Prolotherapy vs Radial Extracorporeal Shock Wave Therapy in the Short-term Treatment of Lateral Epicondylosis: A Randomized Clinical Trial

Effect of acetic acid shockwave phonophoresis on spur morphology, foot pain and function in patients with calcaneal spur: A randomised controlled trial

OBJECTIVE

To investigate the effect of acetic acid shockwave phonophoresis on spur morphology, foot pain, and function in patients with calcaneal spurs.

DESIGN

A double-blinded, randomised clinical trial.

SETTING

Outpatients physical therapy clinics.

PARTICIPANTS

One hundred forty-seven patients with calcaneal spurs, 18-65 years old, were randomly allocated to three equal groups.

INTERVENTION

The study group (A) received acetic acid shockwave phonophoresis plus conventional physical therapy. The study group (B) received shockwave therapy plus conventional physical therapy. The control group received conventional physical therapy programme only. Interventions were applied twice a week for 3 weeks.

OUTCOME MEASURES

Calcaneal spur width, calcaneal spur length, pain intensity level, pain pressure threshold and foot and ankle ability measure activities of daily living subscale were measured at baseline, after 3 weeks of interventions and after 4 weeks of follow-up with no intervention.

RESULTS

Between-group differences were observed for calcaneal spur width and length, pain intensity, pain pressure threshold and function after 3 weeks favouring Group A (p < 0.001). Mean differences (95% CI) between study groups were -1.11 mm (-1.46, -0.77) for spur width; -1.34 mm (-1.67, -1.01) for spur length; -20.71 mm (-24.66, -16.77) for pain; 1.45 kg/cm2 (1.05, 1.85) for pain pressure threshold; and 12.16 points (9.24, 15.09) for function after 3 weeks.

CONCLUSIONS

Acetic acid shockwave phonophoresis combined with exercise clinically and statistically improves calcaneal spur width, length, pain intensity, pain pressure threshold and foot function more than shockwave therapy alone or conventional physical therapy. This method might be considered an effective, feasible, safe, non-invasive and locally applicable treatment for heel spurs.

Prolotherapy in the Treatment of Sports-Related Tendinopathies: A Systematic Review of Randomized Controlled Trials

Background

As sports have increased in popularity, the incidence of tendinopathy has also grown dramatically. Nonoperative techniques and treatments used to address these pathologies continue to evolve and improve. One such treatment, prolotherapy (PrT), has become increasingly popular and may provide patients with an alternative nonoperative treatment option.

Purpose

To review high-quality randomized controlled trials (RCTs) that analyzed PrT treatments for the most common tendinopathies. Specifically, this review aims to provide meaningful data regarding methods and outcomes for each condition treated and guide professionals who are considering PrT as a treatment option.

Study Design

Systematic review; Level of evidence, 2.

Methods

All RCTs published in English between January 1, 1980, and July 30, 2021, and reported in Embase, Medline, and Web of Science databases were reviewed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After the initial search, a total of 3264 articles were identified. Studies analyzing sports medicine injuries and musculoskeletal pathologies using an RCT design were included, while case-reports, case-studies, reviews, and observational studies were excluded. Two independent researchers reviewed the search results, and conflicts were resolved by discussion of inclusion and exclusion criteria among all authors. The articles' quality was evaluated using the Cochrane tool for assessing the risk of bias. Statistical analysis and graphical representations were performed using SPSS Version 28.00.

Results

A total of 20 articles, including 1136 patients, met the inclusion criteria and were included in the study. Overall, in 85% of the studies, PrT was found to be effective in the treatment of tendinopathy. Specifically, PrT was superior to or as effective as the control in 83% (10/12) of the studies analyzing lateral epicondylitis (LE) and rotator cuff (RC) tendinopathies and in 88% (7/8) of the studies on plantar fasciitis (PF), Osgood-Schlatter disease (OSD), and Achilles tendinosis (AT). LE, RC, and PF tendinopathies were the most studied conditions (17/20 studies), while AT and OSD were the least studied (3/20 studies). Of the studies, 95% (19/20) used dextrose solutions, with only 1 using solutions of 2.5% phenol, 25% glycerin, and 25% dextrose in sterile water.

Conclusion

Our systematic review suggests that PrT appears to be a promising alternative treatment for common tendinopathies. Most studies used a hypertonic dextrose solution. Even though further, larger randomized controlled trials comparing PrT with other orthobiologics would be beneficial, based on this review, sports medicine physiciansmay safely pursue PrT as an additional component of conservative treatment.

Effects of Radial Extracorporeal Shockwave Therapy on Piriformis Syndrome: A Single-Case Experimental Design

The effects of radial extracorporeal shockwave therapy (rESWT) on piriformis syndrome were investigated using a single-case study design. This study used an AB single case with a follow-up phase design. The baseline phase consisted of general physical therapy, including piriformis stretching, while the experimental phase consisted of rESWT in addition to general physical therapy. A man in his 70s diagnosed with piriformis syndrome participated in the study. The Numerical Rating Scale (NRS) score, piriformis hardness, and cross-sectional area of the sciatic nerve were measured to determine the effectiveness of the intervention. The baseline and experimental phases were compared using a binomial distribution based on the celeration line. The NRS score, piriformis hardness, and cross-sectional area of the sciatic nerve were significantly decreased in the experimental phase compared to the baseline phase (NRS, p<0.001; piriformis hardness, p<0.001; cross-sectional area of the sciatic nerve, p<0.001). This effect was carried over to the follow-up phase for all variables. rESWT for piriformis syndrome improved the clinical symptoms, piriformis hardness, and cross-sectional area of the sciatic nerve. However, these results are exploratory and require further validation in future clinical trials.

The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized control trials

OBJECTIVES

Tendinopathy is a common condition that affects the body's tendon structures, causing discomfort, restricted movement, and reduced functionality. In this study, we looked at how extracorporeal shock wave therapy (ESWT) affected pain levels in individuals with various forms of tendinopathy around the world.

DESIGN

This study is a comprehensive review and meta-analysis of previously published randomized controlled trials. To gather relevant data, the researchers performed keyword searches in international databases, including PubMed (Medline), Scopus, Web of Sciences, Cochrane Central Register of Controlled Trials (CENTRAL), Research Registers of ongoing trials (ClinicalTrials.gov), as well as Embase. The search was conducted up until March 2023. The quality of the selected articles was assessed using the Cochrane risk-of-bias method for randomized trials (RoB2).

RESULTS

Based on the results of the meta-analysis, which included 45 clinical studies, the use of ESWT was found to have a significant impact on reducing pain in various conditions. The standardized mean difference (SMD) in patients with plantar fasciitis (PF) was reduced by 1.63 (SMD: -1.63, 95% CI: -3.04, -0.21; I2: 77.36%; P heterogeneity: 0.0001). For lateral epicondylitis (LE), the SMD was 0.63 (SMD: -0.63, 95% CI: -1.11, -0.16; I2: 67.50%; P heterogeneity: 0.003). In the case of chronic Achilles tendinopathy, the SMD was 1.38 (SMD: -1.38, 95% CI: -1.66, -1.10; I2: 96.44%; P heterogeneity: 0.0001). Additionally, in individuals with rotator cuff tendinopathy, the SMD for pain reduction was 2.37 units (SMD: -2.37, 95% CI: -3.58, -1.15; I2: 98.46%; P heterogeneity: 0.0001).

CONCLUSION

This study suggests that ESWT can be a highly effective therapy option for relieving pain in people with tendinopathy. Nonetheless, it is encouraged to make additional recommendations based on high-quality clinical research and more accurate information in order to define the optimal therapeutic options for each type of tendinopathy.

Effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy: A systematic review and meta-analysis

BACKGROUND

Lateral elbow tendinopathy is a common musculoskeletal disorder. Effectiveness of non-invasive therapies for this health condition are unclear.

OBJECTIVE

To investigate the effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy.

METHODS

Searches were conducted on MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Library, SPORTDiscus and PsycINFO without language or date restrictions up to May 3rd, 2023. Randomized trials investigating the effectiveness of any non-invasive therapy compared with control or other invasive interventions were included. Two independent reviewers screened eligible trials, extracted data, and assessed the risk of bias of included trials and certainty of the evidence.

RESULTS

Twenty-two different therapies investigated in 47 randomized trials were included in the quantitative analysis. Moderate certainty evidence showed that betamethasone valerate medicated plaster may reduce disability (mean difference -6.7; 95% CI -11.4, -2.0) in the short-term when compared with placebo. Low certainty evidence showed that acupuncture may reduce disability (MD -9.1; 95% CI -11.7, -6.4) in the short-term when compared with sham. Moderate to very low certainty of evidence also showed small to no effect of non-invasive therapies on pain intensity, maximum grip strength, and disability outcomes in the short-term compared to control or invasive interventions. Most therapies had only very low certainty of evidence to support their use.

CONCLUSIONS

Decision-making processes for lateral elbow tendinopathy should be carefully evaluated, taking into consideration that most investigated interventions have very low certainty of evidence. There is an urgent call for larger high-quality trials.

Effectiveness of extracorporeal shockwave therapy in treatment of upper and lower limb tendinopathies: A systematic review and meta-analysis

BACKGROUND

Tendinopathy is caused by repetitive motion, excessive stress on the tendon, overstretch, and motion past the critical angle of rotation or translation. There are various treatment options available for tendinitis, including those affecting both the upper and lower limbs and those of calcific and non-calcific types.

HYPOTHESIS/PURPOSE

Few reviews have analyzed the efficacy of Extracorporeal Shockwave Therapy (ESWT) in treating upper and lower limb tendinopathies while considering calcific and non-calcific-type tendinitis. This paper provides a review and meta-analysis on Randomized Controlled Trials (RCTs), which compared results from a group undergoing ESWT treatment to another group under different treatments.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search was conducted on PubMed, Web of Science, Embase, the Cochrane Central Register of Control Trials (CENTRAL), and Physiotherapy Evidence Database (PEDro) databases for articles published up to January 2022. The reference lists of identified articles were further scanned. Twenty-two studies were included in the meta-analysis.

RESULTS

Meta-analysis showed no difference in pain reduction in ESWT when compared with a comparison group at 4 (p = 0.26) and 12 weeks (p = 0.33). There were no differences in DASH scores at 12 months between the two groups (p = 0.32).

CONCLUSION

Extracorporeal Shockwave Therapy (ESWT) is effective when used to treat lower limb and calcific tendinitis. It does not yield any better results than other treatment options in managing upper limb tendinopathies and non-calcific tendinopathies.

Ultrasound-Guided Injection of Dextrose Versus Corticosteroid in Chronic Plantar Fasciitis Management: A Randomized, Double-Blind Clinical Trial

DESIGN

Chronic plantar fasciitis (PF) is a common cause of chronic heel pain, with different conventional treatment options. In this randomized clinical trial, the effect of ultrasound-guided injection of dextrose versus corticosteroid in chronic PF was evaluated and compared.

METHODS

A total of 44 patients suffering from chronic PF who visited the physical medicine and rehabilitation clinic were enrolled in the study. Two table-randomized groups were formed. They received an ultrasonography-guided, single injection of either 40 mg methylprednisolone or 20% dextrose. Numeric Rating Scale (NRS), Foot and Ankle Ability Measure questionnaire with 2 subscales, Activities of Daily Living (FAAM-A) and Sports (FAAM-S), along with ultrasonographic parameters were evaluated before and at 2 and 12 weeks after the injection. Results. A total of 40 participants completed the study. Both interventions significantly improved pain and function at 2 and 12 weeks postinjection. After 2 weeks, compared with the dextrose prolotherapy, the corticosteroid group had significantly lower daytime and morning NRS scores (2.55 vs 4.1, P = .012, and 2.75 vs 4.65, P = .004), higher FAAM-S (66.84 vs 54.19; P = .047), and lower plantar fascia thickness at insertion and 1 cm distal to the insertion zone (3.89 vs 4.29 mm, P = .004, and 3.13 vs 3.48 mm, P = .002), whereas FAAM-A was similar in both groups (P = .219). After 12 weeks, all study variables were statistically similar between corticosteroid and dextrose prolotherapy groups. No injection-related side effects were recorded in either group.

CONCLUSION

Both methods are effective. Compared with dextrose prolotherapy, our results show that corticosteroid injection may have superior therapeutic effects early after injection, accompanied by a similar outcome at 12 weeks postinjection.

LEVELS OF EVIDENCE

Level II.

Effect of Supervised over Self-Performed Eccentric Exercise on Lateral Elbow Tendinopathy: A Pilot Study

Background: The efficacy of eccentric exercise self-performed by the patient has not been proved in the treatment of lateral elbow tendinopathy (LET). The aim of this study was to compare the effects of a programme of eccentric exercises applied by a physiotherapist to patients with LET through a structured manual programme compared to its self-performance, guided by an illustrated brochure. Method: A single-blind, pilot, randomised, controlled trial was conducted. Twenty patients were randomised. The intervention group carried out eccentric exercises applied directly by a physiotherapist (10 sessions). The control group carried out eccentric exercises that were self-performed by the patient (10 sessions). Both groups received simulated ultrasounds. Pain (visual analogue scale (VAS)), function (DASH questionnaire) and satisfaction (with a Likert scale) were measured at the beginning of the intervention, immediately after the intervention and 3 months after the intervention. Results: The mean age was 53.17 and 54.25 years old. The experimental group presented a greater tendency to improve function (DASH −15.91) and reduce pain (VAS −2.88) compared to the control group, although these differences were not significant (p > 0.05). Conclusion: Eccentric exercise, both performed by the physiotherapist and self-performed by the patient, improved function and pain in the patients with LET.

Exploring the clinical efficacy of different nonsurgical rehabilitation interventions for humeral lateral epicondylitis: A protocol for network meta-analysis

BACKGROUND

Lateral epicondylitis is a common musculoskeletal disorder characterized by the decreased grip and upper limb strength and pain in the lateral aspect of the elbow joint. At present, shock wave, corticosteroid injection, platelet-rich plasma injection, and Dextrose prolotherapy therapy nonsurgical rehabilitation treatment methods are commonly used in clinical. However, the conclusions of studies comparing treatment efficacy between them are controversial, with most studies focusing on limited comparisons and a lack of direct and indirect comparisons between them, making it difficult to have a clearer and more comprehensive understanding of the efficacy between them.

PURPOSE

To comprehensively compare the effectiveness of shockwave, corticosteroid injection, platelet-rich plasma injection, and Dextrose prolotherapy therapy for the treatment of external humeral lateral epicondylitis using a reticulo-meta-analysis.

METHODS

Randomized controlled trials on the effectiveness of shock wave, corticosteroid injection, platelet-rich plasma injection, and Dextrose prolotherapy therapy for the treatment of external humeral lateral epicondylitis were searched in PubMed, The Cochrane Library, CNKI, and Wan-Fang databases for the period January 1, 2016 to January 1, 2021 for each database. Two investigators independently screened the literature, extracted data according to inclusion and exclusion criteria, and evaluated the quality of the literature in parallel. Statistical analyses were performed using Stata 14.0 software to compare differences in efficacy between treatment measures using ratio and 95% confidence interval as effect indicators and to rank efficacy.

RESULTS

Nine randomized controlled trials with a total of 289 patients with external humeral lateral epicondylitis were included, involving 4 nonsurgical rehabilitation measures and 6 intervention options. Quadrilateral ring to test the inconsistency of each closed-loop study finding, and the results show that the inconsistency factor was bounded at 1.65, with lower 95% confidence interval of 0.47 and 2.84 for both, which in summary indicates that the formation between the treatment measures in this study indicates that each closed-loop inconsistency was good. The SUCRA curve showed that platelet-rich plasma injection + shockwave was the first treatment with an area under the curve of 86.9%. Six treatment measures were ranked as follows: platelet-rich plasma injection + shockwave > platelet-rich plasma injection > shockwave > corticosteroid > corticosteroid + shockwave > prolotherapy.

CONCLUSIONS

It is believed that in the course of clinical practice, platelet-rich plasma injection combined with shockwave therapy can be preferred for patients with humeral epicondylitis.

Effects of Hypertonic Dextrose Injection (Prolotherapy) in Lateral Elbow Tendinosis: A Systematic Review and Meta-analysis

OBJECTIVE

To systematic review the effectiveness of hypertonic dextrose prolotherapy (DPT) on pain intensity and physical functioning in patients with lateral elbow tendinosis (LET) compared with other active non-surgical treatments.

DATA SOURCES

Systematic search of CENTRAL, MEDLINE, EMBASE, Web of Science, PubMed, Dimensions, Global Health, NHS Health Technology Assessment, AMED and OVID nursing database from inception to 15 June 2021, without language restrictions.

STUDY SELECTION

Two reviewers independently identified parallel or cross-over RCTs that evaluated the effectiveness of DPT in LET. The search identified 245 records; data from 8 studies (354 patients) were included.

DATA EXTRACTION

Two reviewers independently extracted data and assessed included studies. The Cochrane Risk of Bias 2 tool was used to evaluate risk of bias. The Grading of Recommendation Assessment, Development, and Evaluation approach was used to assess quality of the evidence.

DATA SYNTHESIS

Pooled results favored the use of DPT in reducing tennis elbow pain intensity compared with active controls at 12 weeks post-enrollment, with standardized mean difference (SMD) of -0.44 (95% CI -0.88 to -0.01, P =0.04) and of moderate heterogeneity (I²= 49%). Pooled results also favored the use of DPT on physical functioning compared with active controls at 12 weeks, with DASH score achieving mean difference (MD) -15.04 (95% CI -20.25 to -9.82, P < 0.001) and of low heterogeneity (I²= 0.0%). No major related adverse events have been reported.

CONCLUSIONS

DPT is superior to active controls at 12 weeks for decreasing pain intensity and functioning by margins that meet criteria for clinical relevance in the treatment of LET. While existing studies are too small to assess rare adverse events, for LET patients, especially those refractory to first-line treatments, DPT can be considered a non-surgical treatment option in carefully selected patients. Further high-quality trials with comparison with other injection therapies are needed.

Regenerative Injectable Therapies: Current Evidence

Regenerative medicine is a growing field of musculoskeletal treatments that focuses on amplifying the body's natural healing properties to improve function and pain after injury. Regenerative treatments are applied locally at the site of injury and work though different mechanisms, some of which are unexplained at this time. Current evidence demonstrates benefit for certain regenerative treatments, but further standardization of treatments and additional studies are required to provide additional data to support specific regenerative treatments. This review seeks to explore the evidence and discuss appropriate use of the most common regenerative treatments including platelet-rich plasma, prolotherapy, autologous mesenchymal stem cells, human-derived allograft products, and saline.

Dextrose Prolotherapy Versus Normal Saline Injection for the Treatment of Lateral Epicondylopathy: A Randomized Controlled Trial

Objective: To compare the effect of dextrose prolotherapy (DPT) with saline in the treatment of chronic lateral epicondylopathy (LE). Design: Triple-blinded randomized controlled trial. Setting: Physical medicine and rehabilitation outpatient clinic. Subjects: Sixty cases of chronic LE participants were included in the study. Methods: Participants were randomly divided into two groups as DPT and normal saline. Saline or hypertonic dextrose (15%) was injected at the baseline, and at the end of the 4th and 8th week. Assessments were performed at baseline, and at the end of the 4th, 8th, and 12th week. Outcome measures: Primary outcome measures were Visual Analog Scale (VAS) for pain, Patient Rated Tennis Elbow Evaluation (PRTEE-Total [PRTEE-T], PRTEE-Pain, PRTEE-Function); secondary outcome measures were Disabilities of the Arm, Shoulder, and Hand Score (DASH) and pain-free handgrip strength. Results: Intragroup analysis demonstrated that both groups significantly improved in VAS, PRTEE, DASH scores, and handgrip strength during the study period (p < 0.001, for all outcome measurements in both groups). Intergroup analysis showed that PRTEE-T score changes between baseline-4th and -12th week; VASrest change between baseline and 4th week in the DPT group were significantly higher than the saline group (p = 0.041, p = 0.038, p = 0.013 respectively). There was no significant difference between groups in VAS, DASH scores, and handgrip strength between any time points, in terms of improvement (p > 0.05). Conclusion: Our study results showed that DPT outperformed saline in PRTEE-T score. Although saline seems to be a comparable clinical effect with DPT, further studies comparing the effects of saline injection and DPT are necessary, in chronic LE.

Injection Therapy in Patients with Lateral Epicondylalgia: Hyaluronic Acid or Dextrose Prolotherapy? A Single-Blind, Randomized Clinical Trial

Objective: To compare the effects of hyaluronic acid (HA) and dextrose prolotherapy (DPT) injections in patients with chronic lateral epicondylalgia (LE). Materials and Methods: Thirty-two patients with at least 6 months of signs and symptoms of LE were randomly allocated into two groups: an HA group (n = 16) and a DPT group (n = 16). HA injection was performed as a single dose of 30 mg/2 mL 1500 kDa high-molecular-weight preparation (baseline). DPT injection was administered with 15% dextrose solution in three doses (baseline, third week, and sixth week). Severity of pain using the visual analog scale score, grip strength with a hand dynamometer, and physical function as determined by the Quick-Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score were determined. Results: DPT was favored over HA for improvements from 0 to 12 weeks for pain with activity (4.81 ± 1.2 vs. 3.18 ± 2.3; p = 0.04), pain at night (5.1 ± 1.9 vs. 4.1 ± 2.2; p = 0.03), and pain at rest (3.8 ± 2.09 vs. 2.7 ± 1.7; p = 0.04). Q-DASH scores improved significantly more from 0 to 12 weeks in the DPT group (43.5 ± 17.6 vs. 28.4 ± 13.4; p = 0.04). No between-group improvement was observed for grip pain (7.3 ± 6.4 vs. 4.8 ± 3.2; p = 0.38). Conclusions: HA and DPT injections were both effective in reducing pain and increasing grip strength and function in patients with chronic LE. DPT injection was more effective in the short term than HA injection, in terms of pain relief and functional outcome. The study was registered at ClinicalTrials.gov under the identifier number NCT04395417.

Injection therapies for patellar tendinopathy

Patellar tendinopathy, or jumper's knee is a common musculoskeletal condition characterized by progressive activity-related pain on the anterior aspect of the knee and tenderness on the patellar tendon. A conservative method is often the first choice of treatment, which can include anti-inflammatory medication, injection therapies, physiotherapy, eccentric exercises, extra corporeal shock wave therapy, orthosis, etc. Although there are several treatment options available, the management of patellar tendinopathy is still controversial. The literature reveals many different injection methods are being used by clinicians for the treatment of patellar tendinopathy. Platelet rich plasma, corticosteroids, autologous blood, and aprotinin are the most commonly used injection treatments. Injection therapies give promising results in the management of Patellar tendinopathy. However, due to low quality research and variation in the protocol and population it is difficult to provide a firm conclusion on its effectiveness. More high-quality clinical studies are recommended to determine the effectiveness of injections and at which stage of Patellar tendinopathy they are the most effective. This review can provide insight to clinicians involved in the management of this condition.

Comparison Between Extracorporeal Shock Wave Therapy and Local Corticosteroid Injection for Plantar Fasciitis

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is a nonsurgical treatment for plantar fasciitis (PF) that has had satisfactory clinical outcomes. However, local corticosteroid injection (LCI) is often regarded as first-line treatment of PF, but there have been few studies comparing the 2 methods. Therefore, we compared the effect of ESWT and LCI on patients with PF.

METHODS

This was a block randomized controlled study comparing 49 patients treated with ESWT and 47 patients treated with LCI from January 2017 to December 2018 who were followed for 6 months. We evaluated the clinical outcomes in the 2 groups, including average pain, first-step pain, plantar fascia thickness, and Foot Function Index, Chinese version of the PF patients.

RESULTS

All patients had pain relief and function improvement after treatment, whereas the LCI group did not maintain significant clinical improvement at the 3-month follow-up. The patients in the ESWT group had a significantly better clinical outcome with better duration of improvement than the LCI group.

CONCLUSION

For PF patients, both ESWT and LCI resulted in clinical improvement but EWST provided longer relief than LCI.

LEVEL OF EVIDENCE

Level II, prospective comparative study.