MD 21287, USA
| | | | - Lew Charles Schon
- Medstar Union Memorial Hospital - 3333 Calvert Street, Baltimore, MD, 21218, USA
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Boesen AP, Hansen R, Boesen MI, Malliaras P, Langberg H. Effect of High-Volume Injection, Platelet-Rich Plasma, and Sham Treatment in Chronic Midportion Achilles Tendinopathy: A Randomized Double-Blinded Prospective Study. Am J Sports Med 2017; 45:2034-2043. [PMID: 28530451 DOI: 10.1177/0363546517702862] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse. PURPOSE To determine whether eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment-Achilles [VISA-A]). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up. RESULTS VISA-A scores improved in all groups at all time points ( P < .05), with greater improvement in the HVI group (mean ± SEM, 6 weeks = 27 ± 3 points; 12 weeks = 29 ± 4 points) versus PRP (6 weeks = 14 ± 4; 12 weeks = 15 ± 3) and placebo (6 weeks = 10 ± 3; 12 weeks = 11 ± 3) at 6 and 12 weeks ( P < .01) and in the HVI (22 ± 5) and PRP (20 ± 5) groups versus placebo (9 ± 3) at 24 weeks ( P < .01). VAS scores improved in all groups at all time points ( P < .05), with greater decrease in HVI (6 weeks = 49 ± 4 mm; 12 weeks = 45 ± 6 mm; 24 weeks = 34 ± 6 mm) and PRP (6 weeks = 37 ± 7 mm; 12 weeks = 41 ± 7 mm; 24 weeks = 37 ± 6 mm) versus placebo (6 weeks = 23 ± 6 mm; 12 weeks = 30 ± 5 mm; 24 weeks = 18 ± 6 mm) at all time points ( P < .05) and in HVI versus PRP at 6 weeks ( P < .05). Tendon thickness showed a significant decrease only in HVI and PRP groups during the intervention, and this was greater in the HVI versus PRP and placebo groups at 6 and 12 weeks ( P < .05) and in the HVI and PRP groups versus the placebo group at 24 weeks ( P < .05). Muscle function improved in the entire cohort with no difference between the groups. CONCLUSION Treatment with HVI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. Registration: NCT02417987 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Anders Ploug Boesen
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Orthopaedic Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Rudi Hansen
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Peter Malliaras
- Department of Physiotherapy, School of Primary Health Care Faculty of Medicine, Nursing and Health Science, Monash University, Frankston, Victoria, Australia
| | - Henning Langberg
- CopenRehab, Institute of Social Medicine, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
Chronic patellar tendinopathy affects athletes, with a higher incidence in high-impact sporting activities. It can seriously impair sports activities. Many patients respond well to conservative treatment, but about 10% of them are refractory to conservative treatment. In these cases, surgery is indicated. Multiple surgical techniques have been reported, including both open and arthroscopic procedures with good results. However, in a small percentage of patients surgery is unsuccessful. This group of patients presents a major challenge, as options are limited. We describe our surgical approach in the management of recalcitrant patellar tendinopathy.
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Affiliation(s)
- Nicola Maffulli
- *Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno ‡Department of Orthopaedic and Traumatology, School of Medicine, University of Rome "Tor Vergata," Rome, Italy †Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, UK
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Barker-Davies RM, Nicol A, McCurdie I, Watson J, Baker P, Wheeler P, Fong D, Lewis M, Bennett AN. Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population. BMC Musculoskelet Disord 2017; 18:204. [PMID: 28532478 PMCID: PMC5441076 DOI: 10.1186/s12891-017-1564-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 05/09/2017] [Indexed: 01/06/2023] Open
Abstract
Background Chronic tendinopathy is a significant problem particularly in active populations limiting sporting and occupational performance. The prevalence of patellar tendinopathy in some sports is near 50% and the incidence of lower limb tendinopathy is 1.4% p.a. in the UK Military. Management includes isometric, eccentric, heavy slow resistance exercises and extracorporeal shockwave therapy (ESWT). Often these treatments are inadequate yet there is no good evidence for injection therapies and success rates from surgery can be as low as 50%. High Volume Image Guided Injection (HVIGI) proposes to strip away the neovascularity and disrupt the nerve ingrowth seen in chronic cases and has shown promising results in case series. This study aims to investigate the efficacy of HVIGI in a randomised controlled trial (RCT). Methods RCT comparing 40ml HVIGI, with or without corticosteroid, with a 3ml local anaesthetic sham-control injection. Ninety-six participants will be recruited. Inclusion criteria: male, 18–55 years old, chronic Achilles or patellar tendinopathy of at least 6 months, failed conservative management including ESWT, and Ultrasound (US) evidence of neovascularisation, tendon thickening and echogenic changes. Outcome measures will be recorded at baseline, 6 weeks, 3, 6 and 12 months. Primary outcome measures include The Victoria Institute of Sport Assessments for Achilles and patellar tendinopathy (VISA-A and VISA-P) and VAS pain. Secondary outcome measures include Modified Ohberg score, maximum tendon diameter and assessment of hypoechoic appearance on US, and Functional Activity Assessment. Discussion Despite previous interventional trials and reviews there is still insufficient evidence to guide injectable therapy for chronic tendinopathy that has failed conservative treatment. The scant evidence available suggests HVIGI has the greatest potential however there is no level one RCT evidence to support this. Investigating the efficacy of HVIGI against control in a RCT and separating the effect of HVIGI and corticosteroid will add high level evidence to the management of chronic tendinopathy resistant to conservative treatment. Trial Registration EudraCT: 2015-003587-36 3 Dec 2015
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Affiliation(s)
- Robert M Barker-Davies
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK. .,School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK.
| | - Alastair Nicol
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - I McCurdie
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - James Watson
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - Polly Baker
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
| | - Patrick Wheeler
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Daniel Fong
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Mark Lewis
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine-East Midlands, Loughboruough University, Leicestershire, LE11 3TU, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, DMRC Headley Court, Epsom, Surrey, KT18 6JW, UK
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Abstract
Tendinopathy is increasingly recognized as an important cause of musculoskeletal pain and disability. Tendinopathy is thought to be principally a degenerative process, rather than inflammatory as was traditionally believed. Consequently, traditional tendinopathy treatments focused solely on decreasing inflammation have often been ineffective or even harmful. The advancement of ultrasonography as for guidance of outpatient musculoskeletal procedures has facilitated the development of novel percutaneous procedures for the treatment of tendinopathy, mostly by using mechanical intervention to stimulate regeneration. Several of these techniques, including percutaneous needle tenotomy, percutaneous ultrasonic tenotomy, high-volume injection, and percutaneous needle scraping, are reviewed in this article.
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Affiliation(s)
- Evan Peck
- Section of Sports Health, Department of Orthopaedic Surgery, Cleveland Clinic Florida, 525 Okeechobee Boulevard, Suite 1400, West Palm Beach, FL 33401, USA; Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA.
| | - Elena Jelsing
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, Minneapolis, MN 55403, USA
| | - Kentaro Onishi
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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