Corticosteroid injections for lateral epicondylitis: a systematic review

Experienced versus Inexperienced Interexaminer Reliability on Location and Classification of Myofascial Trigger Point Palpation to Diagnose Lateral Epicondylalgia: An Observational Cross-Sectional Study

The purpose was to evaluate the interexaminer reliability of experienced and inexperienced examiners on location and classification of myofascial trigger points (MTrPs) in two epicondylar muscles and the association between the MTrP found and the diagnosis of lateral epicondylalgia (LE). Fifty-two pianists (some suffered LE) voluntarily participated in the study. Three physiotherapists (one inexperienced in myofascial pain) examined, located, and marked MTrPs in the extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC) muscles. Forearms were photographed and analyzed to establish the degree of agreement on MTrPs diagnosis. Data showed 81.73% and 77.88% of agreement on MTrP classification and 85.58% and 72.12% on MTrP location between the expert evaluators for ECRB and EDC, respectively. The agreement on MTrP classification between experienced and inexperienced examiners was 54.81% and 51.92% for ECRB and 50.00% and 55.77% for EDC. Also, agreement on MTrP location was 54.81% and 60.58% for ECRB and 48.08% and 48.08% for EDC. A strong association was found between presence of relevant MTrPs, LE diagnosis, and forearm pain when the examiners were experts. The analysis of location and classification of MTrPs in the epicondylar muscles through physical examination by experienced evaluators is reliable, reproducible, and suitable for diagnosing LE.

Comparison of the effectiveness of local corticosteroid injection and extracorporeal shock wave therapy in patients with lateral epicondylitis

[Purpose] This study aimed to determine and compare the effectiveness of extracorporeal shock wave therapy and local corticosteroid injection in patients with lateral epicondylitis. [Subjects and Methods] Sixty-four patients with lateral epicondylitis were randomly divided into extracorporeal shock wave therapy and steroid injection groups. Patients were evaluated using hand grip strength, visual analog scale, and short-form McGill pain questionnaire at baseline and at 4 and 12 weeks post-treatment. [Results] Both groups showed statistically significant increase in hand grip strength and decreases on the visual analog scale and short form McGill pain questionnaire overtime. There was no statistically significant difference in the percentage of improvement in hand grip strength and on the short-form McGill pain questionnaire between groups at 4 weeks post-treatment, whereas the extracorporeal shock wave therapy group showed better results on the visual analog scale. The percentages of improvements in all 3 parameters were higher in the extracorporeal shock wave therapy group than in the injection group at 12 weeks post-treatment. [Conclusion] Both the extracorporeal shock wave therapy and steroid injection were safe and effective in the treatment of lateral epicondylitis. However, extracorporeal shock wave therapy demonstrated better outcomes than steroid injection at the long-term follow-up.

Iontophoresis Versus Cyriax-Type exercises in Chronic Tennis Elbow among industrial workers

Introduction:

Tennis elbow (TE) is one of the most commonly encountered upper limb conditions. It mainly affects people who use the hand grip against resistance frequently, resulting in microtrauma to the wrist extensors tendon, causing pain. This study was conducted to compare the application of iontophoresis of 0.4% dexamethasone and Cyriax-type exercises in the treatment of chronic tennis elbow (CTE).

Methods:

Twenty-two industrial worker diagnosed as having CTE participated in this study, and their ages ranged from 25 to 52. They were assigned randomly to two groups, i.e., “group A” in which the workers were treated by iontophoresis of 0.4% Dexamethasone and “group B” in which the workers were treated by conducting Cyriax-type exercises on the affected tendon. Both groups received stretching exercises for the common extensors tendon for 10 minutes in addition to five minutes of pulsed US 1.1 W/cm2 six times over two weeks. The outcome of the treatment was assessed one week after the last session by the visual analog scale (VAS) to assess pain, by the Oxford elbow score (OES) to measure the patient’s satisfaction, and by a handgrip dynamometer to measure the strength of the handgrip.

Results:

The application of 0.4% dexamethasone iontophoresis and the use of Cyriax-type exercises both provided significant improvement in the pain, patient’s satisfaction, and the power of the handgrip, and there were no significant difference (p > 0.001) in any of the three measures after the first week’s treatment.

Conclusions:

Both iontophoresis of 0.4% dexamethasone and Cyriax-type exercises were successful as treatment modalities for patients with CTE, and there were no significant differences between both of them in the treatment of those cases.

Analgesic effect of extracorporeal shock wave therapy versus ultrasound therapy in chronic tennis elbow

[Purpose] This study compared the analgesic effects of extracorporeal shock wave therapy with those of ultrasound therapy in patients with chronic tennis elbow. [Subjects] Fifty patients with tennis elbow were randomized to receive extracorporeal shock wave therapy or ultrasound therapy. [Methods] The extracorporeal shock wave therapy group received 5 treatments once per week. Meanwhile, the ultrasound group received 10 treatments 3 times per week. Pain was assessed using the visual analogue scale during grip strength evaluation, palpation of the lateral epicondyle, Thomsen test, and chair test. Resting pain was also recorded. The scores were recorded and compared within and between groups pre-treatment, immediately post-treatment, and 3 months post-treatment. [Results] Intra- and intergroup comparisons immediately and 3 months post-treatment showed extracorporeal shock wave therapy decreased pain to a significantly greater extent than ultrasound therapy. [Conclusion] Extracorporeal shock wave therapy can significantly reduce pain in patients with chronic tennis elbow.

Image-guided elbow interventions: a literature review of interventional treatment options

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.

Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence

Lateral epicondylosis is common, with various treatment modalities. Platelet-rich-plasma injections from autologous blood have recently been used in centres worldwide for the treatment of tennis elbow. We review and present the recent published evidence on the effectiveness of PRP injections for lateral epicondylosis. Nine studies met our inclusion criteria including 6 RCT's for the purpose of analysis. PRP injections have an important and effective role in the treatment of this debilitating pathology, in cases where physiotherapy has been unsuccessful.

Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis: Mean 4.5-Year Clinical Follow-up

BACKGROUND

Chronic lateral epicondylitis (LE) induces cell apoptosis and autophagy, which lead to the reduction of tendon-derived cells in the torn tendon. Our previous study has shown that ultrasound-guided autologous tenocyte injection (ATI) to the torn tendon in patients with chronic resistant LE significantly improves pain, function, and structural repair at 1 year. This report is the continued assessment of the clinical outcomes of these patients at mean 4.5-year follow-up.

HYPOTHESIS

Improvements in LE clinical function and structural repair after ATI will be maintained at mean 4.5-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with severe refractory LE underwent clinical evaluation and MRI before intervention. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Autologous tenocytes were injected into the central tendinopathy identified at the common extensor tendon origin under ultrasound guidance on a single occasion. Patients underwent serial clinical evaluations for up to 5 years after ATI, including the visual analog scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Upper Extremity Functional Scale (UEFS), and grip strength. Post-ATI MRI scanning was performed at 1 year and final follow-up.

RESULTS

A total of 16 patients (9 male, 7 female), aged between 37 and 63 years, were included in the study. The mean duration of symptoms before study recruitment was 29.24 months (range, 6-240 months). One patient elected to proceed to surgery 3 months after ATI due to reinjury at work, and 1 patient died of prostate cancer with metastases during the follow-up period. The mean final follow-up time for the remaining 15 patients was 4.51 years (range, 3.08-5.17 years). No complications were observed at the patellar tendon biopsy site for any patient. No adverse events, infection, or excessive fibroblastic reactions were observed in any patient at the injection site. Clinical evaluation revealed significant (P < .001) improvement in mean VAS pain score from 5.73 at initial assessment to 1.21 (78% improvement) at final follow-up. Mean QuickDASH, UEFS, and grip strength scores also significantly (P < .001) improved from initial assessment to final follow-up (from 45.88 to 6.61 [84%], from 31.73 to 9.20 [64%], and from 19.85 to 46.60 [208%], respectively). There was no difference in mean QuickDASH and UEFS scores at 1 year and final follow-up (P > .05); however, grip strength continued to improve (P < .001). A validated MRI scoring system indicated that the mean grade of tendinopathy at the common extensor origin improved significantly (P < .001) from initial assessment (4.31) to 1 year (2.88) and was maintained (P > .05) at final follow-up (2.87). At final follow-up, 93% of patients were either highly satisfied or satisfied with their ATI treatment.

CONCLUSION

ATI significantly improved clinical function and MRI tendinopathy scores for up to 5 years in patients with chronic resistant LE who had previously undergone unsuccessful nonsurgical treatment. This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy.

Injection of autologous blood versus corticosteroid for lateral epicondylitis: a randomised controlled study

PURPOSE

To compare the efficacy of autologous blood injection versus corticosteroid injection for lateral epicondylitis.

METHODS

21 men and 59 women (mean age, 45.2 years) presenting with lateral epicondylitis were randomised to receive either autologous blood injection (2 ml of autologous venous blood mixed with 1 ml of 2% prilocaine hydrochloride) or corticosteroid injection (1 ml of 40 mg methylprednisolone acetate mixed with 1 ml of 2% prilocaine hydrochloride) given by a single physician. Patients were assessed before (day 0) and after (days 15, 30, and 90) treatment for elbow pain (using a visual analogue scale [VAS]), function (using the patient-rated tennis elbow evaluation [PRTEE] questionnaire), and grip strength (using a hydraulic hand dynamometer). Patients were followed up at 6 months by telephone to assess elbow pain using the VAS.

RESULTS

No complications (infection, skin atrophy, neurovascular damage, or tendon rupture) were noted. 10 patients reported increased pain for up to 2 days after autologous blood injection. In both groups, the VAS score for elbow pain, PRTEE score, and grip strength improved significantly after treatment (p=0.0001), but the pattern of improvement differed. Compared with autologous blood injection, corticosteroid injection improved all 3 scores at a faster rate over the first 15 days (p=0.0001), and then started to decline slightly until day 90. After autologous blood injection, all 3 scores improved steadily and were eventually better (p=0.0001). If a 37% decrease in PRTEE is defined as complete recovery, 38 (95%) of patients with autologous blood injection and 25 (62.5%) of patients with corticosteroid injection achieved complete recovery (p=0.0001).

CONCLUSION

Autologous blood injection was more effective over the follow-up period than corticosteroid injection in improving pain, function, and grip strength. It is recommended as a first-line injection treatment because it is simple, cheap, and effective.

Comparison of the effect of intra-tendon applications of recombinant human platelet-derived growth factor-BB, platelet-rich plasma, steroids in a rat achilles tendon collagenase model

This study compared the effect of intra-tendon (IT) delivery of recombinant human platelet-derived growth factor-BB (rhPDGF-BB), platelet-rich plasma (PRP) and corticosteroids in a rat tendinopathy model. Seven days after collagenase induction of tendinopathy, a 30-µl IT injection was administered. Treatments included: saline; 3 µg rhPDGF-BB; 10 µg rhPDGF-BB; PRP; and 300 µg triamcinolone acetonide (TCA). Outcomes were assessed 7 and 21 days after treatment. All groups exhibited good to excellent repair. Relative to saline, cell proliferation increased 65% in the 10 µg rhPDGF-BB group and decreased 74% in the TCA group; inflammation decreased 65% in the TCA group. At 7 days, maximum load-to-failure was increased in the 3 µg rhPDGF-BB group relative to saline, PRP, and TCA (p < 0.025). On day 21, maximum load-to-rupture was increased in the 10 µg rhPDGF-BB group relative to saline, PRP, and TCA (p < 0.035) and in the 3 µg rhPDGF-BB group compared to saline and TCA (p < 0.027). Stiffness in the 10 µg rhPDGF-BB group was increased compared to saline, PRP, and TCA (p < 0.038). Histology demonstrated similar repair in all groups. PRP and TCA did not improve mechanical properties compared to saline. Injections of rhPDGF-BB increased maximum load-to-failure (3 and 10 µg) and stiffness (10 µg) relative to controls and commonly used treatments. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:145-150, 2014.

Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review

OBJECTIVES

To evaluate the current evidence for the efficacy of corticosteroid injection and non-electrotherapeutic physiotherapy compared with control for treating lateral epicondylitis.

DESIGN

Systematic review.

PARTICIPANTS

We searched five databases in September 2012 for randomised controlled studies with a minimum quality rating. Of the 640 studies retrieved, 11 were included, representing 1161 patients of both sexes and all ages.

INTERVENTIONS

Corticosteroid injection and non-electrotherapeutic physiotherapy.

OUTCOME MEASURES

Relative risk (RR) or standardised mean difference (SMD) for overall improvement, pain and grip strength at 4-12, 26 and 52 weeks of follow-up.

RESULTS

Corticosteroid injection gave a short-term reduction in pain versus no intervention or non-steroidal anti-inflammatory drugs (SMD -1.43, 95% CI -1.64 to -1.23). At intermediate follow-up, we found an increase in pain (SMD 0.32, 95% CI 0.13 to 0.51), reduction in grip strength (SMD -0.48, 95% CI -0.73 to -0.24) and negative effect on the overall improvement effect (RR 0.66 (0.53 to 0.81)). For corticosteroid injection versus lidocaine injection, the evidence was conflicting. At long-term follow-up, there was no difference on overall improvement and grip strength, with conflicting evidence for pain. Manipulation and exercise versus no intervention showed beneficial effect at short-term follow-up (overall improvement RR 2.75, 95% CI 1.30 to 5.82), but no significant difference at intermediate or long-term follow-up. We found moderate evidence for short-term and long-term effects of eccentric exercise and stretching versus no intervention. For exercise versus no intervention and eccentric or concentric exercise and stretching versus stretching alone, we found moderate evidence of no short-term effect.

CONCLUSIONS

Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. Evidence on the long-term effect is conflicting. Manipulation and exercise and exercise and stretching have a short-term effect, with the latter also having a long-term effect.

Continuum model of tendon pathology - where are we now?

Chronic tendon pathology is a common and often disabling condition, the causes of which remain poorly understood. The continuum model of tendon pathology was proposed to provide a model for the staging of tendon pathology and to assist clinicians in managing this often complex condition (Br. J. Sports Med., 43, 2009, 409). The model presents clinical, histological and imaging evidence for the progression of tendon pathology as a three-stage continuum: reactive tendinopathy, tendon disrepair and degenerative tendinopathy. It also provides clinical information to assist in identifying the stage of pathology, in addition to proposed treatment approaches for each stage. The usefulness of such a model is determined by its ability to incorporate and inform new and emerging research. This review examines the degree to which recent research supports or refutes the continuum model and proposes future directions for clinical and research application of the model.

How to perform local soft-tissue glucocorticoid injections?

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae is the hallmark of many inflammatory rheumatic diseases, but inflammation or rather irritation of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in the literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

Muscle energy technique versus corticosteroid injection for management of chronic lateral epicondylitis: randomized controlled trial with 1-year follow-up

OBJECTIVE

To determine the short- and long-term effectiveness of the muscle energy technique (MET) compared with corticosteroid injections (CSIs) for chronic lateral epicondylitis (LE).

DESIGN

Randomized controlled trial with 1 year of follow-up.

SETTING

Outpatient clinic of a university's department of physical medicine and rehabilitation.

PARTICIPANTS

Patients with chronic LE (N=82; 45 women, 37 men).

INTERVENTIONS

Eight sessions of MET, or a single CSI was applied.

MAIN OUTCOME MEASURES

Grip strength, pain intensity, and functional status were assessed using the pain-free grip strength (PFGS), a visual analog scale (VAS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, respectively. Measurements were performed before beginning treatment and at 6, 26, and 52 weeks afterward.

RESULTS

When the baseline PFGS, VAS, and DASH scores were compared with the scores at the 52-week follow-up, statistically significant improvements were observed in both groups over time. The patients who received a CSI showed significantly better effects at 6 weeks according to the PFGS and VAS scores, but declined thereafter. At the 26- and 52-week follow-ups, the patients who received the MET were statistically significantly better in terms of grip strength and pain scores. At 52 weeks, the mean PFGS score in the MET group was significantly higher (75.08±26.19 vs 62.24±21.83; P=.007) and the mean VAS score was significantly lower (3.28±2.86 vs 4.95±2.36; P=.001) than those of the CSI group. Although improvements in the DASH scores were more pronounced in the MET group, the differences in DASH scores between the groups were not statistically significant.

CONCLUSIONS

This study showed that while both MET and CSI improved measures of strength, pain, and function compared with baseline, subjects receiving MET had better scores at 52 weeks for PFGS and the VAS for pain. We conclude that MET appears to be an effective intervention in the treatment of LE.

Acupuncture for lateral epicondylitis (tennis elbow): study protocol for a randomized, practitioner-assessor blinded, controlled pilot clinical trial

BACKGROUND

Lateral epicondylitis is the most frequent cause of pain around the elbow joint. It causes pain in the region of the elbow joint and results in dysfunction of the elbow and deterioration of the quality of life. The purpose of this study is to compare the effects of ipsilateral acupuncture, contralateral acupuncture and sham acupuncture on lateral epicondylitis.

METHODS/DESIGN

Forty-five subjects with lateral epicondylitis will be randomized into three groups: the ipsilateral acupuncture group, contralateral acupuncture group and the sham acupuncture group. The inclusion criteria will be as follows: (1) age between 19 and 65 years with pain due to one-sided lateral epicondylitis that persisted for at least four weeks, (2) with tenderness on pressure limited to regions around the elbow joint, (3) complaining of pain during resistive extension of the middle finger or the wrist, (4) with average pain of NRS 4 or higher during the last one week at a screening visit and (5) voluntarily agree to this study and sign a written consent. Acupuncture treatment will be given 10 times in total for 4 weeks to all groups. Follow up observations will be conducted after the completion of the treatment, 8 weeks and 12 weeks after the random assignment. Ipsilateral acupuncture group and contralateral acupuncture group will receive acupuncture on LI4, TE5, LI10, LI11, LU5, LI12 and two Ashi points. The sham acupuncture group will receive treatment on acupuncture points not related to the lateral epicondylitis using a non-invasive method. The needles will be maintained for 20 minutes. The primary outcome will be differences in the visual analogue scale (VAS) for elbow pain between the groups. The secondary outcome will be differences in patient-rated tennis elbow evaluation (PRTEE), pain-free/maximum grip strength (Dynamometer), pressure pain threshold, clinically relevant improvement, patient global assessment, and the EQ-5D. The data will be analyzed with the paired t-test and ANCOVA (P <0.05).

DISCUSSION

The results of this study will allow evaluation of contralateral acupuncture from two aspects. First, if the contralateral acupuncture shows the effects similar to ipsilateral acupuncture, this will establish clinical basis for contralateral acupuncture. Second, if the effects of contralateral acupuncture are not comparable to the effects of ipsilateral acupuncture, but are shown to be similar to the effects of the sham acupuncture, we can establish the basis for using the same acupoints of the unaffected side as a control in acupuncture clinical studies.

TRIAL REGISTRATION

This trial has been registered with the 'Clinical Research Information Service (CRIS)', Republic of Korea: KCT0000628.

The effects of corticosteroid injection versus local anesthetic injection in the treatment of lateral epicondylitis: a randomized single-blinded clinical trial

INTRODUCTION

This study seeks to compare two treatment methods of lateral epicondylitis: corticosteroid injection (CSI) and a local anesthetic injection (LAI).

MATERIALS AND METHODS

In this single-blinded randomized clinical trial, 138 patients with the diagnosis of lateral epicondylitis were assigned either into CSI group receiving methylprednisolone 1 ml (49 patients) or LAI group (51 patients) receiving procaine 1 ml 2 % in a single dose at the maximal point tenderness site. The primary outcome measure was elbow disability using Quick DASH, and secondary outcome measures were pain intensity using Visual Analogue Scale (VAS) and recurrence rate at pretreatment visit and at 3-, 6- and 12-week post-treatment visits.

RESULTS

There were no significant differences between the patients in both groups for demographic factors including age, gender, dominant hand, involved hand, and work pressure. Before treatment, the patients in both groups were suffering from the same rates of elbow disability and pain as measured by Quick DASH and VAS, respectively, (p > 0.05). In general, the recovery rate (comparison between pretreatment visit and last post-treatment visit) was significantly more effective and higher in CSI than LAI. CSI was dramatically more effective at 3-week visit, but less and less effective at 6- and 12-week visits. At 12-week visit the recurrence rate was 34.7 % (17 patients) in CSI group.

CONCLUSION

For lateral epicondylitis, CSI has the best short-term treatment results yet the highest recurrent rates. The combination of CSI with other treatment option or with a change in injection technique from single injection to peppering injection may be promising.

Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials

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.

Common medical problems of instrumental athletes

The fields of sports medicine and performing arts medicine have begun recent initiatives to collaborate more closely and to share information pertinent to the treatment of athletes and performing artists. This article provides a review of the common musculoskeletal and neurological problems encountered among performing artists who play instruments. Approaches to history, examination, diagnosis, and treatment are offered, based on literature reviews, expert opinion, and the authors' own experiences in a musician's clinic. Treatments focus on conservative management within a multidisciplinary framework, and indications are given for appropriate surgical referral. Providers are encouraged to build an understanding of the unique issues affecting instrumental athletes.

Dose-response effect of an intra-tendon application of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) in a rat Achilles tendinopathy model

The purpose of this study was to assess whether intra-tendon delivery of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) would improve Achilles tendon repair in a rat collagenase-induced tendinopathy model. Seven days following collagenase induction of tendinopathy, one of four intra-tendinous treatments was administered: (i) Vehicle control (sodium acetate buffer), (ii) 1.02 µg rhPDGF-BB, (iii) 10.2 µg rhPDGF-BB, or (iv) 102 µg rhPDGF-BB. Treated tendons were assessed for histopathological (e.g., proliferation, tendon thickness, collagen fiber density/orientation) and biomechanical (e.g., maximum load-to-failure and stiffness) outcomes. By 7 days post-treatment, there was a significant increase in cell proliferation with the 10.2 and 102 µg rhPDGF-BB-treated groups (p=0.049 and 0.015, respectively) and in thickness at the tendon midsubstance in the 10.2 µg of rhPDGF-BB group (p=0.005), compared to controls. All groups had equivalent outcomes by Day 21. There was a dose-dependent effect on the maximum load-to-failure, with no significant difference in the 1.02 and 102 µg rhPDGF-BB doses but the 10.2 µg rhPDGF-BB group had a significant increase in load-to-failure at 7 (p=0.003) and 21 days (p=0.019) compared to controls. The rhPDGF-BB treatment resulted in a dose-dependent, transient increase in cell proliferation and sustained improvement in biomechanical properties in a rat Achilles tendinopathy model, demonstrating the potential of rhPDGF-BB treatment in a tendinopathy application. Consequently, in this model, data suggest that rhPDGF-BB treatment is an effective therapy and thus, may be an option for clinical applications to treat tendinopathy.

Injuries of the elbow and the current treatment of tendon disease

OBJECTIVE

Overuse and traumatic injuries of the elbow are common, occurring in both athletes and nonathletes. This article will discuss the commonly encountered soft-tissue and osseous pathologic abnormalities around the elbow and their imaging appearance on MRI and ultrasound.

CONCLUSION

The current treatment of tendon disease of the elbow is reviewed, with a focus on platelet-rich plasma injection.

Evidence-based soft tissue rheumatology: epicondylitis and hand stenosing tendinopathy

Lateral and medial epicondylitis represent overuse tendinopathies of wrist extensor and wrist flexor muscles, respectively. In lateral epicondylitis, a short-term therapeutic efficacy of glucocorticoid injection and limited evidence on the efficacy of acupuncture has been shown. De Quervain tendinopathy is caused by tendinous impingement by a thickened retinaculum. There is limited evidence on the efficacy of glucocorticoid injection in this condition.Trigger finger usually results from tendon entrapment beneath a thickened A1 flexor pulley. An association with hand tool use and diabetes has been shown in this condition, and there is evidence on the therapeutic efficacy of glucocorticoid injection. No other therapeutic modality has shown efficacy or has been assessed in a placebo-controlled clinical trial in these conditions.It can be concluded that epicondylitis and stenosing tendinopathy are readily diagnosed, and most patients recover with current therapies. However, still unsolved issues preclude a purely evidence-based approach to these entities.

Optimal case definitions of upper extremity disorder for use in the clinical treatment and referral of patients

OBJECTIVE

Experts disagree about the optimal classification of upper extremity disorders. To explore whether differential response to treatments offers a basis for choosing between case definitions, we analyzed previously published research.

METHODS

We screened 183 randomized controlled trials (RCTs) of treatments for upper extremity disorders identified from the bibliographies of 10 Cochrane reviews and 4 other systematic reviews, and a search in Medline, Embase, and Google Scholar to June 2010. From these, we selected RCTs that allowed estimates of benefit (expressed as relative risks [RRs]) for >1 case definition to be compared when other variables (treatment, comparison group, followup time, outcome measure) were effectively held constant. Comparisons of RRs for paired case definitions were summarized by their ratios, with the RR for the simpler and broader definition as the denominator.

RESULTS

Two RCT reports allowed within-trial comparison of RRs and 13 others allowed between-trial comparisons. Together these provided 17 ratios of RRs (5 for shoulder treatments, 12 for elbow treatments, and none for wrist/hand treatments). The median ratio of RRs was 1.0 (range 0.3-1.7, interquartile range 0.6-1.3).

CONCLUSION

Although the evidence base is limited, our findings suggest that for musculoskeletal disorders of the shoulder and elbow, clinicians in primary care will often do best to apply simpler and broader case definitions. Researchers should routinely publish secondary analyses for subgroups of patients by different diagnostic features at trial entry to expand the evidence base on optimal case definitions for patient management.

LATERAL EPICONDYLITIS OF THE ELBOW

Lateral epicondylitis, also known as tennis elbow, is a common condition that is estimated to affect 1% to 3% of the population. The word epicondylitis suggests inflammation, although histological analysis on the tissue fails to show any inflammatory process. The structure most commonly affected is the origin of the tendon of the extensor carpi radialis brevis and the mechanism of injury is associated with overloading. Nonsurgical treatment is the preferred method, and this includes rest, physiotherapy, cortisone infiltration, platelet-rich plasma injections and use of specific immobilization. Surgical treatment is recommended when functional disability and pain persist. Both the open and the arthroscopic surgical technique with resection of the degenerated tendon tissue present good results in the literature.

Tendinopathy treatment: where is the evidence?

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.

A review of modern management of lateral epicondylitis

Lateral epicondylitis, or tennis elbow, is the most common cause of elbow pain. This degenerative condition can manifest as an acute process lasting < 3 months or a chronic process often refractory to treatment. Symptom resolution occurs in 70% to 80% of patients within the first year. A "watch-and-wait" approach can be an appropriate treatment option, although physical therapy has been shown to be an effective first-line therapy. Corticosteroids, while providing relief of pain in the acute setting, may be detrimental to recovery in the long term. Platelet-rich plasma injections, although recently well publicized, have not been proven by well-controlled clinical trials to be effective therapy. For patients with symptoms refractory to conservative management, surgical intervention has shown to be a successful treatment modality.

A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis

PURPOSE

We designed a prospective, randomized study to evaluate the effects of iontophoresis delivery of dexamethasone versus corticosteroid injection therapy on patient outcomes.

METHODS

We randomized 82 patients to 10 mg dexamethasone via iontophoresis using a self-contained patch with a 24-hour battery; 10 mg dexamethasone injection; or 10 mg triamcinolone injection. All patients received the same hand therapy protocol. Primary outcomes tracked were change in grip strength (flexion vs extension), pain, and function scores on a validated questionnaire. The secondary outcome was return-to-work status. Patients were evaluated at baseline, completion of physical therapy, and 6-month follow-up.

RESULTS

The iontophoresis patients had statistically significant improvement in grip strength at the conclusion of hand therapy compared with baseline. They were also more likely to get back to work without restriction. By 6-month follow-up, all groups had equivalent results for all measured outcomes.

CONCLUSIONS

Dexamethasone via iontophoresis produced short-term benefits because for this group grip strength and unrestricted return to work were significantly better. This study suggests that this iontophoresis technique for delivery of corticosteroid may be considered a treatment option for patients with lateral epicondylitis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Randomized prospective evaluation of injection techniques for the treatment of lateral epicondylitis

Lateral epicondylitis is a commonly made diagnosis for general practitioners and orthopedic surgeons. Corticosteroid injection is a mainstay of early treatment. However, conflicting evidence exists to support the use of steroid injection, and no evidence in the literature supports an injection technique. Nineteen patients diagnosed with acute lateral epicondylitis were evaluated to compare the peppered- and single-injection techniques using the Disabilities of the Arm, Shoulder and Hand (DASH) score, visual analog score (VAS), and grip strength. For elbows with a single injection, mean grip strength increased from 22.9 to 27.8 (P=.053), mean VAS pain score decreased from 4.8 to 3.6 (P=.604), and mean DASH score decreased from 2.6 to 1.8 points (P=.026). For elbows with peppered injections, mean grip strength increased from 28.7 to 32.8 (P=.336), mean VAS pain scores decreased from 3.7 to 2.3 (P=.386), and mean DASH score decreased from 2.6 to 1.3 (P=.008).No studies have directly compared the peppered-injection technique to the single-injection technique. Our results suggest that patient outcome is improved with the single injection. The biomechanical or chemical reason for the distinction is yet unknown, but we postulate that the peppered technique may actually further damage the already compromised tendon. The theory that the peppered injection stimulates blood flow may be overestimated or false. Histochemical studies of the pathologic tissue must be performed to further delineate the reason for improved outcomes with the single-injection technique.

Optimization of ingredients, procedures and rehabilitation for platelet-rich plasma injections for chronic tendinopathy

SUMMARY There is considerable interest amongst clinicians and researchers to create the optimal platelet product to maximize outcomes with platelet-rich plasma (PRP) injections. PRP has been widely introduced as a safe alternative for treating tendinopathies. However, there is still limited clinical evidence describing the components of the platelet product and supporting its use in clinical trials. This article reviews the current literature regarding the role of PRP injections in the treatment of recalcitrant tendinopathies and the different factors in the platelet product that could affect the outcome, including the platelet count, presence of leukocytes, activators used, pH of solution and delivery method, among others. In addition, we address important concepts regarding rehabilitation after PRP procedures, which has little consensus to date and is the subject of much debate. Based on the phases of soft tissue healing, basic science research on platelets, as well as our clinical experience in treating over 500 patients with PRP, we will suggest guidelines regarding the optimal progression of rehabilitation and timing for return to previous activity following the procedure.

Infrared (810 nm) low-level laser therapy in rat achilles tendinitis: a consistent alternative to drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used and can reduce musculoskeletal pain in spite of the cost of adverse reactions like gastrointestinal ulcers or cardiovascular events. The current study investigates if a safer treatment such as low-level laser therapy (LLLT) could reduce tendinitis inflammation, and whether a possible pathway could be through inhibition of either of the two-cyclooxygenase (COX) isoforms in inflammation. Wistar rats (six animals per group) were injected with saline (control) or collagenase in their Achilles tendons. Then, we treated them with three different doses of IR LLLT (810 nm; 100 mW; 10 s, 30 s and 60 s; 3.57 W cm(-2); 1 J, 3 J, 6 J) at the sites of the injections, or intramuscular diclofenac, a nonselective COX inhibitor/NSAID. We found that LLLT dose of 3 J significantly reduced inflammation through less COX-2-derived gene expression and PGE(2) production, and less edema formation compared to nonirradiated controls. Diclofenac controls exhibited significantly lower PGE(2) cytokine levels at 6 h than collagenase control, but COX isoform 1-derived gene expression and cytokine PGE(2) levels were not affected by treatments. As LLLT seems to act on inflammation through a selective inhibition of the COX-2 isoform in collagenase-induced tendinitis, LLLT may have potential to become a new and safer nondrug alternative to coxibs.

Psychosocial work environment and stress-related disorders, a systematic review

BACKGROUND

Knowledge on the impact of the psychosocial work environment on the occurrence of stress-related disorders (SRDs) can assist occupational physicians in the assessment of the work-relatedness of these disorders.

AIMS

To systematically review the contribution of work-related psychosocial risk factors to SRDs.

METHODS

A systematic review of the literature was carried out by searching Medline, PsycINFO and Embase for studies published up until October 2008. Studies eligible for inclusion were prospective cohort studies or patient-control studies of workers at risk for SRDs. Studies were included in the review when data on the association between exposure to psychosocial work factors and the occurrence of SRDs were presented. Where possible, meta-analysis was conducted to obtain summary odds ratios of the association. The strength of the evidence was assessed using four levels of evidence.

RESULTS

From the 2426 studies identified, seven prospective studies were included in this review. Strong evidence was found that high job demands, low job control, low co-worker support, low supervisor support, low procedural justice, low relational justice and a high effort-reward imbalance predicted the incidence of SRDs.

CONCLUSIONS

This systematic review points to the potential of preventing SRDs by improving the psychosocial work environment. However, more prospective studies are needed on the remaining factors, exposure assessment and the relative contributions of single factors, in order to enable consistent assessment of the work-relatedness of SRDs by occupational physicians.

Lateral epicondylalgia. A quantitative and qualitative analysis of interdisciplinary cooperation and treatment choice in the Swedish health care system

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.

Management of tennis elbow

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.

Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up

BACKGROUND

Platelet-rich plasma (PRP) has been shown to be a general stimulation for repair and 1-year results showed promising success percentages.

PURPOSE

This trial was undertaken to determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a 2-year follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

The trial was conducted in 2 Dutch teaching hospitals. One hundred patients with chronic lateral epicondylitis were randomly assigned to a leukocyte-enriched PRP group (n = 51) or the corticosteroid group (n = 49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included visual analog scale (VAS) pain scores and Disabilities of the Arm, Shoulder and Hand (DASH) outcome scores.

RESULTS

The PRP group was more often successfully treated than the corticosteroid group (P < .0001). Success was defined as a reduction of 25% on VAS or DASH scores without a reintervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2-year follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned to baseline levels, while those of the PRP group significantly improved (as-treated principle). There were no complications related to the use of PRP.

CONCLUSION

Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.

Surgery for lateral elbow pain

BACKGROUND

Surgery is sometimes recommended for persistent lateral elbow pain where other less invasive interventions have failed.

OBJECTIVES

To determine the benefits and safety of surgery for lateral elbow pain.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL and Web of Science unrestricted by date or language (to 15 December 2010).

SELECTION CRITERIA

Randomised and controlled clinical trials assessing a surgical intervention compared with no treatment or another intervention including an alternate surgical intervention, in adults with lateral elbow pain.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, assessed risk of bias and extracted data.

MAIN RESULTS

We included five trials involving 191 participants with persistent symptoms of at least five months duration and failed conservative treatment. Three trials compared two different surgical procedures and two trials compared surgery to a non-surgical treatment. All trials were highly susceptible to bias. Meta-analysis was precluded due to differing comparator groups and outcome measures. One trial (24 participants) reported no difference between open extensor carpi radialis brevis (ECRB) surgery and radiofrequency microtenotomy, although reanalysis found that pain was significantly lower in the latter group at three weeks (MD -2.80 points on 10 point scale, 95% CI -5.07 to -0.53). One trial (26 participants) reported no difference between open ECRB surgery and decompression of the posterior interosseous nerve in terms of the number of participants with improvement in pain pain on activity, or tenderness on palpation after an average of 31 months following surgery. One trial (45 participants) found that compared with open release of the ERCB muscle, percutaneous release resulted in slightly better function. One trial (40 participants) found comparable results between open surgical release of the ECRB and botulinum toxin injection at two years, although we could not extract any data for this review. One trial (56 participants) found that extracorporeal shock wave therapy (ESWT) improved pain at night compared with percutaneous tenotomy at 12 months (MD 5 points on 100 point VAS, 95% CI 1.12 to 8.88), but there were no differences in pain at rest or pain on applying pressure.

AUTHORS' CONCLUSIONS

Due to a small number of studies, large heterogeneity in interventions across trials, small sample sizes and poor reporting of outcomes, there was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain. Further well-designed randomised controlled trials and development of standard outcome measures are needed.

Platelet-rich plasma therapy: a systematic literature review and evidence for clinical use

Platelet-rich plasma (PRP) is an autologous blood-derived product with an increased concentration of platelets in plasma, which are used to deliver supraphysiological levels of growth factors. Platelet-rich plasma has been used in many fields, including oral, maxillofacial, and plastic surgery. Its use in sports medicine has been increasing after recent evidence and media publicity suggest that it may augment the treatment of muscle strains, as well as tendon and ligament healing. Basic science and animal studies show promising results, but high-level clinical trials have yet to prove its efficacy. With increasing media coverage on the use of PRP in athletes, it is paramount that orthopedic surgeons and sports medicine physicians understand the various methods of preparation and administration, potential clinical applications, and available clinical results to best counsel patients on its advantages and disadvantages.

Current treatment options for tendinopathy

IMPORTANCE OF THE FIELD

Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management.

AREAS COVERED IN THIS REVIEW

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy.

WHAT THE READER WILL GAIN

The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined.

TAKE-HOME MESSAGE

Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.