Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: A systematic review

Initial PROMIS Scores Correlate With Operative and Nonoperative Management of Lateral Epicondylitis

BACKGROUND

Lateral epicondylitis (LE) is a common source of elbow pain. Treatment options include physical therapy (PT), corticosteroid injection, or surgery, but the efficacy of each remains unclear. In this study, we compare Patient-Reported Outcomes Measurement Information System (PROMIS) scores between patients treated both operatively and nonoperatively for LE.

METHODS

Patients presenting to a tertiary academic medical center from February 2015 to December 2018 with a diagnosis of LE were identified. Those with initial and follow-up PROMIS physical function (PF), pain interference (PI), and Depression scores were included and stratified according to treatment. Single-factor analysis of variance testing was used to compare PROMIS scores between intervention types.

RESULTS

In all, 982 patients were initially identified with the diagnosis of LE and documented PROMIS scores. Initial treatment consisted of 266 patients receiving formal PT, 238 patients receiving injections, 20 patients undergoing surgery, and 296 patients receiving no formal treatment. At final follow-up, 235 (44.8%) patients had been treated with isolated PT, 237 (45.1%) with injections, and 52 (9.9%) with surgery. Patients who underwent formal PT had the highest initial PF scores when compared with all other interventions. Patients who underwent operative management had higher initial PI scores than those who pursued nonoperative management.

CONCLUSIONS

Patient-Reported Outcomes Measurement Information System PF and PI may be useful for determining which treatment course patients suffering from LE are likely to pursue. Pain as a limiting factor in daily living may be a better indication for operative management as opposed to physical metrics.

Physical therapy intervention versus corticosteroid injection for lateral elbow tendinopathy. Does slow and steady win the race? - A systematic review

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.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review

Objective

The primary objective of this review was to summarize systematic reviews and meta-analyses reporting on nonoperative management of lateral epicondyle tendinopathy.

Methods

An umbrella review of all published systematic reviews and meta-analyses was performed. Three databases were searched using the key words "tennis elbow," "lateral epicondylitis," "non-operative," and "non-surgical modalities." The search was limited to English-language systematic reviews and meta-analyses between the years of 2000 and 2022.

Results

There were 114 systematic reviews/meta-analyses, of which 35 met our inclusion criteria. These articles reviewed the following nonoperative management strategies: ultrasound, shockwave therapy, injection procedures, low-level laser therapy, joint mobilizations, exercise therapy, and electrophysical modalities. Exercise therapy was beneficial in decreasing pain regardless of dosage or type. Conflicting results were seen with ultrasound, laser, and shockwave therapy. Corticosteroid injections provided the most short-term pain relief, and platelet-rich plasma and autologous blood injections were most effective in the long term.

Conclusion

A variety of nonoperative interventions were found to be effective for short- and long-term pain relief as well as functional improvement, with most interventions indicating mixed results. Due to variations in study populations and study quality, results should be interpreted with caution.

What are small, medium and large effect sizes for exercise treatments of tendinopathy? A systematic review and meta-analysis

Objective

To quantify and describe effect size distributions from exercise therapies across a range of tendinopathies and outcome domains to inform future research and clinical practice through conducting a systematic review with meta-analysis.

Design

Systematic review with meta-analysis exploring moderating effects and context-specific small, medium and large thresholds.

Eligibility criteria

Randomised and quasi-randomised controlled trials involving any persons with a diagnosis of rotator cuff, lateral elbow, patellar, Achilles or gluteal tendinopathy of any severity or duration.

Methods

Common databases, six trial registries and six grey literature databases were searched on 18 January 2021 (PROSPERO: CRD42020168187). Standardised mean difference (SMD_pre) effect sizes were used with Bayesian hierarchical meta-analysis models to calculate the 0.25 (small), 0.5 (medium) and 0.75 quantiles (large) and compare pooled means across potential moderators. Risk of bias was assessed with Cochrane's Risk of Bias tool.

Results

Data were obtained from 114 studies comprising 171 treatment arms 4104 participants. SMD_pre effect sizes were similar across tendinopathies but varied across outcome domains. Greater threshold values were obtained for self-reported measures of pain (small=0.5, medium=0.9 and large=1.4), disability (small=0.6, medium=1.0 and large=1.5) and function (small=0.6, medium=1.1 and large=1.8) and lower threshold values obtained for quality of life (small=-0.2, medium=0.3 and large=0.7) and objective measures of physical function (small=0.2, medium=0.4 and large=0.7). Potential moderating effects of assessment duration, exercise supervision and symptom duration were also identified, with greater pooled mean effect sizes estimated for longer assessment durations, supervised therapies and studies comprising patients with shorter symptom durations.

Conclusion

The effect size of exercise on tendinopathy is dependent on the type of outcome measure assessed. Threshold values presented here can be used to guide interpretation and assist with further research better establishing minimal important change.

Treatment, Diagnostic Criteria and Variability of Terminology for Lateral Elbow Pain: Findings from an Overview of Systematic Reviews

Background: Lateral elbow pain (LEP) represents a musculoskeletal disorder affecting the epicondyloid region of the elbow. The terminological framework of this problem in literature, to date, is confusing. This systematic review (SR) aims to analyse the panorama of the scientific literature concerning the pathogenetic framework, treatment, and clinical diagnosis of LEP. Methods: We conducted an SR according to the guidelines of the PRISMA statement. We performed research using the electronic Medline, Epistemonikos, and Cochrane Library databases. The research started on 12 January 2022 and finished on 30 April 2022. We included all systematic reviews and meta-analyses published, in English, between 1989 and 2022. The articles’ selection was based on critical appraisal using Amstar 2. In the selected reviews we obtained the etiopathogenic terminology used to describe the symptoms, treatment, and diagnostic criteria of LEP. Results: Twenty-five SRs met the eligibility criteria and were included in the study. From these SRs, 227 RCT articles were analysed and different treatments proposals were extracted, such as exercise, manipulation corticosteroid injection, and surgery. In the selected articles, 10 different terms emerged to describe LEP and 12 different clinical tests. The most common treatments detected in this SR were a conservative multimodal approach (e.g., eccentric exercises, manual therapy, acupuncture, ultrasound), then surgery or other invasive treatments (e.g., corticosteroid injection, tenotomy). The most common term detected in this SR was “lateral epicondylitis” (n = 95, 51.6%), followed by “tennis elbow” (n = 51, 28.1%) and “lateral epicondylalgia” (n = 18, 9.4%). Among the diagnostic tests were painful palpation (n = 101, 46.8%), the Cozen test (n = 91, 42.1%), the pain-free grip-strength test (n = 41, 19.0%), and the Maudsley test (n = 48, 22.2%). A total of 43.1% of RCTs (n = 96) included subjects with LEP > 3 months, 40.2% (n = 85) included patients with LEP < 3 months, and 16.7% of the items (n = 35) were not specified by the inclusion criteria on the onset of symptoms. Conclusions: In this SR, a considerable terminological heterogeneity emerged in the description of LEP, associated with the lack of clear and recognised diagnostic criteria in evaluating and treating patients with lateral elbow pain.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BACKGROUND

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

METHODS

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

CONCLUSIONS

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

Efficacy of a local corticosteroid injection on pain, disability and radial nerve thickness in patients with lateral epicondylitis

Introduction:

The aim of this study was to compare the effect of a steroid injection with conservative therapy (CT) versus CT alone on pain, functional limitations and the cross-sectional area (CSA) of the radial nerve (RN) in patients with lateral epicondylitis (LE).

Methods:

In this clinical trial, seventy subjects in the age group of 30–60 years with a clinical diagnosis of LE were recruited. Patients received an ultrasound-guided steroid injection and CT (Group A, n = 35) or CT alone (Group B, n = 35). Pain intensity (numeric pain rating scale), functional limitations (Quick Disabilities of the Arm, Shoulder, and Hand questionnaire) and the CSA of RN (mm²) using ultrasound were assessed at baseline, 4 and 12 weeks.

Results:

There was a significant difference in pain intensity (P < 0.05) at 4 weeks in favour of Group A but not at 12 weeks. A statistically significant difference was not present favouring either group concerning disability at both the follow-ups. The difference in CSA of the RN at the affected side in both groups A and B was not statistically significant at either the spiral groove or the antecubital fossa at baseline or the subsequent follow-ups.

Conclusions:

The CT with a steroid injection proved to be more efficacious in the short term concerning pain intensity and functional limitations. The RN thickness is not increased in patients with LE, thereby refuting its role to some extent in the pathogenesis of LE.

Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: a randomized controlled trial of patients with lateral elbow tendinopathy

BACKGROUND

Previous studies have suggested that weakening of shoulder and scapula muscles have been associated with increased pain, and decreased functional abilities in patients with lateral elbow tendinopathy (LET).

PURPOSE

To compare the effects of shoulder and scapula muscle training plus conventional physiotherapy with conventional physiotherapy only.

METHODS

A group of 48 patients with LET was randomly allocated into two groups: shoulder and scapula muscle training plus conventional physiotherapy (n = 24), and conventional physiotherapy (n = 24). All patients received 12 sessions of treatment for 4 weeks. Furthermore, both groups were instructed to continue their own exercise program at home until four months after the end of treatment. Pain intensity, grip strength, and functional status were measured preintervention, postintervention, and 4 months after the end of intervention (4-month follow-up).

RESULTS

The shoulder and scapula muscle training plus conventional physiotherapy group showed significantly more reduction in pain and greater improvement in functional status compared with conventional physiotherapy group, but there was no significant difference in pain-free grip strength for two groups.

CONCLUSION

Conventional physiotherapy combined with shoulder and scapula muscle training could be more effective in improving the pain and functional abilities of patients with LET compared with conventional physiotherapy only.

Platelet-rich plasma versus Tenex in the treatment of medial and lateral epicondylitis

BACKGROUND

Medial epicondylitis and lateral epicondylitis are among the most common elbow pathologies affecting people aged between 40 and 50 years. Although epicondylitis is often a self-limiting condition that improves with conservative treatment, the condition can be difficult to eradicate. The purpose of this study was to compare the effectiveness of platelet-rich plasma (PRP) injections and ultrasound-guided percutaneous tenotomy (Tenex) for the treatment of medial or lateral epicondylitis. Our hypothesis was that the Tenex procedure would not be inferior to PRP injections in the treatment of medial or lateral epicondylitis.

METHODS

In this retrospective review, 62 of 75 patients were available for contact via phone and e-mail to complete post-procedure patient-reported outcome surveys. Subjective assessment of pain and function included a visual analog scale for pain; the Quick Disabilities of the Arm, Shoulder and Hand questionnaire; and the EuroQol-5D questionnaire. The inclusion criteria included age of 18 years or older and previous failure of nonoperative treatment.

RESULTS

The average ages in the PRP and Tenex groups were 47 years and 51 years, respectively. The PRP cohort (n = 32) included 10 female and 22 male patients, whereas the Tenex cohort (n = 30) included 12 female and 18 male patients. The PRP and Tenex groups both demonstrated clinical and statistical improvement in visual analog scale pain scores; Quick Disabilities of the Arm, Shoulder and Hand scores; and EuroQol-5D scores. No statistically significant difference was found between the 2 treatment modalities.

CONCLUSION

The PRP and Tenex procedures were both successful in producing clinically and statistically significant improvements in pain, function, and quality of life.

EFFICACY OF ESWT FOR LATERAL EPICONDYLITIS TREATMENT: COMPARISON WITH PHYSICAL THERAPY MODALITIES

Lateral epicondylitis (LE) is a common condition characterized by pain in the lateral side of the elbow with tenderness on lateral epicondyle, caused by repetetive overuse of extensor muscles of the wrist. Extracorporeal shockwave therapy (ESWT) is used in musculoskeletal problems with the possible mechanism of action including hyperstimulation analgesia, neovascularization and induction of healing process. LE generally responds well to conservative treatment. One of the widely used and accepted terms of treatment for LE is physical therapy (PT). In this study, we aimed to compare the efficacy of ESWT for LE treatment with conventional therapy modalities. This is a prospective randomized study with 73 patients with elbow pain and otherwise healthy, diagnosed as LE. Patients were randomized to two groups to receive either ESWT weekly for 3 weeks or PT for 10 days. Our analysis revealed similar treatment success rates for both groups in many of the evaluation parameters. As a result of our study we were unable to display a major difference between the short-term outcome for two options. However, ESWT still has the advantage of being less time consuming for both the patient and the doctor, an important parameter we believe.

Effects of eight-week "gyroscopic device" mediated resistance training exercise on participants with impingement syndrome or tennis elbow

BACKGROUND

Rehabilitation of injuries in the upper extremity and reestablishment of muscle strength throughout the range of motion in overhead movements, are the major concerns of athletes and coaches in the sports field.

PURPOSE

To determine the effect of eight-week "gyroscopic device" mediated resistance training exercise on grip strength, wrist and shoulder strength and proprioception, and upper extremity performance, in participants with impingement syndrome or tennis elbow.

DESIGN AND METHODS

For this study, in a university rehabilitation clinic 45 volleyball players (aged 22-28) purposefully were selected and divided into 3 groups: shoulder impingement (group I), tennis elbow (group II), and control (group III). The experimental groups performed the "gyroscopic device" mediated resistance training, three sessions a week over 8 wks. Grip strength, wrist and shoulder strength and proprioception, and upper extremity performance were measured before and after implementation of the intervention (eight-week resistance training using a "gyroscopic device") using a hand hold dynamometer, isokinetic dynamometer, and Y balance test respectively.

RESULTS

After 8 weeks of "gyroscopic device" exercise, improvement in the shoulder, wrist and grip strength, shoulder and wrist proprioception and performance scores of both experimental groups was significant. There were no significant differences between study groups I and II, both groups, however, demonstrated significant differences when compared to the control group, but between group I and the control group, and between group II and the control group, the difference was significant. However, no significant change was seen in the control group.

CONCLUSIONS

Due to the significant effects of the "gyroscopic device" mediated exercise on grip strength, wrist and shoulder strength and proprioception, and performance of the upper extremity, use of the exercise can be recommended for subjects with impingement syndrome or tennis elbow impairment in measured variables. More research is needed to confirm the result of this study.

The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction

OBJECTIVE

To evaluate extracorporeal shockwave therapy (ESWT) in treating Achilles tendinopathy (AT), greater trochanteric pain syndrome (GTPS), medial tibial stress syndrome (MTSS), patellar tendinopathy (PT) and proximal hamstring tendinopathy (PHT).

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Randomised and non-randomised studies assessing ESWT in patients with AT, GTPS, MTSS, PT and PHT were included. Risk of bias and quality of studies were evaluated.

RESULTS

Moderate-level evidence suggests (1) no difference between focused ESWT and placebo ESWT at short and mid-term in PT and (2) radial ESWT is superior to conservative treatment at short, mid and long term in PHT. Low-level evidence suggests that ESWT (1) is comparable to eccentric training, but superior to wait-and-see policy at 4 months in mid-portion AT; (2) is superior to eccentric training at 4 months in insertional AT; (3) less effective than corticosteroid injection at short term, but ESWT produced superior results at mid and long term in GTPS; (4) produced comparable results to control treatment at long term in GTPS; and (5) is superior to control conservative treatment at long term in PT. Regarding the rest of the results, there was only very low or no level of evidence. 13 studies showed high risk of bias largely due to methodology, blinding and reporting.

CONCLUSION

Low level of evidence suggests that ESWT may be effective for some lower limb conditions in all phases of the rehabilitation.

[Lateral epicondylitis: conservative - operative]

BACKGROUND

Lateral epicondylitis is a common disease of the common extensor origin at the lateral humerus. Despite its common self-limitation it can lead to chronic therapy-resistant pain with remarkable functional disability of the affected arm.

OBJECTIVES

Different conservative and operative treatment options of lateral epicondylitis are described and compared regarding benefits and risks. Additionally, recent surgical techniques and their complications are mentioned. Based on the current literature, it is shown which treatment option can be recommended.

METHODS

This review was based on the literature analysis in PubMed regarding "conservative and operative therapy of lateral epicondylitis" as well as the clinical experience of the authors.

RESULTS

Conservative treatment is the primary choice for the treatment of lateral epicondylitis if concomitant pathologies such as instability among others can be excluded. It should include strengthening against resistance with eccentric stretching of the extensor group. In persistent cases, operative treatment is warranted. Resection of the pathologic tissue at the extensor origin with debridement and refixation of the healthy tendinous tissue yields good results.

CONCLUSIONS

Most patients with lateral epicondylitis can be treated conservatively with success. Radiological evaluation should be performed in therapy-resistant cases. In the case of partial or complete rupture of the extensor origin, operative therapy is indicated.

The application of mechanical diagnosis and therapy in lateral epicondylalgia

BACKGROUND

lateral epicondylalgia (LE) is a musculoskeletal diagnosis that causes pain and dysfunction in the lateral aspect of the elbow. Mechanical diagnosis and therapy (MDT) is an orthopaedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained end-range movement. There has been no investigation of the association between MDT and patients diagnosed with LE.

CASE DESCRIPTION

this report presents three patients matching the currently accepted diagnostic criteria for LE, two with a diagnosis of lateral epicondylitis (tennis elbow) from a medical doctor. These patients were classified and treated by a diplomat of MDT and two third-year doctoral students of physical therapy using MDT.

OUTCOMES

short- and long-term (one year) outcomes were excellent, demonstrating rapid abolishment of symptoms and return to prior levels of function in 3-6 visits between 11-59 days. Patients demonstrated the ability to prevent and manage reoccurrence of symptoms independently without seeking further health care.

DISCUSSION

this case series raises questions about whether or not the pathologies traditionally associated with the aetiology of LE are actually at fault. Moreover, it raises questions about the utility of special tests typically utilized to identify those structures. The series provides preliminary evidence that MDT may be capable of providing effective short- and long-term outcomes in the management of LE.

LEVEL OF EVIDENCE

4.

Autologous whole blood or corticosteroid injections for the treatment of epicondylopathy and plantar fasciopathy? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To compare the efficacy of autologous whole blood with that of corticosteroid injections on epicondylopathy and plantar fasciopathy.

DESIGN

Systematic review and meta-analysis.

METHODS

The databases of PubMed, Web of Science, CENTRAL, and Scopus were searched up to 6th May 2015. Randomized trials comparing the effects of autologous whole blood and corticosteroid injections on epicondylopathy or plantar fasciopathy were included. Trials exploring the efficacy of platelet-rich plasma were excluded. The primary outcome was pain relief. The secondary outcome included the assessment of composite outcomes. All outcomes were assessed at 2-6 (short-term) weeks, 8-13 (intermediate-term) weeks and 24-26 (medium-term) weeks. Quality assessment was performed with the Cochrane risk of bias tool.

RESULTS

Nine trials were included. For pain relief, there was a statistically significant difference in favour of corticosteroids in the short term (SMD 0.52; 95%CIs 0.18 to 0.86; I² = 53%; p < 0.01). A statistically significant difference in favour of autologous whole blood was indicated in the medium-term assessment of pain relief on epicondylopathy.

CONCLUSIONS

Corticosteroids were marginally superior to autologous whole blood in relieving pain on plantar fasciopathy at 2-6 weeks. Autologous whole blood provided significant clinical relief on epicondylopathy at 8-24 weeks. Conclusions were limited by the risk of bias.

What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations

BACKGROUND

Lateral elbow tendinopathy (LET) is a common complaint causing characteristic pain in the lateral elbow and upper forearm, and tenderness of the forearm extensor muscles. It is thought to be an overuse injury and can have a major impact on the patient's social and professional life. The condition is challenging to treat and prone to recurrent episodes. The average duration of a typical episode ranges from 6 to 24 months, with most (89%) reporting recovery by 1 year.

OBJECTIVES

This systematic review aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for LET.

DATA SOURCES

A comprehensive search was conducted from database inception to 2012 in a range of databases including MEDLINE, EMBASE and Cochrane Databases.

METHODS AND OUTCOMES

We conducted an overview of systematic reviews to summarise the current evidence concerning the clinical effectiveness and a systematic review for the cost-effectiveness of conservative interventions for LET. We identified additional randomised controlled trials (RCTs) that could contribute further evidence to existing systematic reviews. We searched MEDLINE, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Web of Science, The Cochrane Library and other important databases from inception to January 2013.

RESULTS

A total of 29 systematic reviews published since 2003 matched our inclusion criteria. These were quality appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist; five were considered high quality and evaluated using a Grading of Recommendations, Assessment, Development and Evaluation approach. A total of 36 RCTs were identified that were not included in a systematic review and 29 RCTs were identified that had only been evaluated in an included systematic review of intermediate/low quality. These were then mapped to existing systematic reviews where further evidence could provide updates. Two economic evaluations were identified.

LIMITATIONS

The summary of findings from the review was based only on high-quality evidence (scoring of > 5 AMSTAR). Other limitations were that identified RCTs were not quality appraised and dichotomous outcomes were also not considered. Economic evaluations took effectiveness estimates from trials that had small sample sizes leading to uncertainty surrounding the effect sizes reported. This, in turn, led to uncertainty of the reported cost-effectiveness and, as such, no robust recommendations could be made in this respect.

CONCLUSIONS

Clinical effectiveness evidence from the high-quality systematic reviews identified in this overview continues to suggest uncertainty as to the effectiveness of many conservative interventions for the treatment of LET. Although new RCT evidence has been identified with either placebo or active controls, there is uncertainty as to the size of effects reported within them because of the small sample size. Conclusions regarding cost-effectiveness are also unclear. We consider that, although updated or new systematic reviews may also be of value, the primary focus of future work should be on conducting large-scale, good-quality clinical trials using a core set of outcome measures (for defined time points) and appropriate follow-up. Subgroup analysis of existing RCT data may be beneficial to ascertain whether or not certain patient groups are more likely to respond to treatments.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003593.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Lateral epicondylosis: emerging management options

Lateral epicondylosis is one of the most prevalent disorders of the arm and results in significantly decreased function among the workforce and athletes. Historically, the disorder has been diagnosed clinically and treated as an inflammatory entity. Management strategies have included anti-inflammatory medications and techniques, including oral nonsteroidal anti-inflammatories, injected corticosteroid, and physical therapy with modalities. More recent literature postulates a degenerative or compressive etiology, directing some clinicians to try new, more regenerative management strategies such as platelet-rich plasma and stem cell injections. To date, literature evaluating these new treatment methods has shown positive results, although no definitive conclusions can be drawn. More research is needed to evaluate these new treatment methods, and a new look at the diagnosis of the disorder with ultrasound imaging may be reasonable to consider.

Evidence-based medicine in hand surgery: clinical applications and future direction

Evidence-based medicine empowers physicians to systematically analyze published data so as to quickly formulate treatment plans that deliver safe, robust, and cost-effective patient care. In this article, we sample some areas in hand and upper extremity surgery where the evidence base is strong enough that it has or should have unified treatment strategies; we identify some problems where good evidence has failed to unify treatment, and discuss problems for which evidence is still lacking but needed because treatment remains controversial. We also discuss circumstances in which level 4 evidence is more likely than randomized trials to guide treatment.

Role of rehabilitation medicine and physical agents in the treatment of cancer-associated pain

PURPOSE

To provide an overview of rehabilitation medicine- and physical modality-based approaches to cancer pain management, and to highlight the fact that these approaches are generally used in conjunction and that a majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.

METHODS

We performed a nonsystematic literature review and provide a description of the current standard of care.

RESULTS

Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Most modalities have been pragmatically refined over the years, and many have an evidence base, although few have been explicitly validated in the oncologic setting. With few exceptions, they are patient controlled and free of adverse effects.

CONCLUSION

Physical modalities and rehabilitation medicine offer a range of pain management approaches that may serve as beneficial adjuncts to the conventional systemic and interventional analgesic strategies used to control cancer-related pain. These approaches may be particularly beneficial to patients with movement-associated pain and those who are ambivalent regarding pharmacoanalgesia.

Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report

BACKGROUND

This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report.

METHODS

A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

RESULTS

25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

CONCLUSIONS

Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

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

OBJECTIVES

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

DESIGN

Systematic review.

PARTICIPANTS

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

INTERVENTIONS

Corticosteroid injection and non-electrotherapeutic physiotherapy.

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review

OBJECTIVE

To establish the effectiveness of eccentric exercise as a treatment intervention for lateral epicondylitis.

DATA SOURCES

ProQuest, Medline via EBSCO, AMED, Scopus, Web of Science, CINAHL.

REVIEW METHODS

A systematic review was undertaken to identify randomized and controlled clinical trials incorporating eccentric exercise as a treatment for patients diagnosed with lateral epicondylitis. Studies were included if: they incorporated eccentric exercise, either in isolation or as part of a multimodal treatment protocol; they assessed at least one functional or disability outcome measure; and the patients had undergone diagnostic testing. The methodological quality of each study was assessed using the Modified Cochrane Musculoskeletal Injuries Group score sheet.

RESULTS

Twelve studies met the inclusion criteria. Three were deemed 'high' quality, seven were 'medium' quality, and two were 'low' quality. Eight of the studies were randomized trials investigating a total of 334 subjects. Following treatment, all groups inclusive of eccentric exercise reported decreased pain and improved function and grip strength from baseline. Seven studies reported improvements in pain, function, and/or grip strength for therapy treatments inclusive of eccentric exercise when compared with those excluding eccentric exercise. Only one low-quality study investigated the isolated effects of eccentric exercise for treating lateral epicondylitis and found no significant improvements in pain when compared with other treatments.

CONCLUSION

The majority of consistent findings support the inclusion of eccentric exercise as part of a multimodal therapy programme for improved outcomes in patients with lateral epicondylitis.

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Common medical problems of instrumental athletes

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

Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012

In September 2010, the first International Scientific Tendinopathy Symposium (ISTS) was held in Umeå, Sweden, to establish a forum for original scientific and clinical insights in this growing field of clinical research and practice. The second ISTS was organised by the same group and held in Vancouver, Canada, in September 2012. This symposium was preceded by a round-table meeting in which the participants engaged in focused discussions, resulting in the following overview of tendinopathy clinical and research issues. This paper is a narrative review and summary developed during and after the second ISTS. The document is designed to highlight some key issues raised at ISTS 2012, and to integrate them into a shared conceptual framework. It should be considered an update and a signposting document rather than a comprehensive review. The document is developed for use by physiotherapists, physicians, athletic trainers, massage therapists and other health professionals as well as team coaches and strength/conditioning managers involved in care of sportspeople or workers with tendinopathy.

Musculoskeletal interventional ultrasonography: the upper limb

Forty percent of the 823 ultrasound-guided injections performed in our centre over a year and a half concerned the upper limb, injections involving the shoulder, for subacromial bursitis and the treatment of calcific tendinitis, being the prime indications (24%). The wrist represented 8% of the prescriptions, for treatment of tendinopathy, ganglion cysts, carpal tunnel syndrome and rhizarthrosis. Trigger finger, tenosynovitis and pulley ganglia made up 6% of the indications and the elbow 2.5%. Ultrasound improves the accuracy of the procedure by helping guide the path of the needle and allowing the distribution of the substance injected to be visualised. We shall give details of the technique used for each indication, with advice and hints and post-procedure recommendations.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

OBJECTIVE AND AIM

Interdisciplinary cooperation is essential to develop a broad range of knowledge and skills. The aim of this study was to describe health care professionals' treatment choices, their cooperation with other professionals and their perceptions of potential risks regarding treatments of acute lateral epicondylalgia (LE).

DESIGN

A quantitative descriptive study design with a summative approach to qualitative analysis.

ETHICAL ISSUES

The ethical committee was asked verbally for approval but, as this study was performed to develop an organised way to treat LE, it did not require approval. The four ethical aspects information, consent, confidentiality and the use of the study materials were all addressed.

SUBJECTS

All orthopaedic surgeons, general practitioners, physiotherapists and occupational therapists in a county.

METHODS

Questionnaire with 18 dichotomous, multiple-response, multiple-choice questions and three open-ended questions were analysed using quantitative cross-tab and qualitative content analysis with summative approach.

RESULTS

The most common treatment choices were Non Steroidal Anti Inflammatory Drugs (NSAID), corticosteroid injections, training programmes, braces and ergonomics. Advantages from interdisciplinary cooperation were higher rated than disadvantages. The qualitative findings dealt with perceptions of interdisciplinary cooperation and resulted in three categories; right level of care, increased quality of care and decreased quality of care. Almost half of the physicians felt potential risks associated with their treatment methods. The qualitative findings dealt with perceptions of the potential risks and resulted in two categories: side effects and inadequate treatment.

STUDY LIMITATIONS

The number of responses varied because some of the respondents did not answered all of the questions.

CONCLUSION

Interdisciplinary cooperation in the treatment of patients with acute LE benefits the patients by shortening the rehabilitation period and provides health care professionals the opportunity for an improved learning and exchanging experiences. These basic conditions must be met to improve health care quality.

Management of tennis elbow

CLINICAL QUESTION

What is the best treatment for tennis elbow?

RESULTS

Despite a wealth of research, there is no true consensus on the most efficacious management of tennis elbow especially for effective long-term outcomes. Corticosteroid injections do show large pain-relieving effects in the short term but are associated with risks of adverse events and long-term reoccurrence. Advice with a "wait and see" approach is recommended as the first-line treatment in primary care for most cases. In the medium term physiotherapy and or low-level laser therapy may be effective.

IMPLEMENTATION

Rule out alternative diagnosis. Onward referral may be indicated if the condition does not resolve after 12 months.