A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma

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.

Platelet-Rich Plasma Promotes Axon Regeneration, Wound Healing, and Pain Reduction: Fact or Fiction

Platelet-rich plasma (PRP) has been tested in vitro, in animal models, and clinically for its efficacy in enhancing the rate of wound healing, reducing pain associated with injuries, and promoting axon regeneration. Although extensive data indicate that PRP-released factors induce these effects, the claims are often weakened because many studies were not rigorous or controlled, the data were limited, and other studies yielded contrary results. Critical to assessing whether PRP is effective are the large number of variables in these studies, including the method of PRP preparation, which influences the composition of PRP; type of application; type of wounds; target tissues; and diverse animal models and clinical studies. All these variables raise the question of whether one can anticipate consistent influences and raise the possibility that most of the results are correct under the circumstances where PRP was tested. This review examines evidence on the potential influences of PRP and whether PRP-released factors could induce the reported influences and concludes that the preponderance of evidence suggests that PRP has the capacity to induce all the claimed influences, although this position cannot be definitively argued. Well-defined and rigorously controlled studies of the potential influences of PRP are required in which PRP is isolated and applied using consistent techniques, protocols, and models. Finally, it is concluded that, because of the purported benefits of PRP administration and the lack of adverse events, further animal and clinical studies should be performed to explore the potential influences of PRP.

New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis

Lateral epicondylitis is a common source of elbow pain. Though it is often a self-limited condition, refractory lateral epicondylitis can lead to problems with activities of daily living and sometimes requires sick leave from work. Therefore prompt treatment is essential. Histopathologic studies have suggested that lateral epicondylitis is a tendinopathy, associated with apoptosis and autophagy, rather than a tendonitis associated with inflammation. Although corticosteroids have been used for short-term treatment, recent studies have suggested that they are not helpful and may even be harmful and delay healing in the treatment of lateral epicondylitis. Researchers have recently begun to investigate the use of biologics as potential treatment options for lateral epicondylitis. Autologous blood preparations including platelet rich plasma (PRP) and autologous whole blood injections (ABIs) have been proposed in order to deliver growth factors and other nutrients to the diseased tendon. Stem cell therapies have also been suggested as a method of improving tendon healing. This review discusses the current evidence for the use of PRP, ABI, and stem cell therapies for treatment of lateral epicondylitis. We also review the evidence for nonbiologic treatments including corticosteroids, prolotherapy, botulinum toxin A, and nitric oxide.

The molecular systemic and local effects of intra-tendinous injection of Platelet Rich Plasma in tendinosis: preliminary results on a rat model with ELISA method

PURPOSE

the aim of our study was thus to quantify the effect of Platelet Rich Plasma (PRP) injection on systemic and local growth factors and to identify molecular markers in a rat model of patellar and Achilles tendinosis treated with PRP.

MATERIAL AND METHOD

twenty two rats were used for the study. Two healthy rats were used as control (T-). We induced tendinosis (T+) in 20 rats (80 tendons by injecting under ultrasonography (US) guidance Collagenase 1® (day 0 = D0, patellar=40 and Achilles=40). At D3, these 20 rats with tendinosis were separated in treatment by either PRP (PRPT+, n=28), physiological serum (PST+, n=28, control) US-guided intratendinous injection, or without no PRP or PS (T+, n=24, control of natural evolution of tendinopathy). Follow-up at D7, D13, D18 and D25 using serum sample and local tendon removal with ELISA technics and comparison between the 3 groups were performed.

RESULTS

during biological follow up, comparison of all serum samples of PRPT+, PST+ and T+ groups showed no significant modification of their biological markers at D7, D13, D18 and D25 (p>0.22). Comparison of immunological sample tendon markers of PRPT+, PST+ and T+ groups also showed no significant modification of markers at D7, D13, D18 and D25 (p>0.16) considering each biological marker and also all subgroups confounded.

CONCLUSION

our study strongly suggests that a single intratendinous US-guided injection of PRP in Achilles and patellar T+ doesn't increase biological markers such as growth factors compared to a control group in mid-term and long-term follow-up.

Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial)

INTRODUCTION

Knee osteoarthritis (OA) is the most common articular disease. Different methods are used to alleviate the symptoms of patients with knee OA, including analgesics, physical therapy, exercise prescription, and intra-articular injections (glucocorticoids, hyaluronic acid [HA], etc). New studies have focused on modern therapeutic methods that stimulate cartilage healing process and improve the damage, including the use of platelet-rich plasma (PRP) as a complex of growth factors. Due to the high incidence of OA and its consequences, we decided to study the long-term effect of intraarticular injection of PRP and HA on clinical outcome and quality of life of patients with knee OA.

METHOD

This non-placebo-controlled randomized clinical trial involved 160 patients affected by knee OA, grade 1-4 of Kellgren-Lawrence scale. In the PRP group (n = 87), two intra-articular injections at 4-week interval were applied, and in the HA group (n = 73), three doses of intra-articular injection at 1-week interval were applied. All patients were prospectively evaluated before and at 12 months after the treatment by Western Ontario and McMaster Universities Arthritis Index (WOMAC) and SF-36 questionnaires. The results were analyzed using SPSS 16.1 software (RCT code: IRCT2014012113442N5).

RESULTS

At the 12-month follow-up, WOMAC pain score and bodily pain significantly improved in both groups; however, better results were determined in the PRP group compared to the HA group (P < 0.001). Other WOMAC and SF-36 parameters improved only in the PRP group. More improvement (but not statistically significant) was achieved in patients with grade 2 OA in both the groups.

CONCLUSION

This study suggests that PRP injection is more efficacious than HA injection in reducing symptoms and improving quality of life and is a therapeutic option in select patients with knee OA who have not responded to conventional treatment.

Long term results in refractory tennis elbow using autologous blood

Tennis elbow (TE) is one of the commonest myotendinosis. Different treatment options are available and autologous blood injection has emerged as the one of the acceptable modalities of treatment. Long term studies over a larger group of patients are however lacking. The purpose of this study was to evaluate these patients on longer durations. One-hundred and twenty patients of TE, who failed to respond to conventional treatment including local steroid injections were taken up for this prospective study over the period from year 2005 to 2011 and were followed up for the minimum of 3 years (range 3-9 years). Two mL of autologous blood was taken from the ipsilateral limb and injected into the lateral epicondyle. The effectiveness of the procedure was assessed by Pain Rating Sscale and Nirschl Staging, which was monitored before the procedure, at first week, monthly for first three months, at 6 months and then 3 monthly for first year, six monthly for next 2 years and then yearly. Statistical analysis was done and a P value of <0.05 was taken as significant. The patients (76 females and 44 males) were evaluated after procedure. The mean age group was 40.67±8.21. The mean follow up was 5.7±1.72 (range 3 to 9 years). The mean pain score and Nirschl stage before the procedure was 3.3±0.9 and 6.2±0.82 respectively. At final follow up the pain score and Nirschl were 1.1±0.9 and 1.5±0.91 respectively. Autologous blood injection was found to be one of the modalities for treatment of TE. Being cheap, available and easy method of treatment, it should be considered as a treatment modality before opting for the surgery. Universal guidelines for the management of tennis elbow should be made as there is lot of controversy regarding the treatment.

IMpact of Platelet Rich plasma OVer alternative therapies in patients with lateral Epicondylitis (IMPROVE): protocol for a multicenter randomized controlled study: a multicenter, randomized trial comparing autologous platelet-rich plasma, autologous whole blood, dry needle tendon fenestration, and physical therapy exercises alone on pain and quality of life in patients with lateral epicondylitis

INTRODUCTION

Lateral epicondylitis, commonly known as tennis elbow, is the most common cause of lateral elbow pain and the second most frequently diagnosed musculoskeletal disorder in the neck and upper limb in a primary care setting. Many therapeutic options, including conservative, surgical, and minimally invasive procedures, have been advocated for the treatment of lateral epicondylitis. Although numerous small studies have been performed to assess the efficacy of various treatments, there are conflicting results with no clear consensus on the optimal treatment. In an economic environment with limited health care resources, it is paramount that optimal cost-effective therapies with favorable patient-important outcomes be identified.

METHODS AND ANALYSIS

This is a protocol paper which outlines a multicenter, multidisciplinary, single-blinded, four-arm randomized controlled trial, comparing platelet-rich plasma (PRP), whole blood injection, dry needle tendon fenestration, and sham injection with physical therapy alone for the treatment of lateral epicondylitis. Patients are screened based on pre-established eligibility criteria and randomized to one of the four study groups using an Internet-based system. The patients are followed at 6-week, 12-week, 24-week, and 52-week time points to assess the primary and secondary outcomes of the study. The primary outcome is pain. Secondary outcomes include health-related quality of life and ultrasound appearance of the common extensor tendon. Two university centers (McMaster University and the University of Michigan) are currently recruiting patients. We have planned a sample size of 100 patients (25 patients per arm) to ensure over 80% power to detect a three-point difference in pain scores at 52 weeks of follow-up.

ETHICS AND DISSEMINATION

This study has ethics approval from the McMaster University Research Ethics Board (REB# 12-146) and the University of Michigan Institutional Review Board (IRB# HUM00067750). Successful completion of this proposed study will significantly impact clinical practice and enhance patients' lives. More broadly, this trial will develop a network of collaboration from which further high-quality trials in ultrasound-guided interventions will follow.

Combined intra-tendinous injection of Platelet Rich Plasma and bevacizumab accelerates and improves healing compared to Platelet Rich Plasma in tendinosis: comprehensive assessment on a rat model

PURPOSE

the aim of our study was to assess the potential of combined intratendinous injection of an anti-angiogenic drug: bevacizumab (AA) and Platelet Rich Plasma (PRP) to treat tendinopathy in a murine model of patellar and Achilles tendinopathy, and to evaluate its local toxicity.

MATERIAL AND METHOD

twenty rats (80 patellar and Achilles tendons) were used for the study. We induced tendinosis (T+) in 80 tendons (patellar=40 and Achilles=40) by injecting under ultrasonography (US) guidance Collagenase 1® (day 0 = D0). Clinical examination was performed at D3, immediately followed by either PRP and AA (AAPRPT+, n=40) or PRP (PRPT+ n=40, control) US-guided intratendinous injection. Follow-up at D6, D18 and D25 using clinical, US and histology, and comparison between the 2 groups were performed. To study AA+PRP toxicity, we looked for necrosis or rupture on the 40 AAPRPT+.

RESULTS

all AAPRPT+ showed better joint mobilization compared to PRPT+ at D6 (p=0.03), D18 (p=0.04) and D25 (p=0.02). Similar results were found regarding US and histology, with smaller collagen fiber diameters (D6, p≤0.017, D25, p≤0.015), less disorganization and fewer neovessels (D25, p=0.004) in AAPRPT+ compared to PRPT+. No AA+PRP local toxicity was discovered in histology assessment.

CONCLUSION

our study suggests that combined injection of AA and PRP in tendinosis accelerates and improves tendon's healing compared PRP used alone, with no local toxicity.

Is Platelet-rich plasma superior to whole blood in the management of chronic tennis elbow: one year randomized clinical trial

BACKGROUND

Lateral humeral epicondylitis, or 'tennis elbow', is a common condition with a variety of treatment options. Platelet-rich plasma (PRP) and Autologous Whole Blood (AWB) represent new therapeutic options for chronic tendinopathies including tennis elbow. The aim of the present study was to compare the long term effects of PRP versus autologous whole blood local injection in patients with chronic tennis elbow.

METHODS

Seventy six patients with chronic lateral humeral epicondylitis with duration of symptoms more than 3 months were included in this study and randomized into 2 groups. Group 1 was treated with a single injection of 2 mL of autologous leukocyte rich PRP (4.8 times of plasma) and group 2 with 2 mL of AWB. Tennis elbow strap, stretching and strengthening exercises were administered for both groups. Pain and functional improvements were assessed using visual analogue scale (VAS), Mayo score (modified Mayo Clinic performance index for the elbow) and pressure pain threshold (PPT) at 0, 4, 8 weeks and 6 and 12 months.

RESULTS

All pain variables including VAS, PPT and Mayo scores improved significantly in both groups at each follow up intervals compared to baseline. No statistically significant difference was noted between groups regarding pain, functional scores and treatment success rates in all follow up examinations (P >0/05).

CONCLUSION

PRP and autologous whole blood injections are both effective methods to treat chronic lateral epicondylitis and their efficacy persisted during long term follow up. PRP was not superior to AWB in long term follow up.

Effect of Platelet-Rich Plasma (PRP) versus Autologous Whole Blood on Pain and Function Improvement in Tennis Elbow: A Randomized Clinical Trial

Background. Autologous whole blood and platelet-rich plasma (PRP) have been both suggested to treat chronic tennis elbow. The aim of the present study was to compare the effects of PRP versus autologous whole blood local injection in chronic tennis elbow. Methods. Forty patients with tennis elbow were randomly divided into 2 groups. Group 1 was treated with a single injection of 2 mL of autologous PRP and group 2 with 2 mL of autologous blood. Tennis elbow strap, stretching, and strengthening exercises were administered for both groups during a 2-month followup. Pain and functional improvements were assessed using visual analog scale (VAS), modified Mayo Clinic performance index for the elbow, and pressure pain threshold (PPT) at 0, 4, and 8 weeks. Results. All pain and functional variables including VAS, PPT, and Mayo scores improved significantly in both groups 4 weeks after injection. No statistically significant difference was noted between groups regarding pain scores in 4-week follow-up examination (P > 0.05). At 8-week reevaluations, VAS and Mayo scores improved only in PRP group (P < 0.05). Conclusion. PRP and autologous whole blood injections are both effective to treat chronic lateral epicondylitis. PRP might be slightly superior in 8-week followup. However, further studies are suggested to get definite conclusion.

The effect of platelet-rich plasma on pain, function, and quality of life of patients with knee osteoarthritis

Background. New studies in the management of knee osteoarthritis have focused on modern therapeutic methods stimulating cartilage healing process. In the present study, we evaluated the effects of 2 courses of leucocyte-rich PRP (LR-PRP) injections on patients' QOL and functions and also the relationship between the PRP concentration and mentioned variables. Material and Methods. Sixty-five patients were evaluated. For each participant, WOMAC and the native (Farsi) edition of the SF-36 questionnaire were filled. Two courses of LR-PRP injections with 4-week interval were used. After 6 months, SF-36 and WOMAC questionnaires were filled again for each patient. Results. 60 patients were included in the final analysis. The mean platelet concentrations and white blood cell in PRP was 5-fold increase and 220 per microliter, respectively. The mean total WOMAC revealed significant change (P = 0.001). In SF-36, the mean changes of 2 major physical and mental domains were meaningful (P = 0.001). Discussion. In our study, 2 injections of PRP, with 4-week interval, improved the pain, stiffness, and functional capacity. Improvements in QOL (both PCS and MCS) were meaningful after injections. These changes were more significant in physical domains. PRP injection may be an alternative therapy in selective patients resistant to current nonsurgical treatments of knee osteoarthritis.

Quality measures for the care of patients with lateral epicondylalgia

Background

Lateral epicondylalgia (LE) defines a condition of varying degrees of pain near the lateral epicondyle. Studies on the management of LE indicated unexplained variations in the use of pharmacologic, non-pharmacological and surgical treatments.

The main aim of this paper was to develop and evaluate clinical quality measures (QMs) or quality indicators, which may be used to assess the quality of the processes of examination, education and treatment of patients with LE.

Methods

Different QMs were developed by a multidisciplinary group of experts in Quality Management of Health Services during a period of one year. The process was based following a 3-step model: i) review and proportion of existing evidence-based recommendations; ii) review and development of quality measures; iii) pilot testing of feasibility and reliability of the indicators leading to a final consensus by the whole panel.

Results

Overall, a set of 12 potential indicators related to medical and physical therapy assessment and treatment were developed to measure the performance of LE care. Different systematic reviews and randomized control trials supported each of the indicators judged to be valid during the expert panel process. Application of the new indicator set was found to be feasible; only the measurement of two quality measures had light barriers. Reliability was mostly excellent (Kappa > 0.8).

Conclusions

A set of good practice indicators has been built and pilot tested as feasible and reliable. The chosen 3-step standardized evidence-based process ensures maximum clarity, acceptance and sustainability of the developed indicators.

Lateral epicondylitis: review of injection therapies

Lateral epicondylitis has several different treatment methods, with no single agreed upon therapy. This article summarizes the current literature on injection therapies for lateral epicondylitis. Glucocorticoid, botulinum toxin, autologous blood, platelet-rich plasma, hyaluronic acid, polidocanol, glycosaminoglycan, and prolotherapy injections are discussed.

Augmenting tendon and ligament repair with platelet-rich plasma (PRP)

Tendon and ligament injuries (TLI) commonly occur in athletes and non-athletes alike, and remarkably debilitate patients' athletic and personal abilities. Current clinical treatments, such as reconstruction surgeries, do not adequately heal these injuries and often result in the formation of scar tissue that is prone to re-injury. Platelet-rich plasma (PRP) is a widely used alternative option that is also safe because of its autologous nature. PRP contains a number of growth factors that are responsible for its potential to heal TLIs effectively. In this review, we provide a comprehensive report on PRP. While basic science studies in general indicate the potential of PRP to treat TLIs effectively, a review of existing literature on the clinical use of PRP for the treatment of TLIs indicates a lack of consensus due to varied treatment outcomes. This suggests that current PRP treatment protocols for TLIs may not be optimal, and that not all TLIs may be effectively treated with PRP. Certainly, additional basic science studies are needed to develop optimal treatment protocols and determine those TLI conditions that can be treated effectively.

Efficacy of second intra-tendinous platelet-rich-plasma injection in case of incomplete response of the first injection: three-year follow up experience

PURPOSE

Tendinopathy is a frequent and ubiquitous disease developing early disorganized collagen fibers with neo-angiogenesis on histology. Peritendinous injection of corticosteroid is the commonly accepted strategy despite the absence of inflammation in tendinopathy. Platelet-rich plasma (PRP) might be a useful strategy to rapidly accelerate healing of the tendinopathy but there is a lack ok knowledge about the amount of PRP to be injected and the opportunity of a second injection in case of partial pain relief. The aim of our study was to assess the potential therapeutic effect of early second PRP intra-tendinous to treat persistent painful tendon tear and tendinosis in a long-term follow-up by ultrasonography (US) and clinical data in case of incomplete efficiency of first PRP treatment injection.

MATERIALS AND METHODS

Twenty-four consecutive patients referred for US treatment of tendon tear or tendinosis (T+) were included retrospectively. All had previously received a single intra-tendinous injection of PRP under US guidance (PRPT+) and benefited of a second PRP injection (PRPT2+) under US guidance in order to treat persistent painful. US and clinical data were collected for each anatomic compartment for upper and lower limbs before treatment (D0), 6 weeks (W6) after first treatment, 6 weeks (W12) after second treatment and until 32-month follow-up. We used Mac Nemar test and regression model to compare US and clinical data.

RESULTS

The residual US size of lesions was not significantly lower at W12 after PRPT2+ as compared to W6 (P=0.86 in upper and P=NS in lower member) independently of age (P=0.22), gender (P=0.97) and kind of tendinopathy (P=NS). Quick dash test values and WOMAC values were not significantly lower in PRPT+ at W12 (average: 21.5 months) as compared to W6 (P>0.66) and long-term follow-up (P>0.75) independently of age (P=0.39), gender (P=0.63) and kind of tendinopathy (P=NS). Nevertheless, comparison between D0 and long-term follow-up (LTF) functionnal score was statistically significant (p<0.001 in upper and lower member).

CONCLUSION

Our study suggests that second early intra-tendinous PRP injection under US guidance does not permit rapid decrease of tendinopathy area in US, nor does it quickly improve clinical pain and functional data in case of incomplete efficiency of first PRP injection. However, in long-term follow-up, patients improved their ability to mobilize pathologic tendons.

Repair of a complete anterior cruciate tear using prolotherapy: a case report

OBJECTIVE AND IMPORTANCE: Surgical reconstruction is considered definitive treatment for anterior cruciate ligament (ACL) tears but precise surgical indications are debated. Some patients are reluctant or inappropriate surgical candidates. Prolotherapy is a non-surgical injection therapy for chronic musculoskeletal pain and instability. This case report documents the non-surgical repair of a torn ACL using prolotherapy and at-home exercise. CLINICAL PRESENTATION AND INTERVENTION: The 18 year old female patient sustained a right knee injury during a downhill skiing accident. Magnetic Resonance Imaging (MRI) revealed a high-grade partial versus complete rupture; Lachman exam findings suggested a complete rupture. She deferred surgical treatment. At 21 weeks post-injury, with unstable gait, inability to climb stairs and more than 1 cm anterior drawer test, she consented to undergo prolotherapy injections. She received 7 prolotherapy sessions over a 15 week period. At-home exercises were initiated at the 3(rd) prolotherapy session. RESULTS: The patient improved. Walking on flat ground improved 4 weeks after initiation of prolotherapy; she could ride a stationary bicycle for 30 minutes by 12 weeks. By 15 weeks, the patient had no instability climbing and descending stairs, the anterior drawer test was negative and MRI showed an intact ACL with fibrosis. Subsequently, she returned to full sport activity. CONCLUSIONS: We document the non-surgical repair of a high-grade partial or complete ACL tear using prolotherapy and at-home exercise. Prolotherapy may be an alternative to surgery in carefully selected patients. This report is consistent with findings of recent pilot-level studies and suggests the need for rigorous clinical trials assessing prolotherapy as treatment for ligament and tendon injury in selected patients.

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.

Overuse injuries

Tendinopathy and chronic tendon issues related to tendinosis are conditions difficult to treat. These conditions often lead to patients' quality of life declining because of the inability to participate in exercise, occupation-related activities, and activities of daily living. By better understanding the pathophysiology related to the development of tendinosis, clinicians will be better able to understand the treatment options available and their limitations while allowing novel therapies to be developed. Conservative treatment of tendinosis starting with a sound rehabilitation program seems to be the best place to start while reserving surgical approaches for cases that have failed conservative management.

Proximal disinsertion of the common extensor tendon for lateral elbow tendinopathy

PURPOSE

To evaluate surgical outcomes of disinsertion of the common extensor tendon for lateral elbow tendinopathy.

METHODS

Records of 277 men and 128 women who underwent surgery for lateral elbow tendinopathy were reviewed. The indication for surgery was insufficient improvement of pain and inability to return to work after 3 weeks of physiotherapy (stretching, ultrasound) and local corticosteroid injections. According to the Tavernier technique, the origin of the tendons of the extensor carpi radialis brevis and extensor digitorum communis was located, and proximal disinsertion of the common extensor tendon was performed.

RESULTS

Outcome was excellent in 344 (85%) of the patients, good in 46 (11.5%), regular in 9 (2%), and poor in 2 (0.5%). The mean time to return to work was 29 (range, 5-93) days. Immediate complications included infection (n=1), seroma (n=1), cicatricial fibrosis (n=10), radial neuritis (sensory) [n=4], and reactive dermatitis (n=2). Late complications included Frohse's arcade syndrome (n=1) and carpal tunnel syndrome (n=2).

CONCLUSION

Disinsertion of the proximal common tendon is a good option for treating lateral elbow tendinopathy.

Platelet rich plasma therapy: A comparative effective therapy with promising results in plantar fasciitis

Chronic muscle & tendon injuries are one of the problems which are encountered by human being since last long time. These injuries are generally repetitive strain injuries, commonly found in athletes. There are various treatments which include conservative methods in initial stages to surgery in later stages. On minimal invasive aspect Ultrasound-guided fenestration and tenotomy surgery has been used with good results as an effective treatment of chronic tendinopathies.(1,2) There are various injectable agents which were also researched including simple solutions such as hyperosmolar dextrose(3) (prolotherapy) to complex orthobiologic agents such as bone morphogenic protein,(4) but none have achieved uniform success. Platelet rich plasma (PRP) injection has emerged as a treatment alternative for many musculoskeletal conditions. We have done this study on sixty patients to evaluate & compare the effects of platelet rich plasma & steroid injection on patients with planter fasciitis. The results at the 1, 3 & 6 months were evaluated, which showed the good results with platelet rich plasma in comparison to steroid injections.

Overuse injuries of the lower extremity

Overuse injuries are a common and important cause of morbidity in elite and recreational athletes. They are increasingly recognized in the sedentary population. This article reviews the major classes of overuse injuries of the lower extremity. The underlying pathologic condition is correlated with the imaging appearances, and the often variable relationship between the imaging appearances and patients' symptoms are reviewed. Attempts at imaged-based grading systems and the ability of imaging to predict patients' prognosis are considered. Image-guided injection therapy for tendinopathy is an important and rapidly changing area; the indications, risks, and potential benefits of these interventions are reviewed.

Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial

Objective:

To compare the effects of platelet-rich plasma injection with those of dry needling on shoulder pain and function in patients with rotator cuff disease.

Design:

A single-centre, prospective, randomized, double-blinded, controlled study.

Setting:

University rehabilitation hospital.

Participants:

Thirty-nine patients with a supraspinatus tendon lesion (tendinosis or a partial tear less than 1.0 cm, but not a complete tear) who met the inclusion criteria recruited between June 2010 and February 2011.

Intervention:

Two dry needling procedures in the control group and two platelet-rich plasma injections in the experimental group were applied to the affected shoulder at four-week intervals using ultrasound guidance.

Measurements:

The Shoulder Pain and Disability Index, passive range of motion of the shoulder, a physician global rating scale at the six-month follow-up, adverse effects monitoring and an ultrasound measurement were used as outcome measures.

Results:

The clinical effect of the platelet-rich plasma injection was superior to the dry needling from six weeks to six months after initial injection ( P < 0.05). At six months the mean Shoulder Pain and Disability Index was 17.7 ± 3.7 in the platelet-rich plasma group versus 29.5 ± 3.8 in the dry needling group ( P < 0.05). No severe adverse effects were observed in either group.

Conclusions:

Autologous platelet-rich plasma injections lead to a progressive reduction in the pain and disability when compared to dry needling. This benefit is certainly still present at six months after treatment. These findings suggest that treatment with platelet-rich plasma injections is safe and useful for rotator cuff disease.

Tendinosis: pathophysiology and nonoperative treatment

Tendinosis is a troublesome clinical entity affecting many active people. Its treatment remains a challenge to sports medicine clinicians. The etiopathophysiology of tendinosis has not been well delineated. The known pathophysiology and the recent advances in the understanding of the etiologic process of tendinosis are discussed here, including new concepts in mechanotransduction and the biochemical alterations that occur during tendon overload. The optimal, nonoperative treatment of tendinosis is not clear. This article reviews recent evidence of the clinical efficacy of the following interventions: eccentric exercise, extracorporal shock wave treatment, corticosteroid and nonsteroidal anti-inflammatory medications, sclerosing injections, nitric oxide, platelet-rich plasma injections, and matrix metalloproteinase inhibitors. Eccentric exercise has strongest evidence of efficacy. Extracorporal shock wave treatment has mixed evidence and needs further study of energy and application protocols. Sclerosing agents show promising early results but require long-term studies. Corticosteroid and nonsteroidal anti-inflammatory medications have not been shown to be effective, and many basic science studies raise possible concerns with their use. Nitric oxide has been shown in several basic science studies to be promising, but clinical efficacy has not been well established. More clinical trials are needed to assess dosing, indications, and clinical efficacy of nitric oxide. Platelet-rich plasma injections have offered encouraging short-term results. Larger and longer-term clinical trials are needed to assess this promising modality. Matrix metalloproteinase inhibitors have had few clinical studies, and their role in the treatment of tendinosis is still in the early phase of investigation.

Tendinopathies of the elbow, wrist, and hand: histopathology and clinical considerations

This article reviews the current opinion of the histopathological findings of common elbow, wrist, and hand tendinopathies. Implications for client management including examination, diagnosis, prognosis, intervention, and outcomes are addressed. Concepts for further research regarding common therapeutic interventions are discussed.

Two cases of work-related lateral epicondylopathy treated with Graston Technique® and conservative rehabilitation

OBJECTIVE

To chronicle the conservative treatment and management of two work-related cases of lateral elbow pain diagnosed as lateral epicondylopathy.

CLINICAL FEATURES

PATIENT 1: A 48-year old female presented with gradual onset of right lateral elbow pain over the course of six weeks related to work activities of repetitive flexion/extension movements of the wrist and finger keying. PATIENT 2: A 47-year old female presented with gradual onset of left lateral elbow pain over the course of four weeks related to work activities of repetitive squeezing and gripping.

INTERVENTION AND OUTCOME

The conservative treatment approach consisted of activity modification, bracing, medical acupuncture with electrical stimulation, Graston Technique®, and rehabilitative exercise prescription. Outcome measures included verbal pain rating scale (VPRS), QuickDASH Work Module Score (QDWMS), and a return to regular work activities. Both patients attained resolution of their complaints, and at eight month follow-up reported no recurrence of symptoms.

CONCLUSION

A combination of conservative rehabilitation strategies may be used by chiropractors to treat work-related lateral epicondylopathy and allow for individuals to minimize lost time related to this condition.

Effect of regenerative injection therapy on function and pain in patients with knee osteoarthritis: a randomized crossover study

OBJECTIVE

We assessed the effectiveness of regenerative injection therapy (RIT) to relieve pain and restore function in patients with knee osteoarthritis.

DESIGN

Crossover study where participants were randomly assigned to receive exercise therapy for 32 weeks in combination with RIT on weeks 0, 4, 8, and 12 or RIT on weeks 20, 24, 28, and 32.

PATIENTS

Thirty-six patients with chronic knee osteoarthritis.

INTERVENTIONS

RIT, which is made up of injections of 1 cc of 15% dextrose 0.6% lidocaine in the collateral ligaments and a 5 cc injection of 20% dextrose 0.5% lidocaine inside the knee joint.

OUTCOME MEASURES

The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index of severity of osteoarthrosis symptoms (WOMAC) score (range: 0-96).

RESULTS

Following 16 weeks of follow-up, the participants assigned to RIT presented a significant reduction of their osteoarthritis symptoms (mean ± standard deviation: -21.8 ± 12.5, P < 0.001). WOMAC scores in this group did not change further during the last 16 weeks of follow-up, when the participants received exercise therapy only (-1.2 ± 10.7, P = 0.65). WOMAC scores in the first 16 weeks did not change significantly among the participants receiving exercise therapy only during this period (-6.1±13.9, P=0.11). There was a significant decrease in this groups' WOMAC scores during the last 16 weeks when the participants received RIT (-9.3±11.4, P=0.006). After 36 weeks, WOMAC scores improved in both groups by 47.3% and 36.2%. The improvement attributable to RIT alone corresponds to a 11.9-point (or 29.5%) decrease in WOMAC scores.

CONCLUSIONS

The use of RIT is associated with a marked reduction in symptoms, which was sustained for over 24 weeks.

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.

Platelet-rich plasma in sports medicine: hot favourite or non-starter?

In the field of sports injury, musculoskeletal injuries require prompt treatment to allow a quick return to the pre-injury level of function. Ideally, any given treatment should, among other factors, be minimally invasive and highly effective, with minimal side effects. One emerging strategy to accelerate tissue healing is the use of platelet rich plasma. Platelet-rich plasma has been used in clinical practice since the 1980s, in dentistry, maxillofacial surgery and dermatology (Margolis et al, 2001). The treatment developed because platelet-rich plasma is seen as a preparation of growth factors which facilitate rapid healing of damaged tissue. There have been wide variations in agreeing a definition of platelet-rich plasma.

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.

Elbow tendinopathy

Lateral epicondylosis is a common pathology of the upper extremity. The origin of the ECRB is the most commonly cited anatomic location of lateral epicondylosis pathology. Histologic examination shows the features of a failed healing response, with absence of acute inflammatory cells. The typical patient with lateral epicondylosis is an adult in the fourth or fifth decade of life, with no difference about the sex. Diagnosis is based on history and physical examination. The role of imaging is to confirm the diagnosis. The most consistent symptom of lateral epicondylosis is pain over the lateral aspect of the elbow. Therapeutic modalities for lateral epicondylosis vary widely and lack definitive evidence. Open, percutaneous or arthroscopic surgery is recommended when functional disability and pain persist after 6 to 12 months of nonoperative management. Future studies using validated clinical measures and imaging are needed to determine the best management for patients with lateral epicondylosis.

Concise review: the clinical application of mesenchymal stem cells for musculoskeletal regeneration: current status and perspectives

Regenerative therapies in the musculoskeletal system are based on the suitable application of cells, biomaterials, and/or factors. For an effective approach, numerous aspects have to be taken into consideration, including age, disease, target tissue, and several environmental factors. Significant research efforts have been undertaken in the last decade to develop specific cell-based therapies, and in particular adult multipotent mesenchymal stem cells hold great promise for such regenerative strategies. Clinical translation of such therapies, however, remains a work in progress. In the clinical arena, autologous cells have been harvested, processed, and readministered according to protocols distinct for the target application. As outlined in this review, such applications range from simple single-step approaches, such as direct injection of unprocessed or concentrated blood or bone marrow aspirates, to fabrication of engineered constructs by seeding of natural or synthetic scaffolds with cells, which were released from autologous tissues and propagated under good manufacturing practice conditions (for example, autologous chondrocyte implantation). However, only relatively few of these cell-based approaches have entered the clinic, and none of these treatments has become a "standard of care" treatment for an orthopaedic disease to date. The multifaceted reasons for the current status from the medical, research, and regulatory perspectives are discussed here. In summary, this review presents the scientific background, current state, and implications of clinical mesenchymal stem cell application in the musculoskeletal system and provides perspectives for future developments.

Ultrasound-guided sclerosis of neovessels in patellar tendinopathy: a prospective study of 101 patients

BACKGROUND

A randomized controlled study has shown promising clinical results after treatment with sclerosing injections in a group of patients with patellar tendinopathy, but no study has investigated medium- or long-term outcome in a large and unselected group of patients.

PURPOSE

To investigate if sclerosing treatment would affect the level of patellar tendon pain and knee function after 24 months in a large group of patients with patellar tendinopathy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This prospective study recruited patients with a clinical diagnosis of jumper's knee and visible neovascularization corresponding to the painful area on power Doppler ultrasound. They received up to a maximum of 5 ultrasound-guided sclerosing injections using polidocanol at 4- to 6-week intervals. Knee pain and function were recorded using the Victorian Institute of Sport Assessment-Patella (VISA-P) score before treatment and 6, 12, and 24 months after the first injection.

RESULTS

In total, 101 patients (15 women and 86 men) with 120 tendons were included and given from 1 to 5 sclerosing injections (mean [SD], 2.5 [0.9]). The patients reported a significantly improved VISA-P score from baseline (mean, 39; 95% confidence interval [CI], 36-42) to the 24-month follow-up (mean, 65; 95% CI, 60-70) (range, 21-100; P < .001, paired t test). However, a VISA-P score of >95 points was reported in only 22 cases (20%), whereas 37 cases (36%) reported a VISA-P score of <50 at 24 months.

CONCLUSION

Sclerosing treatment with polidocanol resulted in a moderate improvement in knee function and reduced pain in a heterogeneous group of patients with patellar tendinopathy. Nevertheless, few of the patients were cured, and the majority still had reduced function and substantial pain after 24 months of follow-up.

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.

Conservative management of tendinopathy: an evidence-based approach

Tendinopathy is one of the most frequent overuse injuries associated with sport. It is a failure of a chronic healing response associated with both chronic overloaded and unloaded states. Although several conservative therapeutic options have been proposed, very few of them are supported by randomized controlled trials. Eccentric exercises provide excellent clinical results both in athletic and sedentary patients, with no reported adverse effects. Combining eccentric loading and low-energy shock wave therapy produces higher success rates compared with eccentric training alone or shock wave therapy alone. High-volume injection of normal saline solution, corticosteroids, or anesthetics can reduce pain and improve long-term function in patients with Achilles or patellar tendinopathy. The use of injectable substances such as platelet-rich plasma, autologous blood, polidocanol, and corticosteroids in and around tendons is not support by strong clinical evidence. Further randomized controlled trials are necessary to define the best conservative management of tendinopathy.

Tennis elbow

INTRODUCTION

Lateral pain in the elbow affects up to 3% of the population, and is considered an overload injury of the extensor tendons of the forearm where they attach at the lateral epicondyle. Although usually self-limiting, symptoms may persist for over 1 year in up to 20% of people.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for tennis elbow? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, autologous whole blood injections, corticosteroid injections, combination physical therapies, exercise, extracorporeal shock wave therapy, iontophoresis, low-level laser therapy, manipulation, non-steroidal anti-inflammatory drugs (oral and topical), orthoses (bracing), platelet-rich plasma injections, pulsed electromagnetic field treatment, surgery, and ultrasound.

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.

Current opinions on tendinopathy

Tendinopathy is characterized by pain in the tendon and impaired performance sometimes associated with swelling of the tendon. Its diagnosis is usually clinical but ultrasonography and magnetic resonance imaging can refine the diagnosis. Tendinopathy is highly prevalent and is one of the most frequently self reported musculoskeletal diseases in physical workers and sports people. Nevertheless, it is very difficult to carry out general epidemiologic studies on tendinopathy because of the varying sports cultures and sports habits in different countries. The aetiology of tendinopathy seems to be multi-factorial, involving intrinsic and extrinsic factors. The role of inflammation is still debated but the absence of inflammatory cells does not mean that inflammatory mediators are not implicated. Different theories have been advanced to explain pain and chronicity mechanisms, but these mechanisms remain largely unknown. "Conventional "treatments are generally employed empirically to fight pain and inflammation but they do not modify the histological structure of the tendon. However, these treatments are not completely satisfactory and the recurrence of symptoms is common. Currently, eccentric training remains the treatment of choice for tendinopathy, even though some studies are contradictory. Moreover, many interesting new treatments are now being developed to treat tendinopathy, but there is little evidence to support their use in clinical practice. Key pointsThe word "tendinopathy "is the correct term for the clinical diagnosis of pain accompanied by impaired performance, and sometimes swelling in the tendon.The aetiology of tendinopathy seems to be a multi-factorial process, involving promoting factors that are intrinsic or extrinsic, working either alone or in combination.US (with color Doppler) and MRI are usually prescribed when tendinopathy is unresponsive to treatment and entails lingering symptoms.Eccentric training is currently considered to be the most efficient treatment for tendinopathy; nevertheless, in order to be effective, this treatment needs specific modalities: slow speed, low intensity and gradual intensification, with minimum 20 to 30 sessions of exercises often being needed.Many interesting new treatments are now being developed to treat tendinopathy, but currently there is little evidence to support their use in clinical practice.

Musculoskeletal applications of platelet-rich plasma: fad or future?

OBJECTIVE

The purpose of this article is to detail the biology of platelet-rich plasma (PRP), critically review the existing literature, and discuss future research applications needed to adopt PRP as a mainstay treatment method for common musculoskeletal injuries.

CONCLUSION

Any promising minimally invasive therapy such as PRP deserves further investigation to avoid surgery. Diagnostic imaging outcome assessments, including ultrasound-guided needle precision, should be included in future investigations.

Treatment of tendinopathy: is there a role for autologous whole blood and platelet rich plasma injection?

BACKGROUND

Chronic tendinopathies are a common source of disability and can be recalcitrant to conservative measures, which once exhausted may necessitate operative intervention. Blood and platelets, in particular, are a rich source of factors necessary for tissue healing. Autologous blood injections (ABI) are thought to promote tendon healing, but have been explored clinically in only a few limited studies. However, recently they have attracted media attention in relation to the world of professional athletes and sports-related injuries.

METHOD

We review the evidence base for this technique using the available literature on PubMed.

CONCLUSION

Refractory chronic tendinopathy may be responsive to ABIs, but the data available to date are limited by quality and size of study, as well as length of follow up, and are currently insufficient to recommend this modality for routine clinical use.