1
|
Lowdon H, Chong HH, Dhingra M, Gomaa AR, Teece L, Booth S, Watts AC, Singh HP. Comparison of Interventions for Lateral Elbow Tendinopathy: A Systematic Review and Network Meta-Analysis for Patient-Rated Tennis Elbow Evaluation Pain Outcome. J Hand Surg Am 2024; 49:639-648. [PMID: 38678448 DOI: 10.1016/j.jhsa.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/22/2024] [Accepted: 03/13/2024] [Indexed: 04/30/2024]
Abstract
PURPOSE There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET), and not all available treatment options have been compared directly with placebo/control. A network meta-analysis was conducted to compare the effectiveness of different LET treatments directly and indirectly against control/placebo based on a validated outcome, the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score. METHODS Randomized, controlled trials comparing different treatment methods for LET were included, provided they reported outcome data using the PRTEE pain score. A network meta-analysis with random effect was used to combine direct and indirect evidence between treatments compared with placebo in the short term (up to six weeks) and midterm (more than six weeks and up to six months) after intervention. RESULTS Thirteen studies with 12 comparators including control/placebo were eligible. The results indicated no significant improvement in PRTEE pain score in the short term across all treatments compared with control/placebo. In the midterm, physiotherapy/exercise showed benefit against placebo (mean difference: -4.32, 95% confidence interval: -7.58 and -1.07). Although steroid injections, dry needling, and autologous blood also exhibited potential treatment effects, it is crucial for the clinician to consider certain pitfalls when considering these treatments. The limited number of small studies and paucity of data call for caution in interpreting the results and need for further evidence. CONCLUSIONS Patients should be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared with control/placebo in the short and medium terms. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.
Collapse
Affiliation(s)
- Hamish Lowdon
- University Hospital of Leicester NHS Trust, Leicester, UK
| | - Han Hong Chong
- University Hospital of Leicester NHS Trust, Leicester, UK.
| | - Mohit Dhingra
- University Hospital of Leicester NHS Trust, Leicester, UK
| | - Abdul-Rahman Gomaa
- Human Anatomy Resource Centre (HARC), University of Liverpool, Liverpool, UK
| | - Lucy Teece
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sarah Booth
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wrightington, UK
| | | |
Collapse
|
2
|
Sharma S, Berwal P, Verma N, Pandey AK, Saxena S, Gamad N. Physical therapy intervention versus corticosteroid injection for lateral elbow tendinopathy. Does slow and steady win the race? - A systematic review. Shoulder Elbow 2024; 16:59-73. [PMID: 38425735 PMCID: PMC10901174 DOI: 10.1177/17585732221132545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/05/2022] [Accepted: 09/24/2022] [Indexed: 03/02/2024]
Abstract
Background Lateral elbow tendinopathy is one of the most common chronic and degenerative diseases which significantly affects quality of life and the activities of daily living of a person. The following is a systematic review reporting a comparison between physical therapy intervention and corticosteroid injection for the treatment of lateral elbow tendinopathy. Method PubMed, Web of Science, and Embase were searched using headings related to treatment options for Lateral elbow tendinopathy. The following keywords were used: lateral epicondylitis, physical therapy, and corticosteroid injection. Result We descriptively analyzed and reviewed a total of 12 studies including a total of 1253 patients for lateral elbow tendinopathy. The physical therapy intervention included interventions like electrotherapy, manual therapy, and exercise. The studies included had an overall low to unknown risk of bias. Conclusion Our review suggests corticosteroid injection provides beneficial short-term effects and physical therapy interventions provide intermediate to long-term effects, less additional treatment and low recurrence rate in patients with lateral elbow tendinopathy. Although high-quality randomized control trials are required in order to have a better understanding of both intervention types.
Collapse
Affiliation(s)
- Shivam Sharma
- Department of Physical and Rehabilitation Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prerana Berwal
- Department of Physical and Rehabilitation Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nishank Verma
- Department of Physical and Rehabilitation Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Avaneesh Kumar Pandey
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Somya Saxena
- Department of Physical and Rehabilitation Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nanda Gamad
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
3
|
Hohmann E, Tetsworth K, Glatt V. Corticosteroid injections for the treatment of lateral epicondylitis are superior to platelet-rich plasma at 1 month but platelet-rich plasma is more effective at 6 months: an updated systematic review and meta-analysis of level 1 and 2 studies. J Shoulder Elbow Surg 2023; 32:1770-1783. [PMID: 37247780 DOI: 10.1016/j.jse.2023.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND The purpose of this study was to perform a systematic review and meta-analysis of studies comparing local injections of either platelet-rich plasma (PRP) or corticosteroid for the treatment of lateral elbow epicondylitis. METHODS A systematic review of MEDLINE, Embase, Scopus, and Google Scholar was performed, and all level 1 and 2 randomized studies from 2000 to 2022 were included. Clinical symptoms, patient perceived outcomes, and pain were assessed by the DASH (disabilities of the arm, shoulder and hand questionnaire) and pain by the visual analog scale (VAS). Publication bias and risk of bias were assessed using the Cochrane Collaboration's tools. The modified Coleman Methodology Score (CMS) and the GRADE system were used to assess the quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS Thirteen studies were included in the analysis. Five studies had a high risk of bias, and the risk of bias across studies was assessed as unclear. There was no publication bias identified. Two of the four GRADE domains (inconsistency of results, imprecision of results) were downgraded to low quality, and the final GRADE assessment was downgraded to a low quality of evidence. The mean CMS score was 62.8, indicating fair quality. The pooled estimate for VAS at 1 month favored corticosteroids (P = .75) but favored PRP at three (P = .003) and six months (P = .0001). The pooled estimate for the DASH score favored corticosteroids at 1 month (P = .028) but favored PRP at three (P = .01) and six months (P = .107) CONCLUSION: The results of this meta-analysis suggest that PRP has no advantage over steroid injections within the first month of treatment, but that it is superior to steroids at both 3 and 6 months. These results also suggest that corticosteroids have a short-term beneficial effect during the early treatment period, although the quality of the available evidence is not very robust in support of this finding. However, these findings must all be viewed with caution as the high risk of bias and moderate to low quality of the included studies may not justify a recommendation of one treatment over another.
Collapse
Affiliation(s)
- Erik Hohmann
- Medical School, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; Department of Orthopaedic Surgery and Sports Medicine, Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates.
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia; Department of Surgery, School of Medicine, University of Queensland, Australia; Limb Reconstruction Center, Macquarie University Hospital, Macquarie Park, Australia Orthopaedic Research Centre of Australia, Brisbane, Australia
| | - Vaida Glatt
- Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX, USA; Orthopaedic Research Centre of Australia, Brisbane, Australia
| |
Collapse
|
4
|
Abstract
This article provides a guidance summary for the management of lateral elbow tendinopathy (LET) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of the rating quality of the literature and grading the strength of available evidence. The process began by assembling a guideline development group of volunteers including orthopaedic surgeons, trainees, physiotherapists, rheumatologists, radiologists and patients. Virtual meetings were organised to set out explicit PICO questions, including specification of all important outcomes (including patient reported tennis elbow evaluation (PRTEE) as an important primary outcome) to determine the clinical effectiveness of common treatment options for LET compared with no treatment or placebo. Clinical librarian searched (date 31 April 2022) for available systematic reviews and randomised controlled trials reviewing the management of the LET January 2011 onwards and evidence was collected and summarized using explicit GRADE criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations were characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of alternative management options. This informative summary provides the quality of available evidence for the management of LET.
Collapse
Affiliation(s)
| | - Adam C Watts
- Upper Limb Unit, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| |
Collapse
|
5
|
Mirvish AB, Fowler JR. Surgical Management of Lateral Epicondylitis: A Retrospective Review of Technique Success. Hand (N Y) 2023:15589447231151432. [PMID: 36752081 DOI: 10.1177/15589447231151432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Lateral epicondylitis usually stems from overuse and failed tendon healing. Following attempt of conservative management, surgery is often considered, although there is variation in techniques and outcomes cited in the literature. METHODS This retrospective review analyzed 293 operative patients for lateral epicondylitis following conservative management. The primary outcome was change in pain from preoperative status, including pain-free, improved, unchanged, or worse. Positive outcomes included pain-free or improved symptoms postoperatively. Negative outcomes were unchanged or worse pain. Patients returned 2 weeks, 6 weeks, and 3 months postoperatively. We analyzed patients' profession, handedness, operating surgeon, surgical technique, sex, magnetic resonance imaging findings, concomitant procedures, age, race, revisions, and complications. One surgeon repaired the common extensor using a suture anchor, whereas 2 surgeons performed a side-side repair of the extensor carpi radialis longus and extensor digitorum communis interval. RESULTS By the 3-month visit, 41% were pain-free and 52% improved compared with preoperatively. None were worse, and 7% were unchanged. Mean pain scores at the 2-week, 6-week, and 3-month visits were 4.22/10, 3.61/10, and 3.44/10, respectively. There were 7 revisions (2.4%) and 6 complications (2%). Manual laborers experienced more negative outcomes than sedentary workers (P = .04). The remaining parameters were insignificant, including the operative technique. CONCLUSIONS Surgery is successful for both techniques, with 93% positive outcomes by 3 months. There was no statistical difference in postoperative pain between patients who had suture repair versus anchor repair. Therefore, surgeons should consider suture-only repair given the cost of anchors.
Collapse
|
6
|
Sousa Filho LF, Barbosa Santos MM, Dos Santos GHF, da Silva Júnior WM. Corticosteroid injection or dry needling for musculoskeletal pain and disability? A systematic review and GRADE evidence synthesis. Chiropr Man Therap 2021; 29:49. [PMID: 34857021 PMCID: PMC8638538 DOI: 10.1186/s12998-021-00408-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/22/2021] [Indexed: 12/24/2022] Open
Abstract
Background Corticosteroid injection and dry needling have been used in the treatment of musculoskeletal conditions, but it is unclear which intervention is the most effective. The purpose of this study was to compare the effects of corticosteroid injection and dry needling for musculoskeletal conditions at short-, medium-, and long-term follow-up. Methods Electronic databases were searched up to 31 October 2021. Two researchers independently screened titles, abstracts and full-text articles. Randomized clinical trials (RCTs) that investigated the effectiveness of dry needling compared to corticosteroid injection in patients over 18 years with a musculoskeletal condition were included in the review. The studies had to report pain and/or disability as outcome. Risk of bias was assessed by using the revised Cochrane Collaboration tool (RoB 2.0). Quality of evidence was evaluated by using the GRADE approach. Results Six studies were included (n = 384 participants). Four musculoskeletal conditions were investigated. There is very low-quality evidence that CSI is superior to DN for reducing heel pain (plantar fasciitis) and lateral elbow pain at short- and medium-term follow-up, but not for myofascial pain and greater trochanteric pain. There is very low-quality evidence that DN is more effective than CSI at long-term follow-up for reducing pain in people with plantar fasciitis and lateral epicondylitis. Very low-certainty evidence shows that there is no difference between DN and CSI for disability at short-term follow-up. One study showed that CSI is superior to DN at medium-term follow-up and another observed that DN is superior to CSI for reducing disability at long-term. Conclusions There are no differences between DN and CSI in pain or disability for myofascial pain and greater trochanteric pain syndrome. Very-low certainty evidence suggests that CSI is superior to DN at shorter follow-up periods, whereas DN seems to be more effective than CSI at longer follow-up durations for improving pain in plantar fasciitis and lateral epicondylitis. Large RCTs with higher methodological quality are needed in order to draw more incisive conclusions. PROSPERO registration number CRD42020148650. Supplementary Information The online version contains supplementary material available at 10.1186/s12998-021-00408-y.
Collapse
Affiliation(s)
- Luis Fernando Sousa Filho
- Graduate Program in Physical Education, Federal University of Sergipe, Av Marechal Rondon, s/n, Rosa Elze, São Cristovão, Sergipe, 49100-000, Brazil. .,Department of Physical Therapy, Federal University of Sergipe, Av Marechal Rondon, s/n, Rosa Elze, São Cristovão, Sergipe, 49100-000, Brazil.
| | - Marta Maria Barbosa Santos
- Department of Physical Therapy, Federal University of Sergipe, Av Marechal Rondon, s/n, Rosa Elze, São Cristovão, Sergipe, 49100-000, Brazil
| | - Gabriel Henrique Freire Dos Santos
- Department of Physical Therapy, Federal University of Sergipe, Av Marechal Rondon, s/n, Rosa Elze, São Cristovão, Sergipe, 49100-000, Brazil
| | - Walderi Monteiro da Silva Júnior
- Graduate Program in Physical Education, Federal University of Sergipe, Av Marechal Rondon, s/n, Rosa Elze, São Cristovão, Sergipe, 49100-000, Brazil.,Department of Physical Therapy, Federal University of Sergipe, Av Marechal Rondon, s/n, Rosa Elze, São Cristovão, Sergipe, 49100-000, Brazil
| |
Collapse
|
7
|
Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD, Murrell GAC, McInnes IB, Rodeo SA. Tendinopathy. Nat Rev Dis Primers 2021; 7:1. [PMID: 33414454 DOI: 10.1038/s41572-020-00234-1] [Citation(s) in RCA: 275] [Impact Index Per Article: 91.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/14/2022]
Abstract
Tendinopathy describes a complex multifaceted pathology of the tendon, characterized by pain, decline in function and reduced exercise tolerance. The most common overuse tendinopathies involve the rotator cuff tendon, medial and lateral elbow epicondyles, patellar tendon, gluteal tendons and the Achilles tendon. The prominent histological and molecular features of tendinopathy include disorganization of collagen fibres, an increase in the microvasculature and sensory nerve innervation, dysregulated extracellular matrix homeostasis, increased immune cells and inflammatory mediators, and enhanced cellular apoptosis. Although diagnosis is mostly achieved based on clinical symptoms, in some cases, additional pain-provoking tests and imaging might be necessary. Management consists of different exercise and loading programmes, therapeutic modalities and surgical interventions; however, their effectiveness remains ambiguous. Future research should focus on elucidating the key functional pathways implicated in clinical disease and on improved rehabilitation protocols.
Collapse
Affiliation(s)
- Neal L Millar
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
| | | | - Kristian Thorborg
- Institute of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Paul D Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | | |
Collapse
|
8
|
Does the Type of Extracorporeal Shock Therapy Influence Treatment Effectiveness in Lateral Epicondylitis? A Systematic Review and Meta-analysis. Clin Orthop Relat Res 2020; 478:2324-2339. [PMID: 32332245 PMCID: PMC7491893 DOI: 10.1097/corr.0000000000001246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Extracorporeal shock wave therapy (ESWT) has been used in various musculoskeletal disorders, including lateral epicondylitis. However, in 2005, a meta-analysis of randomized controlled trials showed that ESWT provides minimal or no benefit in terms of pain and function in patients with lateral epicondylitis. Since the review, several randomized controlled trials including different types of ESWT such as radial type for lateral epicondylitis have been published. Investigations of the effect modifiers such as symptom and follow-up duration on the effects of ESWT on lateral epicondylitis have not been performed. QUESTIONS/PURPOSES (1) Does ESWT reduce pain and improve grip strength in patients with lateral epicondylitis? (2) Which type of ESWT, radial or focused, is more effective? (3) Is the duration of symptoms associated with the efficacy of ESWT for lateral epicondylitis? (4) Do improvements in pain scores remain in patients with longer follow-up? METHODS The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched up to July 2019 for articles published in English or Korean. Studies were included if patient allocation was randomized, the sample was composed of patients with lateral epicondylitis, interventions were ESWT (focused or radial), comparison group only received sham stimulation or no additional treatment, and the study outcome was pain intensity or grip strength. The quality of the evidence was assessed using the Cochrane risk of bias tool. Twelve studies including 1104 participants fulfilled the inclusion criteria and were included in the meta-analysis. The mean difference for pain reduction and improvement in grip strength was calculated. RESULTS The meta-analysis showed no clinically important difference in the VAS score (2.48 ± 7.55 versus 3.17 ± 9.78, mean difference -0.68 [95% confidence interval -1.17 to -0.19]; p = 0.006) and grip strength (38.02 ± 70.56 versus 34.85 ± 108.26, mean difference 3.33 [95% CI 0.93 to 5.73]; p = 0.007) after ESWT relative to the comparison group's score. Even though radial ESWT showed more improvement than focused, the mean difference for VAS did not exceed the minimal clinically important differences threshold. There were no clinically important effects on the VAS scores of patients with lateral epicondylitis (2.78 ± 5.57 versus 3.92 ± 6.29, mean difference -1.13 [95% CI -1.84 to -0.42]; p = 0.002) and focused ESWT did not improve pain in patients with lateral epicondylitis. In the subgroup analysis, ESWT was effective in patients with a symptom duration of more than 6 months (2.28 ± 8.48 versus 3.31 ± 11.81, mean difference -0.95 [95% CI -1.75 to -0.15]; p = 0.02) but not for those with shorter symptom duration. The effects did not last beyond 24 weeks (2.52 ± 9.19 versus 3.34 ± 5.93, mean difference -0.82 [95% CI -2.57 to 0.93]; p = 0.36). CONCLUSIONS ESWT did not show clinically important improvement in pain reduction and grip strength. Radial ESWT, symptom duration of longer than 6 months, and short follow-up duration (less than 24 weeks) were related to better effects. Further studies are needed to determine the appropriate protocol and elucidate the effects according to the intervention type and specific disease condition. LEVEL OF EVIDENCE Level I, therapeutic study.
Collapse
|
9
|
Abstract
Pain over the lateral aspect of the elbow without nerve injury or elbow instability often is diagnosed as lateral epicondylitis or, colloquially, tennis elbow. It is a common complaint, seen most frequently in women between ages 40 and 60, although it is common in men too. Typical presenting symptoms include pain with prolonged wrist extension activities, pain with resisted wrist or elbow extension, and pain at rest radiating from the elbow along the dorsum of the forearm.
Collapse
Affiliation(s)
- Matthew Meunier
- Orthopedic Surgery, UC San Diego Health System, 350 West Dickinson Avenue, Suite 121, San Diego, CA 92103, USA.
| |
Collapse
|
10
|
Furness ND, Phillips A, Gallacher S, Beazley JCS, Evans JP, Toms AD, Thomas W, Smith CD. Vibration therapy versus standard treatment for tennis elbow: A randomized controlled study. J Orthop Surg (Hong Kong) 2019; 26:2309499018792744. [PMID: 30111240 DOI: 10.1177/2309499018792744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM To determine whether a mechanical, high-frequency vibration device (Tenease™) can improve pain and function for the treatment of tennis elbow (TE), compared with standard treatment. METHODS Adults presenting to an elbow clinic with a clinical diagnosis of TE were randomized to standard treatment with physiotherapy, activity modification and analgesia or standard treatment plus Tenease therapy. Tenease therapy consisted of a 6-week period of treatment using the Tenease device with three 10-min episodes each day. The primary outcome measure was the quick Disabilities of the Arm, Shoulder and Hand score at 6 months, with scores also taken at 6 weeks. Secondary outcome measures were the Patient Rated Tennis Elbow Evaluation Score and EuroQol 5-Dimension Visual Analogue Scale at the same time points. RESULTS Fifty-four patients were recruited into the study. Following randomization and initial dropout, 18 patients were included in the standard group and 27 in the Tenease group. Both groups reported improvements in primary outcome measure scores. The control group had a mean score of 44.3 (standard deviation (SD) = 18.8) at baseline, which dropped to 31.2 (SD = 17.2) at 6 months ( p = 0.002). The Tenease group had a mean score of 43.2 (SD = 22.7) at baseline, which dropped to 23.4 (SD = 15.0) at 6 months ( p = 0.064). Similar improvements were seen in secondary outcome measures with none reaching statistical significance. There were no statistically significant differences seen between the primary outcome scores at 6 weeks ( p = 0.9) or 6 months ( p = 0.5). No complications were noted in either group. CONCLUSIONS Vibration therapy did not result in any statistically significant improvement in functional outcome scores compared to standard treatment for TE. It is important to note that this was a relatively small cohort and a high dropout rate was observed.
Collapse
Affiliation(s)
| | - Alistair Phillips
- 2 University of Southampton Hospital NHS Foundation Trust, Southampton, UK
| | - Sian Gallacher
- 1 Shoulder and Elbow Unit, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | | | - Jonathan Peter Evans
- 1 Shoulder and Elbow Unit, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Andrew David Toms
- 1 Shoulder and Elbow Unit, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - William Thomas
- 1 Shoulder and Elbow Unit, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | | |
Collapse
|
11
|
Short-Term Effects of Steroid Injection, Kinesio Taping, or Both on Pain, Grip Strength, and Functionality of Patients With Lateral Epicondylitis. Am J Phys Med Rehabil 2019; 98:751-758. [DOI: 10.1097/phm.0000000000001184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
12
|
Roh YH, Gong HS, Baek GH. The Prognostic Value of Pain Sensitization in Patients With Lateral Epicondylitis. J Hand Surg Am 2019; 44:250.e1-250.e7. [PMID: 30037764 DOI: 10.1016/j.jhsa.2018.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/09/2018] [Accepted: 06/11/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Pain sensitization is a contributing factor to conditions of chronic pain. The aim of this study was to evaluate the influence of pain sensitization on the prognosis of lateral epicondylitis (LE) treated by self-stretching exercises and the use of a counterforce brace. METHODS We enrolled 131 patients who presented with isolated LE symptoms for less than 6 months. We initially measured pain sensitization by assessing patients' pressure pain thresholds (PPTs) in the contralateral middorsal forearm and administering a pain sensitization questionnaire (PSQ). For outcome assessments, we assessed the self-administered, patient-reported Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire at 6 and 12 months' follow-up. RESULTS Initial PSQ scores correlated moderately with baseline DASH scores and slightly with symptom duration; PPTs correlated slightly with baseline DASH scores. After we accounted for confounding variables, patient-reported disability was associated with lower PPTs, higher PSQ scores, and manual labor at 6 months. These 3 factors accounted for 36% of variance in the DASH scores; however, at 12 months only the PSQ score was associated with higher DASH scores, accounting for 14% of variance. CONCLUSIONS Pain sensitization during the early stages of LE correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment. More research is needed to show whether early identification and treatment of pain sensitization will enhance LE treatment outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
Collapse
Affiliation(s)
- Young Hak Roh
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea.
| | - Hyun Sik Gong
- Seoul National University College of Medicine, Seoul National University Bundang Hospital, Sungnam, South Korea
| | - Goo Hyun Baek
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| |
Collapse
|
13
|
Cogné M, Creuzé A, Petit H, Delleci C, Dehail P, de Seze M. Number of botulinum toxin injections needed to stop requests for treatment for chronic lateral epicondylar tendinopathy. A 1-year follow-up study. Ann Phys Rehabil Med 2019; 62:336-341. [PMID: 30639581 DOI: 10.1016/j.rehab.2018.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/24/2018] [Accepted: 12/21/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epicondylar tendinopathy ("tennis elbow") is a serious issue in manual labourers. Symptoms can persist over months or even more than 1 year, even when treated with trinitrine patches, acupuncture, sclerosis of neovessels, shock-wave therapy, autologous blood injections, platelet-rich plasma or hyaluronic acid. Botulinum toxin (BoNT-A) injections showed promising short-term results, but the long-term beneficial effects are not yet known. OBJECTIVE We aimed to assess the long-term effect, side effects and recurrence rate after BoNT-A injections on chronic lateral epicondylar tendinopathy during 1 year. METHODS This open study followed a 3-month randomized controlled trial. We included 50 patients followed at day 0 (V0), 90 (V1), 180-270 (V2) and 365 (V3). The main judgment criterion was the number of BoNT-A injections required to achieve pain relief with no further request for treatment by the patient. RESULTS After one BoNT-A injection, 22/50 (44%) patients did not ask for further treatment during follow-up because of complete pain relief, and 20/50 (40%) asked for a second BoNT-A injection. For 20 patients with a second injection, 18 (90%) did not ask for further treatment during follow-up. Only 1 patient had a recurrence of pain after an initial pain relief of greater than 75%. Quality of life, and painful and maximal gripping force improved significantly at V1, V2 and V3 as compared with V0, and repercussions on daily and professional activities decreased significantly (P<0.05). CONCLUSIONS One or 2 BoNT-A injections has favourable results for chronic epicondylar tendinopathy.
Collapse
Affiliation(s)
- Mélanie Cogné
- Physical and Rehabilitation Medicine Unit (PRM), University Hospital, 33076 Bordeaux, France; EA4136 Handicap, Activité, Cognition, Santé, Bordeaux University, 33076 Bordeaux, France; University Hospital of Rennes, 2, rue Henri-le-Guilloux, 35000 Rennes, France.
| | - Alexandre Creuzé
- Physical and Rehabilitation Medicine Unit (PRM), University Hospital, 33076 Bordeaux, France
| | - Hervé Petit
- Physical and Rehabilitation Medicine Unit (PRM), University Hospital, 33076 Bordeaux, France
| | - Claire Delleci
- Physical and Rehabilitation Medicine Unit (PRM), University Hospital, 33076 Bordeaux, France
| | - Patrick Dehail
- Physical and Rehabilitation Medicine Unit (PRM), University Hospital, 33076 Bordeaux, France; EA4136 Handicap, Activité, Cognition, Santé, Bordeaux University, 33076 Bordeaux, France
| | - Mathieu de Seze
- Physical and Rehabilitation Medicine Unit (PRM), University Hospital, 33076 Bordeaux, France; EA4136 Handicap, Activité, Cognition, Santé, Bordeaux University, 33076 Bordeaux, France
| |
Collapse
|
14
|
Shim JW, Yoo SH, Park MJ. Surgical management of lateral epicondylitis combined with ligament insufficiency. J Shoulder Elbow Surg 2018; 27:1907-1912. [PMID: 30170794 DOI: 10.1016/j.jse.2018.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/03/2018] [Accepted: 06/03/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral collateral ligament (LCL) insufficiency may occur in patients with chronic lateral epicondylitis (LE). We report on 14 consecutive patients with chronic LE and LCL insufficiency. METHODS We performed a retrospective review of 14 patients with LE and LCL insufficiency diagnosed between 2006 and 2015. The patients had undergone débridement for LE and ligament reconstruction for LCL insufficiency. The study included 9 men and 5 women with an average age of 53 years (range, 41-69 years). The mean follow-up period was 36 months (range, 24-97 months). We analyzed the pain visual analog scale score; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; range of motion; and posterolateral rotatory drawer test. We compared histories of steroid injection, trauma, and surgery. RESULTS The pain visual analog scale score, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score were significantly improved postoperatively and improved in all patients. Three patients had mild instability on the stress test at final follow-up. All patients had a history of steroid injection, 2 had a history of trauma, and 3 had a history of surgery. The number of steroid injections and the number of cases receiving steroid injections more than 3 times were significantly higher in patients with LCL insufficiency. CONCLUSIONS Assessment of stability is important in patients with chronic LE and risk factors such as multiple steroid injections. Simultaneous surgical treatment including open débridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency.
Collapse
Affiliation(s)
- Jae Woo Shim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Si Hoon Yoo
- Department of Orthopedic Surgery, Inseong Hallym Hospital, Incheon, Republic of Korea
| | - Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
15
|
Gaspar MP, Motto MA, Lewis S, Jacoby SM, Culp RW, Lee Osterman A, Kane PM. Platelet-Rich Plasma Injection With Percutaneous Needling for Recalcitrant Lateral Epicondylitis: Comparison of Tenotomy and Fenestration Techniques. Orthop J Sports Med 2017; 5:2325967117742077. [PMID: 29238734 PMCID: PMC5721972 DOI: 10.1177/2325967117742077] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Recalcitrant lateral epicondylitis (LE) is a common debilitating condition, with numerous treatment options of varying success. An injection of platelet-rich plasma (PRP) has been shown to improve LE, although it is unclear whether the method of needling used in conjunction with a PRP injection is of clinical importance. Purpose To determine whether percutaneous needle tenotomy is superior to percutaneous needle fenestration when each is combined with a PRP injection for the treatment of recalcitrant LE. Study Design Cohort study; Level of evidence, 3. Methods A total of 93 patients with recalcitrant LE were treated with a PRP injection and percutaneous needle fenestration (n = 45) or percutaneous needle tenotomy (n = 48) over a 5-year study interval. Preoperative patient data, including visual analog scale for pain (VAS-P), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores and grip strength, were obtained from a chart review and compared with postoperative values obtained prospectively. Secondary outcomes included the incidence of complications, need for additional interventions, return to work, and patient satisfaction. Results At a mean follow-up of 40 months, significant improvements in VAS-P (mean, -6.1; 95% CI, -6.8 to -5.5; P < .0001), QuickDASH (mean, -46; 95% CI, -52 to -40; P < .0001), and PRTEE (mean, -57; 95% CI, -64 to -50; P < .0001) scores and grip strength (mean, +6.1 kg; 95% CI, 4.9 to 7.3; P < .0001) were observed across the entire study cohort, with no significant differences noted between the fenestration and tenotomy groups. Nine of 45 patients (22%) underwent additional procedures to treat recurrent symptoms in the fenestration group compared with 5 of 48 patients (10%) in the tenotomy group (P = .05). No complications occurred in any patients, and no patients expressed dissatisfaction with their treatment course. Conclusion A PRP injection with concomitant percutaneous needling is an effective treatment for recalcitrant LE, with sustained improvements in pain, strength, and function demonstrated at a mean follow-up of longer than 3 years. Although the method of concomitant needling does not appear to have a significant effect on treatment outcomes, more aggressive needle tenotomy is less likely to require conversion to open tenotomy than needle fenestration in the short term to midterm.
Collapse
Affiliation(s)
- Michael P Gaspar
- Philadelphia Hand to Shoulder Center, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Darden School of Business, University of Virginia, Charlottesville, Virginia, USA
| | - Michael A Motto
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sarah Lewis
- Philadelphia Hand to Shoulder Center, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Orthopaedics, Southern California Permanente Medical Group, Fontana, California, USA
| | - Sidney M Jacoby
- Philadelphia Hand to Shoulder Center, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Randall W Culp
- Philadelphia Hand to Shoulder Center, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - A Lee Osterman
- Philadelphia Hand to Shoulder Center, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Patrick M Kane
- Philadelphia Hand to Shoulder Center, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
16
|
Roh YH, Oh M, Noh JH, Gong HS, Baek GH. Effect of Metabolic Syndrome on the Functional Outcome of Corticosteroid Injection for Lateral Epicondylitis: Retrospective Matched Case-Control Study. Sci Rep 2017; 7:10845. [PMID: 28883422 PMCID: PMC5589833 DOI: 10.1038/s41598-017-11179-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 08/21/2017] [Indexed: 01/08/2023] Open
Abstract
Both obesity and diabetes mellitus are well-known risk factors for tendinopathies. We retrospectively compared the efficacy of single corticosteroid injections in treating lateral epicondylitis in patients with and without metabolic syndrome (MetS). Fifty-one patients with lateral epicondylitis and MetS were age- and sex-matched with 51 controls without MetS. Pain severity, Disability of the Arm, Shoulder, and Hand score, and grip strength were assessed at base line and at 6, 12 and 24 weeks post-injection. The pain scores in the MetS group were greater than those in the control group at 6 and 12 weeks. The disability scores and grip strength in the MetS group were significantly worse than those of the control group at 6 weeks. However, there were no significant differences at 24 weeks between the groups in terms of pain, disability scores and grip strengths. After 24 weeks, three patients (6%) in the control group and five patients (10%) in the MetS group had surgical decompression (p = 0.46). Patients with MetS are at risk for poor functional outcome after corticosteroid injection for lateral epicondylitis in the short term, but in the long term there was no difference in outcomes of steroid injection in patients with and without MetS.
Collapse
Affiliation(s)
- Young Hak Roh
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, South Korea
| | - Minjoon Oh
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, South Korea
| | - Jung Ho Noh
- Department of Orthopaedic Surgery, Kangwon National University Hospital, 156 Baengnyeong-ro, Chuncheon-si, Gangwon-do, 200-722, South Korea.
| | - Hyun Sik Gong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173 Gumi-ro, Bundang-gu, Sungnam, 13620, South Korea
| | - Goo Hyun Baek
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| |
Collapse
|