Botulinum toxin injection versus surgical treatment for tennis elbow: a randomized pilot study

Botulinum Toxin in Chronic Lateral Epicondylitis, from Tendon to Muscle Approach-A Review

BACKGROUND

Chronic lateral epicondylitis challenges the therapeutical approach; underlying mechanisms are incompletely understood; neuropathic pain and central and peripheral sensitization may explain the fact that botulinum toxin has been found to play a role in pain and function management.

METHODS

We searched the literature for MeSH terms: lateral epicondylitis or synonyms and botulinum toxin.

RESULTS

We found 14 papers containing trials on botulinum toxin injection into the tendon or into the extensor muscles (specifically, extensor carpi radialis brevis and extensor communis digitorum). We followed the administration pathways, doses, timing, and side effects.

CONCLUSIONS

With a chronic course, the focus of the therapy shifts from the afflicted tendon to the inserting muscles, as muscle contracture may create a vicious loop to perpetuate and aggravate the disease. Doses, timing, and side effects are discussed.

Clinical efficacy of botulinum toxin in lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Botulinum toxin injections for lateral elbow tendinopathy have been used as an alternative therapeutic option. However, few studies have quantitatively summarized the effect of botulinum toxin as well as its clinical significance. We aimed to evaluate the clinical efficacy (based on pain and grip strength) and adverse events of botulinum toxin on lateral elbow tendinopathy.

PATIENTS AND METHODS

The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched until March 2023 for randomized controlled trials reporting the effects of botulinum toxin injections on lateral elbow tendinopathy. A random- or fixed-effects model (depending of inter-study variability) and generic inverse variance method were used to pool quantitative data from outcomes. The risk of bias was assessed with the Cochrane Risk of Bias 2.0 tool.

RESULTS

A total of 8 clinical trials recruiting 438 subjects were included for meta-analysis. Pooled analysis revealed that botulinum toxin significantly reduced pain (mean difference [MD] -0.95, 95% CI [-1.63, -0.26], p=0.007) but it was not clinically relevant. No significant effect was detected for grip strength (MD-0.62kg, 95% CI [-2.25, 1.02], p=0.46) or in the risk for adverse events (odds ratio [OR] 0.41, 95% CI [0.05, 3.56], p=0.42) between botulinum toxin injection and control interventions.

DISCUSSION

The use of botulinum toxin reached greater pain relief than control interventions and normal saline after a period of 12 to 24 weeks. However, changes in pain relief did not reach clinical significance. The studies that had the greatest reduction in pain used higher doses of botulinum toxin (60 U). Additionally, differences in grip strength and adverse events did not reach statistical or clinical importance. A subanalysis indicated that botulinum toxin outperformed corticosteroid injections in terms of improving grip strength. Botulinum toxin only causes local and minimal side effects such as irritation, ecchymosis, and paralysis.

LEVEL OF EVIDENCE

I.

The effectiveness of a Botulinum Toxin A infiltration in the management of bicipital cramps after arthroscopic biceps tenotomy

A challenging complication of arthroscopic biceps surgery is the persistent painful cramping of the biceps. There is a paucity of data upon nonsurgical treatment of this debilitating complication. We pro- pose an intramuscular injection of botulinum toxin A (BTX-A) for painful bicipital cramping after tenotomy of the long head of the biceps brachii tendon (LHBT). Ten patients with a painful Popeye sign after tenotomy of LHBT, were treated with intramuscular injection of 100 IU of BTX-A. Mean patient age was 56 years and mean time from surgery to infiltration was 317 days. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was obtained. Pain was objectified by a visual analogue scale (VAS). Patient satisfaction was described as excellent, good, satisfactory, or poor, three and six months after injection. Mean VAS prior to infiltration was 6.8 and decreased significantly to 2.6 at follow-up. Mean QuickDash was 54.04 prior to infiltration and decreased to 19.84 at follow-up. Patient satisfaction was excellent in 9 and good in 1 patient. We report a significant pain reduction and functional improvement following BTX-A infiltration as treatment of painful bicipital cramping after tenotomy of LHBT.

Efficacy of Botulinum Toxin in Treating Lateral Epicondylitis-Does Injection Location Matter?: A Systematic Review

OBJECTIVE

Clinical trials assessing the efficacy of botulinum toxin in treating recalcitrant lateral epicondylitis have demonstrated varied results and differed greatly in methodology. The objective of this systematic review was to demonstrate injection location as a significant contributor to outcome heterogeneity.

DESIGN

Two reviewers independently conducted a systematic review using Scopus, Embase, and PubMed for randomized controlled trials assessing botulinum toxin in the treatment of lateral epicondylitis. After applying inclusion/exclusion criteria to abstracts and reviewing the full-text articles, seven studies were found representing six separate injection locations. Reduction in visual analog scale pain and change in grip strength were the principal outcomes of interest.

RESULTS

The largest reduction in pain was seen in injection at 1/3 of the length of the forearm from the lateral epicondyle at 16-wk follow-up, whereas the smallest reduction was seen at 12-wk follow-up after injection at the 0-cm mark. Differences were also identified in grip strength, although all studies reported return to baseline strength by weeks 12-18.

CONCLUSIONS

This study demonstrates injection location as a potential source of heterogeneity. This clinical question warrants further evaluation with direct comparison of outcomes at different injection locations while controlling for dosage, toxin type, and ultrasound/electromyographic guidance.

Botulinum Toxin for Chronic Lateral Epicondylitis (LE)

Lateral epicondylitis is a common disease in orthopaedic practice. Although the majority of cases do not become chronic, patients who do not respond to the initial treatment may suffer from pain in the long term and effective treatment is challenging. The off-label use of botulinum toxin is one of the common potential indications for the substance in orthopaedics and traumatology. In a literature review of 2000 - 2019, eight EBM ≥ level 3 studies evaluating the use of botulinum toxin in lateral epicondylitis were found. Five of these studies evaluated botulinum toxin versus placebo in chronic cases; two other studies compared botulinum toxin with corticosteroids in acute cases and classic Hohmann surgery in chronic cases; the eighth study compared botulinum toxin in two different injection sites and corticosteroids by classic injection. Our findings suggest that the use of this substance may be a treatment option in refractory chronic cases before surgery is indicated. The working group on botulinum toxin in O & T of the International Musculoskeletal Pain Society (IMPS/IGOST) introduced an alternative injection schedule, which combines findings from the recent clinical literature with practical experience in order to reduce the risk of side effects while ensuring treatment effectiveness. Using 2 simple tests of function and, if necessary, sonographic verification, 2 separate injection sites in the extensor carpi radialis or the extensor digitorum can be identified by palpation. The tendon level on the lateral epicondyle acts as the third injection site. With optimal use of the ampoule content, the 3 injection sites can be infiltrated individually, depending on the muscle status. On the one hand, this enables treatment to take place after a dual therapy approach and, on the other hand, the risk of overdose in a muscle with subsequent unnecessary muscle weakening can be reduced.

Treatment methods for post-traumatic elbow stiffness caused by heterotopic ossification

HYPOTHESIS

Heterotopic ossification (HO) is a common complication of surgically treated elbow fractures that can inhibit range of motion and impair quality of life. Although there are many treatment methods for HO, there is a lack of consensus as to the best option. We hypothesized that contracture release combined with Botox injection would lead to improved functional outcome scores when compared with current treatment methods.

METHODS

A retrospective review was conducted of patients who presented to a single surgeon with HO secondary to elbow fracture between 2005 and 2018. A total of 59 patients were identified who met inclusion criteria. Data were classified into 3 groups: contracture release (control - CR), Botox injection with CR (Botox + CR), and radiation therapy with CR (CR + RT). Range of motion measurements were obtained, including flexion, extension, pronation, and supination.

RESULTS

A total of 30 patients (30 of 59, 50.8%) received CR, 6 (6 of 59, 9.2%) were treated with CR + RT, and 23 (23 of 59, 40.0%) had CR + Botox. There was a significant difference between pre- and postoperative arc of motion for both CR + RT (P < .01) and CR + Botox (P < .01). In addition, there was a significant difference in pre- and postoperative extension for patients who received intraoperative Botox injections (P < .05). There was no significant difference between pre- and postoperative motion nor extension in the CR group.

CONCLUSION

Intraoperative Botox injection with CR is an effective method in the treatment of post-traumatic elbow stiffness caused by HO.

How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials

Purpose

To assess the effectiveness of surgery on all tendinopathies by comparing it to no treatment, sham surgery and exercise-based therapies for both mid-term (12 months) and long-term (> 12 months) outcomes.

Methods

Our literature search included EMBASE, Medline, CINAHL and Scopus. A combined assessment of internal validity, external validity and precision of each eligible study yielded its overall study quality. Results were considered significant if they were based on strong (Level 1) or moderate (Level 2) evidence.

Results

12 studies were eligible. Participants had the following types of tendinopathy: shoulder in seven studies, lateral elbow in three, patellar in one and Achilles in one. Two studies were of good, four of moderate and six of poor overall quality. Surgery was superior to no treatment or placebo, for the outcomes of pain, function, range of movement (ROM) and treatment success in the short and midterm. Surgery had similar effects to sham surgery on pain, function and range of motion in the midterm. Physiotherapy was as effective as surgery both in the midterm and long term for pain, function, ROM and tendon force, and pain, treatment success and quality of life, respectively.

Conclusion

We recommend that healthcare professionals who treat tendinopathy encourage patients to comply with loading exercise treatment for at least 12 months before the option of surgery is seriously entertained.

Surgery for tennis elbow: a systematic review

BACKGROUND

There is no consensus on the most suitable treatment for tennis elbow but, in the USA, surgical intervention is increasing despite a lack of supportive research evidence. The aim of this systematic review was to provide a balanced update based on all relevant published randomized controlled trials conducted to date.

METHODS

An electronic search of MEDLINE, EMBASE, CINAHL, BNI, AMED, PsycINFO, HBE, HMIC, PubMed, TRIP, Dynamed Plus and The Cochrane Library was complemented by hand searching. Risk of bias was assessed using the Cochrane Risk of Bias Tool and data were synthesized narratively, based on levels of evidence, as a result of heterogeneity.

RESULTS

Twelve studies of poor methodological quality were included. The available data suggest that surgical interventions for tennis elbow are no more effective than nonsurgical and sham interventions. Surgical technique modifications may enhance effectiveness compared to traditional methods but have not been tested against a placebo.

CONCLUSIONS

Current research evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment based on evidence with significant methodological limitations. Given the recalcitrant nature of tennis elbow for some patients, further research in the form of a high-quality placebo-controlled surgical trial with an additional conservative arm is required to usefully inform clinical practice.

Number of botulinum toxin injections needed to stop requests for treatment for chronic lateral epicondylar tendinopathy. A 1-year follow-up study

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.

Fifty Most-cited Articles on Lateral Epicondylitis of the Elbow

Introduction:

Citation number can be used as a marker of a scientific article's influence. This study sought to determine and characterize the most-cited investigations on lateral epicondylitis and identify the most influential studies pertaining to this pathology.

Methods:

The Institute for Scientific Information Web of Science database was queried for articles investigating lateral epicondylitis, and the 50 most-cited articles were selected. For each article, number of citations, citation density, journal, publication year, country of origin, language, article type, article subtype, and level of evidence were recorded.

Results:

Citation numbers ranged from 72 to 332 (mean, 127.4), and densities ranged from 1.6 to 34.0 (mean, 9.4). Articles were published across 26 different journals. Most articles (41) were clinical, with randomized controlled trials (29.3%) being the most commonly cited articles.

Discussion:

Compared with previous investigations looking at citation density within orthopaedics, the most commonly cited clinical articles on lateral epicondylitis had a high percentage of level I or II evidence (39.0%). This compilation of the literature can aid in establishing reading curriculums for trainees in both orthopaedic residencies and fellowships. This is a Level V study.

Botulinum toxins for the prevention of migraine in adults

BACKGROUND

Migraine occurs in around 15% of adults and is ranked as the seventh most disabling disease amongst all diseases globally. Despite the available treatments many people suffer prolonged and frequent attacks which have a major impact on their quality of life. Chronic migraine is defined as 15 or more days of headache per month, at least eight of those days being migraine. People with episodic migraine have fewer than 15 headache days per month. Botulinum toxin type A has been licensed in some countries for chronic migraine treatment, due to the results of just two trials.

OBJECTIVES

To assess the effects of botulinum toxins versus placebo or active treatment for the prevention or reduction in frequency of chronic or episodic migraine in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE & MEDLINE in Process, Embase, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry (to December 2017). We examined reference lists and carried out citation searches on key publications. We sent correspondence to major manufacturers of botulinum toxin.

SELECTION CRITERIA

Randomised, double-blind, controlled trials of botulinum toxin (any sero-type) injections into the head and neck for prophylaxis of chronic or episodic migraine in adults. Eligible comparators were placebo, alternative prophylactic agent or different dose of botulinum toxin.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data. For continuous outcomes we used mean change data when available. For dichotomous data we calculated risk ratios (RRs). We used data from the 12-week post-treatment follow-up time point. We assessed the evidence using GRADE and created two 'Summary of findings' tables.

MAIN RESULTS

Description of trialsWe found 90 articles describing 28 trials (4190 participants), which were eligible for inclusion. The longest treatment duration was three rounds of injections with three months between treatments, so we could not analyse long-term effects. For the primary analyses, we pooled data from both chronic and episodic participant populations. Where possible, we also separated data into chronic migraine, episodic migraine and 'mixed group' classification subgroups. Most trials (21 out of 28) were small (fewer than 50 participants per trial arm). The risk of bias for included trials was low or unclear across most domains, with some trials reporting a high risk of bias for incomplete outcome data and selective outcome reporting.Botulinum toxin versus placeboTwenty-three trials compared botulinum toxin with placebo. Botulinum toxin may reduce the number of migraine days per month in the chronic migraine population by 3.1 days (95% confidence interval (CI) -4.7 to -1.4, 4 trials, 1497 participants, low-quality evidence). This was reduced to -2 days (95% CI -2.8 to -1.1, 2 trials, 1384 participants; moderate-quality evidence) when we removed small trials.A single trial of people with episodic migraine (N = 418) showed no difference between groups for this outcome measure (P = 0.49).In the chronic migraine population, botulinum toxin reduces the number of headache days per month by 1.9 days (95% CI -2.7 to -1.0, 2 trials, 1384 participants, high-quality evidence). We did not find evidence of a difference in the number of migraine attacks for both chronic and episodic migraine participants (6 trials, N = 2004, P = 0.30, low-quality evidence). For the population of both chronic and episodic migraine participants a reduction in severity of migraine rated during clinical visits, on a 10 cm visual analogue scale (VAS) of 3.3 cm (95% CI -4.2 to -2.5, very low-quality evidence) in favour of botulinum toxin treatment came from four small trials (N = 209); better reporting of this outcome measure from the additional eight trials that recorded it may have improved our confidence in the pooled estimate. Global assessment and quality-of-life measures were poorly reported and it was not possible to carry out statistical analysis of these outcome measures. Analysis of adverse events showed an increase in the risk ratio with treatment with botulinum toxin over placebo 30% (RR 1.28, 95% CI 1.12 to 1.47, moderate-quality evidence). For every 100 participants 60 experienced an adverse event in the botulinum toxin group compared with 47 in the placebo group.Botulinum toxin versus other prophylactic agentThree trials studied comparisons with alternative oral prophylactic medications. Meta-analyses were not possible for number of migraine days, number of headache days or number of migraine attacks due to insufficient data, but individually trials reported no differences between groups for a variety of efficacy measures in the population of both chronic and episodic migraine participants. The global impression of disease measured using Migraine Disability Assessment (MIDAS) scores were reported from two trials that showed no difference between groups. Compared with oral treatments, botulinum toxin showed no between-group difference in the risk of adverse events (2 trials, N = 114, very low-quality evidence). The relative risk reduction (RRR) for withdrawing from botulinum toxin due to adverse events compared with the alternative prophylactic agent was 72% (P = 0.02, 2 trials, N = 119).Dosing trialsThere were insufficient data available for the comparison of different doses.Quality of the evidenceThe quality of the evidence assessed using GRADE methods was varied but mostly very low; the quality of the evidence for the placebo and active control comparisons was low and very low, respectively for the primary outcome measure. Small trial size, high risk of bias and unexplained heterogeneity were common reasons for downgrading the quality of the evidence.

AUTHORS' CONCLUSIONS

In chronic migraine, botulinum toxin type A may reduce the number of migraine days per month by 2 days compared with placebo treatment. Non-serious adverse events were probably experienced by 60/100 participants in the treated group compared with 47/100 in the placebo group. For people with episodic migraine, we remain uncertain whether or not this treatment is effective because the quality of this limited evidence is very low. Better reporting of outcome measures in published trials would provide a more complete evidence base on which to draw conclusions.

Ultrasound-guided tendon fenestration versus open-release surgery for the treatment of chronic lateral epicondylosis of the elbow: protocol for a prospective, randomised, single blinded study

INTRODUCTION

Chronic lateral epicondylosis (CLE) of the elbow is a prevalent condition among middle-aged people with no consensus on optimal care management but for which surgery is generally accepted as a second intention treatment. Among conservative treatment options, ultrasound (US)-guided fenestration has shown encouraging results that should be explored before surgery is considered. The primary objective of this study is to compare the efficacy of US-guided fenestration with open-release surgery in patients with failure to improve following a minimum 6 months of conservative treatment.

METHODS AND ANALYSIS

This study protocol entails a two-arm, single-blinded, randomised, controlled design. Sixty-four eligible patients with clinically confirmed CLE will be assigned to either US-guided fenestration or open-release surgery. Fisher's exact test will be used to compare the proportion of patients reporting a change of 11/100 points or more in the Patient Rated Tennis Elbow Evaluation score at 6 months, according to an intention-to-treat analysis. Secondary analyses will compare the two treatment groups in terms of pain and disability, functional limitations at work, pain-free grip strength, medication burden, patients' global impression of change and level of satisfaction at 6 weeks, 3, 6 and 12 months, using mixed linear models for repeated measures or Fisher's exact test, as appropriate. Finally, recursive partitioning analyses will investigate US and elastography parameters as predictors of treatment success at 6 and 12 months. This data will contribute to evidence-based treatment guidelines for CLE and explore the value of imaging biomarkers to improve risk stratification plans and assist clinicians.

ETHICS AND DISSEMINATION

The study has been approved by the Research Ethics Board of our institution on 23 March 2016 (REB 15.327). In case of important protocol modifications, a new version of the protocol with appropriate amendments will be submitted to the REB for approval. Study results will be published in peer-reviewed journals and presented at local, national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02710682.

Short-Term Effect of Low-Dose, Electromyography-Guided Botulinum Toxin A Injection in the Treatment of Chronic Lateral Epicondylar Tendinopathy: A Randomized, Double-Blinded Study

BACKGROUND

Botulinum toxin A (BoNT-A) is a novel treatment for chronic lateral epicondylar tendinopathy. Preliminary studies have demonstrated promising results; however, confirmation of the effectiveness of BoNT-A treatment and further assessment of its side effects are required. This study investigated the analgesic effects of BoNT-A in the treatment of chronic lateral epicondylar tendinopathy.

METHODS

This was a phase-III, single-center, randomized, double-blinded, placebo-controlled study including 60 patients with chronic lateral epicondylar tendinopathy that had been resistant to treatment for >6 months. Patients received either a 40-IU injection of BoNT-A or saline solution placebo into the extensor carpi radialis brevis (ECRB) muscle, aided by electromyographic (EMG) stimulation. Follow-up was 3 months. The primary assessment criterion was the percentage of patients whose pain was reduced by >50% at 90 days after injection. Secondary outcomes, including pain intensity, pain frequency, interference with quality of life, sick leave taken, maximum grip strength, and side effects, were assessed at days 30 and 90, and the number of participants per group requesting additional therapies at day 90 was recorded.

RESULTS

Twenty-nine patients in the BoNT-A group and 28 patients in the placebo group were included in the day-90 analysis. Fifteen (51.7%) of the patients who were administered BoNT-A and 7 (25%) of the patients who received placebo reported a >50% reduction in initial pain intensity at day 90 (p = 0.005). Pain intensity and the effect on quality of life, measured using visual analog scales, were both significantly lower in the group treated with BoNT-A compared with placebo at day 90 (p < 0.05). The rate of clinically detected transitory paresis of the third finger on extension was 17.2% in the BoNT-A group, with no associated functional impairment.

CONCLUSIONS

BoNT-A at 40 IU injected into the ECRB is an effective treatment for chronic lateral epicondylar tendinopathy that has been otherwise resistant to medical treatment. The rate of paresis of the third finger was low, with no associated functional impairment.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Open, Arthroscopic, and Percutaneous Surgical Treatment of Lateral Epicondylitis: A Systematic Review

Background: Approximately 10% of patients with lateral epicondylitis go on to have surgical treatment; however, multiple surgical treatment options exist. The purpose of this study was to review the literature for the clinical outcomes of open, arthroscopic, and percutaneous treatment of lateral epicondylitis. The authors hypothesized that the clinical outcome of all 3 analyzed surgical treatments would be equivalent. Methods: A systematic review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Google Scholar in July 2016 to compare the functional outcome, pain, grip strength, patient satisfaction, and return to work at 1-year follow-up for open, arthroscopic, and percutaneous treatment of lateral epicondylitis. Results: Six studies (2 Level I and 4 Level II) including 179 elbows (83 treated open, 14 arthroscopic, 82 percutaneous) were analyzed. Three outcome measures (Disabilities of the Arm, Shoulder, and Hand [DASH] score, visual analog scale [VAS], and patient satisfaction) were reported for more than one category of surgical technique. Of these, the authors noted no clinically significant differences between the techniques. Conclusions: This is the first systematic review looking at high-level evidence to compare open, percutaneous, and arthroscopic techniques for treating lateral epicondylitis. There are no clinically significant differences between the 3 surgical techniques (open, arthroscopic, and percutaneous) in terms of functional outcome (DASH), pain intensity (VAS), and patient satisfaction at 1-year follow-up.

Ultrasound-guided percutaneous bone drilling for the treatment of lateral epicondylitis

OBJECTIVE

To determine the clinical efficacy of sonographically-guided percutaneous bone drilling of the lateral epicondyle (LE) for the treatment of patients with LE.

METHODS

We included 24 patients with LE who reported pain in this study. All patients underwent sonographically-guided percutaneous bone drilling of the lateral epicondyle. Follow-up sonography and physical examinations were performed 1, 3 and 6 months after the procedure. The outcome measures included sonographic findings, visual analogue scale (VAS) score, maximum voluntary grip strength (MVGS) and patient-related tennis elbow evaluation (PRTEE) score.

RESULTS

None of the patients had immediate complications during the procedure. The area of the extensor carpi radialis brevis (ECRB) tears decreased significantly at 1 month and declined gradually over the remaining 5 months of the study (p < 0.001). The mean pain VAS score was significantly lower at 6 months than preoperatively (respectively; p < 0.001). The mean MVGS increased significantly between pretreatment and 6 months post-treatment (p < 0.001), whereas the PRTEE score decreased significantly during the same period (p < 0.001).

CONCLUSION

Sonographically-guided percutaneous drilling is a quick and safe treatment option for LE that can be performed in an outpatient setting.

KEY POINTS

• Percutaneous drilling of the lateral condyle is effective for the treatment of LE. • The area of ECRB tears can be measured by US-guided saline injection. • US-guided percutaneous drilling is a quick and safe treatment option for LE.

Tendinopathies around the Elbow Part 1: Lateral Elbow Tendinopathy

Tendinopathies of the elbow and in particular of the common extensor origin are a common cause of elbow pain. Part one of this two part review of tendinopathies of the elbow will focus on the pathophysiology and management of lateral elbow tendinopathy, frequently referred to as tennis elbow. Lateral elbow tendinopathy is a common condition with an incidence of 1 – 2%. The pathology arises from the origin of extensor carpi radialis brevis where changes, consistent with all tendinopathies, of angiofibroblastic hyperplasia occur secondary to repetitive micro trauma. It is not an inflammatory condition. Clinical history and examination is usually sufficient for diagnosis although MRI and ultrasound can be used. The many treatment options that have been proposed have a mixed quality of supporting evidence. Thus management protocols are difficult to define. Treatment depends on the length of symptoms. Acute presentation is managed through conservative measures including activity modification, topical NSAIDs and physiotherapy. For patients with recalcitrant symptoms, injection therapy with, for example, platelet rich plasma can be used. Alternatively surgical excision of the diseased tissue can be performed. This review article will consider the available evidence in order to identify both treatments that are effective and those that are not.

Treatment of Plantar Fasciitis With Botulinum Toxin

BACKGROUND

This study examined the effect of botulinum toxin upon plantar fasciitis through a randomized, controlled, and blinded trial.

MATERIALS

Between 2012 and 2015, 50 patients presented with plantar fasciitis. Twenty-five patients each randomly received an IncobotulinumtoxinA (IBTA) or saline injection of their affected foot. Pre- and postinjection function and pain were graded with the Foot and Ankle Ability Measures (FAAM) and visual analog scale (VAS), respectively. All 50 study patients who randomly received either placebo or IBTA presented at 6 and 12 months after injection.

RESULTS

At 6 months, the mean FAAM increased from 35.9 to 40.9 of 100, and the mean pain score decreased from 8.4 to 7.9 of 10 within the placebo group. At 6 months, the mean FAAM increased from 36.3 to 73.8 of 100, and mean pain score decreased from 7.2 to 3.6 of 10 within the IBTA group. These postinjection scores were significantly better than the placebo group ( P = .01). At 12 months after injection, the IBTA group maintained significantly better function and pain than the placebo group ( P < .05). By that time, 0 (0%) and 3 (12%) patients who received IBTA and saline, respectively, underwent surgery for recalcitrant plantar fasciitis ( P < .005).

CONCLUSION

Compared with placebo saline injection, using IBTA to treat plantar fasciitis resulted in significantly better improvement in foot function and pain. IBTA also lessened the need for operative treatment of plantar fasciitis.

LEVEL OF EVIDENCE

I, Randomized, double-blinded, placebo-controlled study.

Autologous Platelet-rich Plasma versus Corticosteroid in the Management of Elbow Epicondylitis: A Randomized Study

INTRODUCTION

Elbow epicondylar tendinitis is a common problem for patients whose activities require strong gripping or repetitive wrist movements in the day-to-day activities of life. Histologic specimens from chronic cases confirm that tendinitis is not an acute inflammatory condition but rather a failure of the normal tendon repair mechanism associated with angiofibroblastic degeneration. Tendon regeneration may be improved by injecting autologous growth factors obtained from the patient's own blood. Autologous growth factors can be injected with autologous whole blood or platelet-rich plasma (PRP).

MATERIALS AND METHODS

A randomized study with 83 patients was done. The study population comprised two groups. Group A (n = 50) treated with local steroid injection and Group B (n = 33) treated with autologous PRP. Patients were allocated randomly using computer-generated random number table. The base-line evaluation was done using visual analog score (VAS) and modified Mayo performance index for elbow (MAYO). Re-evaluation was after 1, 2, and 6 months of the procedure. Statistical analysis was done using independent t-test.

RESULTS

Six months after treatment with PRP, patient's with elbow epicondylitis had a significant improvement in their VAS (P < 0.05) and MAYO (P < 0.05) in contrast to steroid, whereas no statistical difference was found between the two groups at 1 and 2 months after intervention.

CONCLUSION

Treatment of patients with epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection.

Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years

BACKGROUND

A previously published study found positive outcomes for a novel technique for ultrasound-guided percutaneous ultrasonic tenotomy, showing good tolerability, safety, and early efficacy within an office setting.

PURPOSE

In this follow-up study, all 20 members of the original cohort were contacted after 3 years to explore the sustainability of symptomatic relief, functional improvement, and sonographic soft tissue response for percutaneous ultrasonic tenotomy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All 20 subjects of the clinical trial that was performed from June to November 2011 were further assessed at 36 months after the procedure in terms of visual analog scale for pain, Disabilities of the Arm, Shoulder and Hand (DASH)-Compulsory/Work scores, need for adjunct procedures, and overall satisfaction. Importantly, all 20 were reassessed with ultrasound imaging at 36 months, and evidence of the common extensor tendon response was assessed in terms of tendon hypervascularity, tendon thickness, and the progress of the hypoechoic scar tissue.

RESULTS

A 100% clinical follow-up was achieved, inclusive of ultrasonographic assessment. None of the subjects required further treatment procedures, and 100% expressed satisfaction. Previous improvements in visual analog scale (current median ± SD, 0 ± 0.9; range, 0-3) and DASH-Work scores (current median, 0 ± 0) were sustained with conformity to a linear pattern on polynomial measures. There was further reduction in DASH-Compulsory scores to a median of 0 ± 0.644 (range, 0-2) with a significant decrease on repeated measures (P = .008). Tendon hypervascularity was resolved in 94% of patients, and 100% had reduction in tendon thickness. Overall reduction in the hypoechoic scar tissue was observed in all subjects, with a 90% response achieved by 6 months. Between 6 and 36 months, further reduction in the scar was observed in around 60% of patients, with 20% of patients having complete resolution of the hypoechoic scar.

CONCLUSION

Minimally invasive percutaneous ultrasonic tenotomy provided sustained pain relief and functional improvement for recalcitrant tennis elbow at 3-year follow-up. It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy.

Platelet-rich plasma versus open surgical release in chronic tennis elbow: A retrospective comparative study

PURPOSE

To compare short and mid-term results in the treatment of chronic elbow tendinosis with platelet-rich plasma (PRP) or Nirschl surgical technique.

METHOD

A retrospective study was conducted on patients with chronic lateral epicondylitis, treated by Nirschl surgical technique (50 elbows) or PRP (60 elbows). Outcome was evaluated with Visual Analog Score (VAS), Mayo Elbow Scores and grip strength measurements.

RESULTS

VAS and Mayo Elbow Scores of the PRP group had improved as a mean of 83% (p = 0.0001), 74% (p = 0.0001) over baseline and 34.2 pounds gain of grip strength.

CONCLUSION

The PRP seems to be better for pain relief and functionality in the short and mid-term periods.

Use of botulinum toxin in musculoskeletal pain

Chronic musculoskeletal pain is a common cause of chronic pain, which is associated with a total cost of $635 billion per year in the U.S. Emerging evidence suggests an anti-nociceptive action of botulinum toxin, independent of its muscle paralyzing action. This review provides a summary of data from both non-randomized and randomized clinical studies of botulinum toxin in back pain and various osteoarticular conditions, including osteoarthritis, tennis elbow, low back pain and hand pain. Three randomized controlled trials (RCTs) of small sizes provide evidence of short-term efficacy of a single intra-articular injection of 100 units of botulinum toxin A (BoNT/A) for the relief of pain and the improvement of both function and quality of life in patients with chronic joint pain due to arthritis. Three RCTs studied intramuscular BoNT/A for tennis elbow with one showing a significant improvement in pain relief compared with placebo, another one showing no difference from placebo, and the third finding that pain and function improvement with BoNT/A injection were similar to those obtained with surgical release. One RCT of intramuscular BoNT/A for low back pain found improvement in pain and function compared to placebo. Single RCTs using local injections of BoNT in patients with either temporomandibular joint (TMJ) pain or plantar fasciitis found superior efficacy compared to placebo. One RCT of intramuscular BoNT/B in patients with hand pain and carpal tunnel syndrome found improvement in pain in both BoNT/B and placebo groups, but no significant difference between groups. Most evidence is based on small studies, but the use of BoNT is supported by a single, and sometimes up to three, RCTs for several chronic musculoskeletal pain conditions. This indicates that botulinum toxin may be a promising potential new treatment for chronic refractory musculoskeletal pain. Well-designed large clinical trials are needed.

Is posterior synovial plica excision necessary for refractory lateral epicondylitis of the elbow?

BACKGROUND

Arthroscopic treatments for lateral epicondylitis including débridement of the extensor carpi radialis brevis (ECRB) origin (Baker technique) or resection of the radiocapitellar synovial plica reportedly improve symptoms. However the etiology of the disease and the role of the plica remain unclear.

QUESTIONS/PURPOSES

We asked if posterior radiocapitellar synovial plica excision made any additional improvement in pain or function after arthroscopic ECRB release.

METHODS

We retrospectively reviewed 38 patients who had arthroscopic treatment for refractory lateral epicondylitis between November 2003 and October 2009. Twenty patients (Group A) underwent the Baker technique and 18 patients (Group B) underwent a combination of the Baker technique and posterior synovial plica excision. The minimum followup was 36 months (mean, 46 months; range, 36-72 months) for Group A and 25 months (mean, 30 months; range, 25-36 months) for Group B. Postoperatively we obtained VAS pain and DASH scores for each group.

RESULTS

Two years postoperatively, we found no differences in the VAS pain score or DASH: the mean VAS pain scores were 0.3 points in Group A and 0.4 points in Group B, and the DASH scores were 5.1 points and 6.1 points respectively.

CONCLUSIONS

The addition of débridement of the posterior synovial fold did not appear to enhance either pain relief or function compared with the classic Baker technique without decortication.

Percutaneous soft tissue release for treating chronic recurrent myofascial pain associated with lateral epicondylitis: 6 case studies

Objective. The purpose of this pilot study is to investigate the effectiveness of the percutaneous soft tissue release for the treatment of recurrent myofascial pain in the forearm due to recurrent lateral epicondylitis. Methods. Six patients with chronic recurrent pain in the forearm with myofascial trigger points (MTrPs) due to chronic lateral epicondylitis were treated with percutaneous soft tissue release of Lin's technique. Pain intensity (measured with a numerical pain rating scale), pressure pain threshold (measured with a pressure algometer), and grasping strength (measured with a hand dynamometer) were assessed before, immediately after, and 3 months and 12 months after the treatment. Results. For every individual case, the pain intensity was significantly reduced (P < 0.01) and the pressure pain threshold and the grasping strength were significantly increased (P < 0.01) immediately after the treatment. This significant effectiveness lasts for at least one year. Conclusions. It is suggested that percutaneous soft tissue release can be used for treating chronic recurrent lateral epicondylitis to avoid recurrence, if other treatment, such as oral anti-inflammatory medicine, physical therapy, or local steroid injection, cannot control the recurrent pain.

Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis

BACKGROUND

In patients with lateral epicondylitis recalcitrant to nonsurgical treatments, surgical intervention is considered. Despite the numerous therapies reported, the current trend of treatment places particular emphasis on minimally invasive techniques.

PURPOSE

The authors present a newly developed minimally invasive procedure, ultrasonographically guided percutaneous radiofrequency thermal lesioning (RTL), and its clinical efficacy in treating recalcitrant lateral epicondylitis.

CASE SERIES

Level of evidence, 4.

METHODS

Thirty-four patients (35 elbows), with a mean age of 52.1 years (range, 35-65 years), suffered from symptomatic lateral epicondylitis for more than 6 months and had exhausted nonoperative therapies. They were treated with ultrasonographically guided RTL. Patients were followed up at least 6 months by physical examination and 12 months by interview. The intensity of pain was recorded with a visual analog scale (VAS) score. The functional outcome was evaluated using grip strength, the upper limb Disability of Arm, Shoulder and Hand (QuickDASH) outcome measure, and the Modified Mayo Clinic Performance Index (MMCPI) for the elbow. The ultrasonographic findings regarding the extensor tendon origin were recorded, as were the complications.

RESULTS

At the time of the 6-month follow-up, the average VAS score in resting (from 4.9 to 0.9), palpation (from 7.6 to 2.5), and grip (from 8.2 to 2.9) had improved significantly compared with the preoperative condition (P < .01). The grip strength (from 20.6 to 27.0 kg) and QuickDASH score (from 54.3 to 21.0) had also improved significantly (P < .01). The MMCPI score improved from "poor" to "excellent." The ultrasonographic finding revealed that the thickness of the common extensor tendon origin did not change significantly. At the final follow-up (mean, 14.3 months; range, 12-21 months), the patients reported a 78% reduction in pain compared with the preoperative status. No major complications were noted in any patient.

CONCLUSION

Ultrasonographically guided RTL for recalcitrant lateral epicondylitis was found to be a minimally invasive treatment with satisfactory results in this pilot investigation. This innovative method can be considered as an alternative treatment of recalcitrant lateral epicondylitis before further surgical intervention.

The effect of muscle paralysis using Botox on the healing of tendon to bone in a rat model

HYPOTHESIS

Despite good clinical results after rotator cuff repair, follow-up studies show significant rates of failed healing. This may be because of excessive tension on the repaired tendon due to shoulder motion. We hypothesized that botulinum toxin A injections would result in improved attachment strength and collagen organization at the tendon-bone interface at early time points but may result in decreased mechanical properties at later time points because of the negative effects of stress deprivation.

MATERIALS AND METHODS

We performed division and repair of the supraspinatus tendon in 132 rats: 66 underwent repair alone and 66 received injections of botulinum toxin into the muscle before repair. Rats were killed at 4, 8, and 24 weeks and were evaluated by use of histologic, biomechanical, and micro-computed tomography analyses.

RESULTS

At 4 and 24 weeks, there was no significant difference in load to failure between groups. At 8 weeks, the botulinum group had a significantly lower load to failure compared with controls (27.7 N vs 46.7 N, P < .01). The weight of the supraspinatus muscle was significantly decreased at 4 and 8 weeks in the botulinum group, but it recovered by 24 weeks. Micro-computed tomography analysis showed the botulinum group to have significantly less bone volume, total mineral content, and total mineral density at 8 weeks. Histologic analysis showed formation of a more normal tidemark and increased collagen fiber organization in the botulinum specimens at 4 weeks.

DISCUSSION

Botulinum toxin A-treated specimens had increased collagen fiber organization at 4 weeks and decreased mechanical properties at later time points. The rapid healing of the rat rotator cuff likely makes it difficult to realize benefits from reduction in strain.

Surgery for lateral elbow pain

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Arthroscopic versus percutaneous release of common extensor origin for treatment of chronic tennis elbow

BACKGROUND

Lateral epicondylitis is a common orthopedic problem. Rest, activity modification, and conservative therapies are generally efficacious in relieving symptoms in the majority of patients; however, a small percentage of people will experience refractory pain and require surgical intervention to alleviate their discomfort. Surgical release of the common extensor origin can be done through an open, percutaneous, or arthroscopic approach.

PATIENTS AND METHODS

This prospective study includes 33 patients with chronic resistant lateral epicondylitis who had received conservative treatment including modification of activity and 2 injections of 80 mg of hydrocortisone, for more than 6 months, aiming to compare two different techniques of treatment. The first group included 14 patients with a mean age of 42 years treated by arthroscopic release of common extensor origin. The second group included 19 patients with a mean age of 48 years treated by percutaneous tenotomy. The mean follow up was 12 months for the arthroscopic group and 10 months for the percutaneous tenotomy group.

RESULTS

The results were evaluated according to the Disabilities of the Arm, Shoulder and Hand (DASH) score and the visual analogue scale (VAS). In the first group (treated by arthroscopy), the average DASH score improved from 72 to 48 and the average VAS improved from 9.1 to 2. In the second group (treated by percutaneous tenotomy), the average DASH score improved from 70 to 50 and the average VAS improved from 9 to 2.1. Concerning patient satisfaction after surgery, in the first group 7 patients (50%) were pleased, 6 (42.85%) were satisfied and 1 case (7.14%) was not satisfied. In the second group, 7 patients (36.84%) were pleased, 10(52.63%) were satisfied and 2 cases (10.52%) were not satisfied.

CONCLUSION

Both arthroscopic and percutaneous release of the common extensor origin can be effective in treatment of lateral epicondylitis. Arthroscopic treatment of lateral epicondylitis gives more favorable results than percutaneous tenotomy. Although technically more difficult than percutaneous tenotomy, arthroscopy has the advantage of visualization of the pathology and much better improvement of elbow functions.

Botulinum toxin for shoulder pain: a cochrane systematic review

OBJECTIVE

To perform a Cochrane Systematic Review of benefits and harms of botulinum toxin for shoulder pain.

METHODS

We included clinical trials of adults with shoulder pain (population), comparing botulinum toxin (intervention) to placebo or other therapies (comparison), and reporting benefits or harms (outcomes). We calculated relative risk (RR) for categorical outcomes and mean differences (MD) for continuous outcomes.

RESULTS

Six randomized controlled trials (RCT) with 164 patients all comparing single botulinum toxin type A injections to placebo were included. Five RCT in patients with post-stroke shoulder pain found that an intramuscular injection of botulinum toxin type A significantly reduced pain at 3-6 months (MD -1.2 points on 0-10 scale, 95% CI -2.4 to -0.07) and improved shoulder external rotation at 1 month (MD 9.8°, 95% CI 0.2° to 19.4°). Number of adverse events did not differ between groups (RR 1.46, 95% CI 0.6 to 24.3). One RCT in arthritis-related shoulder pain showed that single intraarticular botulinum toxin type A injection reduced pain (MD -2.0 on 0-10 scale, 95% CI -3.7 to -0.3) and shoulder disability (MD -13.4 on 0-100 scale, 95% CI -24.9 to -1.9) and improved shoulder abduction (MD 13.8°, 95% CI 3.2° to 44.0°) at 1 month, compared with placebo. Serious adverse events did not differ between groups (RR 0.35, 95% CI 0.11, 1.12).

CONCLUSION

With evidence from few studies with small sample sizes and medium to high risk of bias, botulinum toxin type A injections decreased pain and improved shoulder function in patients with chronic shoulder pain due to spastic hemiplegia or arthritis.

Botulinum toxin for shoulder pain

BACKGROUND

Recent evidence suggests an anti-nociceptive effect of botulinum toxin.

OBJECTIVES

To compare the efficacy and safety of botulinum toxin in comparison to placebo or other treatment options for shoulder pain.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, CINAHL (via EBSCOhost), Ovid SPORTDiscus, EMBASE and Science Citation Index.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing botulinum toxin with placebo or active treatment in people with shoulder pain were included.

DATA COLLECTION AND ANALYSIS

For continuous measures we calculated mean difference (MD), and for categorical measures risk ratio (RR) (with 95% confidence interval (CI)).

MAIN RESULTS

Six RCTs with 164 patients were included. Five RCTs in participants with post-stroke shoulder pain indicated that compared with placebo, a single intramuscular injection of botulinum toxin A significantly reduced pain at three to six months post-injection (MD -1.2 points, 95% CI -2.4 to -0.07; 0 to 10 point scale) but not at one month (MD -1.1 points, 95% CI -2.9 to 0.7). Shoulder external rotation was increased at one month (MD 9.8 degrees , 95% CI 0.2 to 19.4) but not at three to six months. Shoulder abduction, external rotation or spasticity did not differ between groups, nor did the number of adverse events (RR 1.46, 95% CI 0.6 to 24.3).One RCT in arthritis-related shoulder pain indicated that botulinum toxin reduced pain severity (MD -2.0, 95% CI -3.7 to -0.3; 10 point scale) and shoulder disability with a reduction in Shoulder Pain and Disability Index score (MD -13.4, 95% CI -24.9 to -1.9; 100 point scale) when compared with placebo. Shoulder abduction was improved (MD 13.8 degrees, 95% CI 3.2 to 44.0). Serious adverse events did not differ between groups (RR 0.35, 95% CI: 0.11, 1.12).

AUTHORS' CONCLUSIONS

The results should be interpreted with caution due to few studies with small sample sizes and high risk of bias. Botulinum toxin A injections seem to reduce pain severity and improve shoulder function and range of motion when compared with placebo in patients with shoulder pain due to spastic hemiplegia or arthritis. It is unclear if the benefit of pain relief in post-stroke shoulder pain at three to six months but not at one month is due to limitations of the evidence, which includes small sample sizes with imprecise estimates, or a delayed onset of action. More studies with safety data are needed.

Intraarticular botulinum toxin A for refractory painful total knee arthroplasty: a randomized controlled trial

OBJECTIVE

To assess short-term efficacy of single intraarticular botulinum toxin (IA-BoNT/A) injection in patients with chronically painful total knee arthroplasty (TKA) in a randomized, placebo-controlled, triple-blind study.

METHODS

Patients with chronic TKA pain (pain > 6 on 0-10 scale and > 6 months post-TKA) evaluated in and referred from orthopedic surgery clinics were recruited. The primary outcome, proportion of patients with clinically meaningful decrease of at least 2 points on 0-10 visual analog scale (VAS) for pain, was compared between treatment groups at 2 months using comparison of proportions test and for all efficacy timepoints (2, 3, and 4 months) using generalized estimating equations (GEE). Secondary outcomes of global assessment, function, and quality of life were compared using GEE, duration of pain relief by t-test, and adverse events by chi-square test.

RESULTS

In total, 54 patients with 60 painful TKA were randomized, with main analyses restricted to one TKA per patient (49 TKA in 49 patients). Mean age was 67 years, 84% were men, and mean duration of TKA pain was 4.5 years. A significantly greater proportion of patients (71%) in the IA-BoNT/A group compared to IA-placebo (35%) achieved clinically meaningful reduction in VAS pain at 2 months (p = 0.028) and at all efficacy timepoints (p = 0.019). Duration of meaningful pain relief was significantly greater after IA-BoNT/A, 39.6 days (SD 50.4) compared to IA-placebo, 15.7 days (SD 22.6; p = 0.045). Statistically significantly better scores were seen in IA-BoNT/A vs IA-placebo for all efficacy timepoints for the following outcomes: "very much improved" on physician global assessment of change (p = 0.003); Western Ontario McMaster Osteoarthritis Index physical function (p = 0.026), stiffness (p = 0.004), and total scores (p = 0.024); and Short-Form 36 pain subscale score (p = 0.049). Number of total and serious adverse events was similar between groups, with no patients in either group with new objective motor or sensory deficits during followup.

CONCLUSION

In this single-center randomized trial, single IA-BoNT/A injection provided clinically meaningful short-term improvements in pain, global assessment, and function in patients with chronic painful TKA. A multicenter trial is needed to confirm these findings.

Comparison between botulinum toxin and corticosteroid injection in the treatment of acute and subacute tennis elbow: a prospective, randomized, double-blind, active drug-controlled pilot study

OBJECTIVE

To compare botulinum toxin type A injection with corticosteroid injection in the treatment of tennis elbow.

DESIGN

In this prospective, randomized, double-blind, drug-controlled trial,19 affected elbows of 16 patients were randomly assigned to receive injection with botulinum toxin type A (Botox group) or triamcinolone acetonide (steroid group). We used the Visual Analog Scale, pain-free grip strength, and World Health Organization Quality of Life Brief Questionnaire to assess the perception of pain, grip strength, and quality of life, respectively. Measures were performed before and at 4, 8, and 12 wks after the treatment.

RESULTS

Four weeks after the treatment, the Botox group had smaller decrease in pain (P = 0.02) but greater decrease in grip strength (P = 0.01). The difference in grip strength remained significant at 8 wks (P = 0.03). No significant differences in quality of life were observed throughout the study period.

CONCLUSIONS

Corticosteroid is superior to botulinum toxin type A in relieving pain in tennis elbow at 4 wks after injection. Because botulinum toxin injection did not relieve pain significantly but is associated with weakness, the muscle weakness caused by botulinum toxin is unlikely to be the sole mechanism of the pain relief observed in previous studies.

Use of anatomic measurement to guide injection of botulinum toxin for the management of chronic lateral epicondylitis: a randomized controlled trial

BACKGROUND

When using botulinum toxin for the management of lateral epicondylitis, injection at a fixed distance from an anatomic landmark could result in inadequate paralysis of the intended muscle. We assessed the effectiveness of injection of botulinum toxin using precise anatomic measurement in individual patients.

METHODS

In this randomized placebo-controlled trial, 48 patients with chronic refractory lateral epicondylitis were randomly assigned to receive a single injection of either botulinum toxin (60 units) or placebo (normal saline). The site of injection was chosen as a distance one-third the length of the forearm from the tip of the lateral epicondyle on the course of the posterior interosseus nerve. The primary outcome measure was intensity of pain at rest, measured with the use of a 100-mm visual analogue scale, at baseline and at 4, 8 and 16 weeks after injection.

RESULTS

Compared with the placebo group, the group given botulinum toxin had significant reductions in pain at rest during follow-up (decrease at 4 weeks 14.1 mm, 95% confidence interval [CI] 5.8-22.3; at 8 weeks 11.5 mm, 95% CI 2.0-21.0; at 16 weeks 12.6 mm, 95% CI 7.7-17.8; p = 0.01). As for the secondary outcomes, the intensity of pain during maximum pinch decreased in the botulinum toxin group; there was no difference in pain during maximum grip or in grip strength between the two groups. All but one of the patients in the intervention group experienced weakness in the extension of the third and fourth fingers at week 4 that resolved by week 16. No serious adverse events were reported.

INTERPRETATION

The use of precise anatomic measurement to guide injection of botulinum toxin significantly reduced pain at rest in patients with chronic refractory lateral epicondylitis. However, the transient extensor lag makes this method inappropriate for patients whose job requires finger extension.

Botulinum toxin therapy for osteoarticular pain: an evidence-based review

Botulinum (BoNT) toxin has been used for its muscle-paralyzing action in conditions such as treatment of wrinkles, cervical dystonia and blephrospasm. There is preclinical and emerging clinical evidence of another mechanism of action of BoNT, namely, an antinociceptive action. In this review, we provide an evidence-based review of clinical studies of BoNT in osteoarticular conditions, such as osteoarthritis, tennis elbow, low back pain, and hand pain. Many randomized controlled trials (RCTs) found evidence of short-term efficacy of an injection of BoNT in relief of pain, and in some cases, improvement of function and quality of life. However, more clinical trials are needed to better define the clinical use of BoNT for treatment of refractory osteoarticular pain.