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Couch B, Hayward D, Baum G, Sakthiyendran NA, Harder J, Hernandez EJ, MacKay B. A systematic review of steroid use in peripheral nerve pathologies and treatment. Front Neurol 2024; 15:1434429. [PMID: 39286807 PMCID: PMC11402678 DOI: 10.3389/fneur.2024.1434429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/21/2024] [Indexed: 09/19/2024] Open
Abstract
Background The use of corticosteroids has become a part of the standard of care in various pathologies but their use in peripheral nerve injury treatment is limited. Given corticosteroids' anti-inflammatory properties and their regulatory role in neuronal protein production and myelination, corticosteroids could serve as an adjunct therapy for peripheral nerve injuries. This review aims to systematically investigate the current use of corticosteroid treatment in peripheral nerve pathologies. Methods The systematic search was performed on PubMed, MEDLINE, EMBASE, Scopus, Cochrane, and Web of Science using keywords such as "corticosteroid treatment," "peripheral nerve damage," "peripheral neuropathy," and "complications." The PRISMA guidelines were used to conduct the systematic review and all articles were reviewed by the corresponding author. After the initial search, individual study titles and abstracts were further screened and categorized using an inclusion and exclusion criteria followed by a final full-text review. Results Out of the total 27,922 identified records, 203 studies were included based on the selection criteria. These studies focused on the use and efficacy of steroids across a spectrum of compression and non-compression peripheral neuropathies such as cubital tunnel syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. Various studies noted the promising role of steroids in offering pain relief, nerve block, and nerve regeneration effects. Additionally, safety considerations and potential complications regarding steroid use in peripheral nerve injuries were analyzed. Conclusion While there is currently limited clinical utilization of corticosteroids in peripheral nerve pathologies, the anti-inflammatory and regenerative effects that steroids provide may be a beneficial tool in managing various peripheral neuropathies and their associated pain. Additional clinical trials and investigation into the mechanism of action could improve the reputation of steroid use as peripheral nerve injury treatment.
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Affiliation(s)
- Brandon Couch
- Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Dan Hayward
- Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Gracie Baum
- Department of Orthopaedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | | | - Justin Harder
- Department of Orthopaedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Evan J Hernandez
- Department of Orthopaedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Brendan MacKay
- Department of Orthopaedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States
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2
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Chang HN, Chen CK, Yu TY, Pang JHS, Hsu CC, Lin LP, Tsai WC. Lidocaine inhibits migration of tenocytes by downregulating focal adhesion kinase and paxillin phosphorylation. J Orthop Res 2024; 42:985-992. [PMID: 38044475 DOI: 10.1002/jor.25762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
Lidocaine is the most frequently applied local infiltration anesthetic agent for treating tendinopathies. However, studies have discovered lidocaine to negatively affect tendon healing. In the current study, the molecular mechanisms and effects of lidocaine on tenocyte migration were evaluated. We treated tenocytes intrinsic to the Achilles tendons of Sprague-Dawley rats with lidocaine. The migration ability of cells was analyzed using electric cell-substrate impedance sensing (ECIS) and scratch wound assay. We then used a microscope to evaluate the cell spread. We assessed filamentous actin (F-actin) cytoskeleton formation through immunofluorescence staining. In addition, we used Western blot analysis to analyze the expression of phospho-focal adhesion kinase (FAK), FAK, phospho-paxillin, paxillin, and F-actin. We discovered that lidocaine had an inhibitory effect on the migration of tenocytes in the scratch wound assay and on the ECIS chip. Lidocaine treatment suppressed cell spreading and changed the cell morphology and F-actin distribution. Lidocaine reduced F-actin formation in the tenocyte during cell spreading; furthermore, it inhibited phospho-FAK, F-actin, and phospho-paxillin expression in the tenocytes. Our study revealed that lidocaine inhibits the spread and migration of tenocytes. The molecular mechanism potentially underlying this effect is downregulation of F-actin, phospho-FAK, and phospho-paxillin expression when cells are treated with lidocaine.
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Affiliation(s)
- Hsiang-Ning Chang
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Chih-Kuang Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Taoyuan, Taoyuan City, Taiwan
| | - Tung-Yang Yu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Jong-Hwei S Pang
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City, Taiwan
| | - Chih-Chin Hsu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Keelung, Keelung City, Taiwan
| | - Li-Ping Lin
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Taoyuan, Taoyuan City, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City, Taiwan
| | - Wen-Chung Tsai
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Taoyuan, Taoyuan City, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Center of Comprehensive Sports Medicine, Chang Gung Memorial Hospital at Taoyuan, Taoyuan City, Taiwan
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3
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Varela-Margolles D, Milani A, Kamel SI. Percutaneous Interventions for Injuries in Athletes: Implications on Return to Play. Semin Musculoskelet Radiol 2024; 28:146-153. [PMID: 38484767 DOI: 10.1055/s-0043-1778026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
For nonsurgical musculoskeletal (MSK) injuries in athletes, image-guided percutaneous intervention may aid in recovery and decrease return to play (RTP) time. These interventions fall into two major categories: to reduce inflammation (and therefore alleviate pain) or to promote healing. This review describes the risks and benefits of the various percutaneous interventions in MSK athletic injury and surveys the literature regarding the implication of these interventions on RTP.
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Affiliation(s)
- Diana Varela-Margolles
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ava Milani
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sarah I Kamel
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Kamel SI, Rosas HG, Gorbachova T. Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications. AJR Am J Roentgenol 2024; 222:e2330458. [PMID: 38117096 DOI: 10.2214/ajr.23.30458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.
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Affiliation(s)
- Sarah I Kamel
- Department of Radiology, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107
| | - Humberto G Rosas
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Cognetti DJ, Defoor MT, Yuan TT, Sheean AJ. Knee Joint Preservation in Tactical Athletes: A Comprehensive Approach Based upon Lesion Location and Restoration of the Osteochondral Unit. Bioengineering (Basel) 2024; 11:246. [PMID: 38534520 DOI: 10.3390/bioengineering11030246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/18/2024] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
The unique physical demands of tactical athletes put immense stress on the knee joint, making these individuals susceptible to injury. In order to ensure operational readiness, management options must restore and preserve the native architecture and minimize downtime, while optimizing functionality. Osteochondral lesions (OCL) of the knee have long been acknowledged as significant sources of knee pain and functional deficits. The management of OCL is predicated on certain injury characteristics, including lesion location and the extent of subchondral disease. Techniques such as marrow stimulation, allograft and autologous chondrocyte implantation are examined in detail, with a focus on their application and suitability in tactical athlete populations. Moreover, the restoration of the osteochondral unit (OCU) is highlighted as a central aspect of knee joint preservation. The discussion encompasses the biomechanical considerations and outcomes associated with various cartilage restoration techniques. Factors influencing procedure selection, including lesion size, location, and patient-specific variables, are thoroughly examined. Additionally, the review underscores the critical role of post-operative rehabilitation and conditioning programs in optimizing outcomes. Strengthening the surrounding musculature, enhancing joint stability, and refining movement patterns are paramount in facilitating the successful integration of preservation procedures. This narrative review aims to provide a comprehensive resource for surgeons, engineers, and sports medicine practitioners engaged in the care of tactical athletes and the field of cartilage restoration. The integration of advanced preservation techniques and tailored rehabilitation protocols offers a promising avenue for sustaining knee joint health and function in this demanding population.
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Affiliation(s)
- Daniel J Cognetti
- Department of Orthopedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Mikalyn T Defoor
- Department of Orthopedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Tony T Yuan
- Advanced Exposures Diagnostics, Interventions and Biosecurity Group, 59 Medical Wing, Lackland Air Force Base, San Antonio, TX 78236, USA
- Center for Biotechnology (4D Bio3), Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew J Sheean
- Department of Orthopedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
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Leupold O, Cheng J, Barcavage C, Press J, Wyss J. Treatment of Interspinous Pain With Extracorporeal Shockwave Therapy: A Case Report. Am J Phys Med Rehabil 2024; 103:e23-e25. [PMID: 37903621 DOI: 10.1097/phm.0000000000002353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
ABSTRACT The interspinous region is an atypical source of low back pain, and it can often be difficult to identify. There are many structural components in the interspinous region that can contribute to interspinous pain, including the interspinous ligament, which plays a role in providing stabilization to the spine. Successful treatments of interspinous pain have not been well characterized in the literature. This case presents the first documentation of the use of extracorporeal shockwave therapy as a noninvasive treatment for refractory interspinous-related low back pain. Extracorporeal shockwave therapy has previously been shown to facilitate regeneration and tissue healing in tendons and ligaments but has not previously been used to treat interspinous pain. A 24-yr-old former collegiate softball player presented with 5 mos of low back pain; the interspinous ligament was clinically suspected as a pain generator, and this was confirmed via an ultrasound-guided injection. She underwent a course of physical therapy that improved function but did not improve pain, and nonsteroidal anti-inflammatory drugs only provided minimal and temporary relief. Three consecutive extracorporeal shockwave therapy treatment sessions provided 90% improvement in pain and function, and she was able to return to exercise and recreational sports. At more than 6 mos after extracorporeal shockwave therapy treatment, she reported no recurrences or functional limitations.
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Affiliation(s)
- Olivia Leupold
- From the Department of Physiatry, Hospital for Special Surgery, New York, New York
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Rhim HC, Shin J, Kang J, Dyrek P, Crockett Z, Galido P, Wade C, Hollander K, Borg-Stein J, Sampson S, Tenforde AS. Use of extracorporeal shockwave therapies for athletes and physically active individuals: a systematic review. Br J Sports Med 2024; 58:154-163. [PMID: 38228375 DOI: 10.1136/bjsports-2023-107567] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To determine the efficacy of extracorporeal shockwave therapy (ESWT) and investigate outcomes following the use of ESWT for athletes and physically active individuals. DESIGN Systematic review. DATA SOURCES We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and searched four databases: PubMed (NLM), Embase (Elsevier), CINAHL Complete (EBSCO) and Web of Science (Clarivate). ELIGIBILITY CRITERIA FOR SELECTING STUDIES Included studies were randomised controlled trials, cohort and case-control studies, cases series and reports that evaluated outcomes following ESWT for athletes, physically active individuals and occupational groups requiring regular physical activity such as military cadets. RESULTS 56 studies with 1874 athletes or physically active individuals were included. Using the Oxford level of evidence rating, included studies were 18 level I (32.1%), 3 level II (5.4%), 10 level III (17.9%), 13 level IV (23.2%) and 12 level V (21.4%). Based on the level I studies, ESWT may be effective alone in plantar fasciitis, lateral epicondylitis and proximal hamstring tendinopathy and as an adjunct to exercise treatment in medial tibial stress syndrome and osteitis pubis in athletes or physically active individuals. In most studies, athletes were allowed to continue activities and training and tolerated ESWT with minimal side effects. CONCLUSION ESWT may offer an efficacious treatment alone or as an adjunct to concurrent exercise therapy in selected sports-related injuries and without major adverse events. Further high-level research is needed to better define the role and clinical outcomes of ESWT.
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Affiliation(s)
- Hye Chang Rhim
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jaehyung Shin
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jane Kang
- Riverside University Health System, Moreno Valley, California, USA
| | - Paige Dyrek
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Zack Crockett
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Pearl Galido
- Western University of Health Sciences, Pomona, California, USA
| | - Carrie Wade
- Countway Library, Harvard Medical School, Boston, Massachusetts, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Joanne Borg-Stein
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | | | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
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8
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Abstract
Importance Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment. Observations Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used. Conclusions and Relevance Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.
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Bafaloukos D, Gazouli I, Koutserimpas C, Skarlos PD, Samonis G. Bilateral Spontaneous Supraspinatus Tendon Rupture Under Prolonged BRAF/MEK Targeting Treatment in a Melanoma Patient. Cureus 2023; 15:e50567. [PMID: 38222175 PMCID: PMC10788042 DOI: 10.7759/cureus.50567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/16/2024] Open
Abstract
The B-Raf proto-oncogene, serine/threonine kinase (BRAF)/ mitogen-activated protein kinase kinase (MEK) targeting agents have become the treatment of choice for BRAF-mutated melanoma during the last decade. However, it is possible that some long-term adverse events of these drugs have not yet been reported. A case of bilateral spontaneous, non-traumatic, supraspinatus tendon rupture in a 65-year-old Caucasian male suffering metastatic melanoma under prolonged and successful combination treatment with dabrafenib plus trametinib is presented. These damages could not be attributed to some other probable cause. The ruptured tendons were promptly restored arthroscopically. Oncologists should remain vigilant for the early detection of potential side effects of BRAF/MEK targeting agents that have not been systematically recorded yet but may appear and affect patients in the long run.
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Affiliation(s)
| | - Ioanna Gazouli
- Department of Medical Oncology, Metropolitan Hospital, Athens, GRC
| | - Christos Koutserimpas
- Department of Orthopedics and Traumatology, 251 Air Force General Hospital, Athens, GRC
- Department of Anatomy, National and Kapodistrian University of Athens, Athens, GRC
| | | | - George Samonis
- Department of Medicine, University of Crete, Heraklion, GRC
- Department of Medical Oncology, Metropolitan Hospital, Athens, GRC
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McMorrow K, Allahabadi S, Frazier L, Quigley R, Serrano B, Cole BJ. One to Two Days of Rest Is Recommended Before Returning to Sport After Intra-Articular Corticosteroid Injection in the High-Level Athlete. Arthrosc Sports Med Rehabil 2023; 5:100763. [PMID: 37560144 PMCID: PMC10407144 DOI: 10.1016/j.asmr.2023.100763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/13/2023] [Indexed: 08/11/2023] Open
Abstract
UNLABELLED Return to sport following a corticosteroid injection is a complex decision. Multiple considerations should be taken into account, including steroid dose and formulation, involvement of the affected joint in the activity, and intensity of the activity. Research investigating the adverse effects of corticosteroid injections with early initiation of high-intensity activity is limited and has produced mixed results. Rest following injections has typically been recommended to minimize both chondrotoxic effects and systemic absorption. Based on the current research and extensive experience treating professional athletes, we recommend 1 to 2 days of rest of the affected joint or region with a progressive increase of activity following a corticosteroid injection with possible benefits including maximizing the beneficial effects of the injection and a reduced systemic effect. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
| | | | | | - Ryan Quigley
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | | | - Brian J. Cole
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
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Tsechelidis OB, Sabido-Sauri R, Aydin SZ. Enthesitis in Spondyloarthritis Including Psoriatic Arthritis-To Inject or Not To Inject?: A Narrative Review. Clin Ther 2023; 45:852-859. [PMID: 37716837 DOI: 10.1016/j.clinthera.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE Enthesitis is a key manifestation of psoriatic arthritis (PsA) and spondyloarthritis (SpA) and is considered to be the tissue where the disease initiates. Enthesitis leads to pain and substantial limitations in patients with PsA. Treatment is key in achieving remission or minimal disease activity. Whether it is safe to apply injections to entheseal tissue is unknown. This narrative review aimed to summarize the literature on the efficacy and tolerability of entheseal corticosteroid (CS) injections. METHODS The published literature was searched through PubMed as well as identifying relevant articles from their citations, for articles on the anatomic location of the injection, tissue characteristics (eg, whether there is a tendon sheath), blind versus imaging-guided and entheseal versus perientheseal injections, and related studies in animals. Given that articles on SpA are limited, those on mechanical enthesopathies were also included. FINDINGS The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA are limited. In most articles on entheseal injection, the entheseal tissue has not actually been targeted. The decision of entheseal injection should be made on an individual basis, with consideration of the use of CS injection as the last treatment option following more conservative measures such as NSAIDs, physiotherapy, rest, and lifestyle modifications. Entheseal injection should be avoided in high-risk patients, such as those who have rupture at the enthesis. Diagnostic ultrasound is advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture. In the authors' perspective, perientheseal injections should be tried before intraentheseal injections. Finally, ultrasound guidance for needle placement is strongly encouraged. IMPLICATIONS The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA is limited. With the lack of quality data, recommendations on entheseal corticosteroid injection remain expert opinion.
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Affiliation(s)
| | - Ricardo Sabido-Sauri
- Department of Rheumatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Sibel Zehra Aydin
- Department of Rheumatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada.
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12
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Norman MB, Norman ER, Langer GH, Allen MR, Meller L, Vitale KC. Return to Sport Using Corticosteroid Injections for Knee Pain in Triathletes. Cureus 2023; 15:e39985. [PMID: 37416041 PMCID: PMC10321459 DOI: 10.7759/cureus.39985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction Despite the prevalence of corticosteroid injections in athletes, little is known about their efficacy in triathletes. We aim to assess attitudes, use, subjective effectiveness, and time to return to sport with corticosteroid injections compared to alternative methods in triathletes with knee pain. Methods This is an observational study during the COVID-19 pandemic. Triathletes answered a 13-question survey posted to three triathlon-specific websites. Results Sixty-one triathletes responded, 97% of whom experienced knee pain at some point in their triathlete career; 63% with knee pain received a corticosteroid injection as treatment (average age 51 years old). The most popular attitude (44.3%) regarding corticosteroid injections was "tried them, with good improvement". Most found the cortisone injection helpful for two to three months (28.6%), or more than one year (28.6%); of individuals who found the injections useful for more than one year, four-eight (50%) had received multiple injections during that same period. After injection, 80.6% returned to sport within one month. The average age of people using alternative treatment methods was 39 years old; most returned to sport within one month (73.7%). Compared to alternative methods, there was an ~80% higher odds of returning to sport within one month using corticosteroid injections; however, this relationship was not significant (OR=1.786, p=0.480, 95% CI:0.448-7.09). Conclusion This is the first study to examine corticosteroid use in triathletes. Corticosteroid use is more common in older triathletes and results in subjective pain improvement. A strong association does not exist for a quicker return to sport using corticosteroid injections compared to alternative methods. Triathletes should be counseled on the timing of injections, duration of side effects, and be aware of potential risks.
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Affiliation(s)
| | - Emily R Norman
- Physical Medicine and Rehabilitation, Dartmouth Geisel School of Medicine, Hanover, USA
| | | | - Matthew R Allen
- Orthopedic Surgery, University of California San Diego School of Medicine, La Jolla, USA
| | - Leo Meller
- Orthopedic Surgery, University of California San Diego School of Medicine, La Jolla, USA
| | - Kenneth C Vitale
- Orthopedic Surgery, University of California San Diego School of Medicine, La Jolla, USA
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Shomal Zadeh F, Shafiei M, Hosseini N, Alipour E, Cheung H, Chalian M. The effectiveness of percutaneous ultrasound-guided needle tenotomy compared to alternative treatments for chronic tendinopathy: a systematic review. Skeletal Radiol 2023; 52:875-888. [PMID: 35896736 DOI: 10.1007/s00256-022-04140-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare percutaneous ultrasound-guided needle tenotomy (PUNT) to alternative treatments for chronic tendinopathy. MATERIALS AND METHODS A systematic literature search was performed with the following combination of keywords: ultrasound-guided, percutaneous, needling, tenotomy, Tenex, tendinopathy, and fasciotomy. Original studies comparing PUNT to alternative treatments for chronic tendinopathy were included in this systematic review. RESULTS Twelve (n = 12) studies with 481 subjects were included. Two (2/12) articles compared PUNT to surgical tenotomy and concluded that PUNT provides the same outcomes as surgical tenotomy. Six (6/12) studies compared PUNT to platelet-rich plasma (PRP) injections, and two of them found both treatment modalities effective with no significant between-group differences. Three trials claimed that PUNT followed by PRP injections showed superior clinical outcomes compared to PUNT alone. However, the difference at long-term follow-up was statistically significant only in one of them. One study found PUNT superior to PUNT + PRP injection at short-term follow-up, although there were no between-group differences at long-term follow-up. Four (4/12) studies compared PUNT to steroid injection (SI) and showed that SI causes fast (2 weeks) but temporary pain relief, PUNT results in persistent but relatively slower improvement to SI, and the combined procedure has a more rapid and steady reduction in symptoms. CONCLUSION PUNT is an effective treatment technique for chronic tendinopathy and should be considered when non-invasive treatments have failed. Effects of PRP and SI are transient and dissipate over time and do not contribute to long-term outcome.
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Affiliation(s)
- Firoozeh Shomal Zadeh
- Musculoskeletal Imaging and Intervention, Department of Radiology, University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
| | - Mehrzad Shafiei
- Musculoskeletal Imaging and Intervention, Department of Radiology, University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
| | - Nastaran Hosseini
- Musculoskeletal Imaging and Intervention, Department of Radiology, University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
| | - Ehsan Alipour
- Musculoskeletal Imaging and Intervention, Department of Radiology, University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Hoiwan Cheung
- Musculoskeletal Imaging and Intervention, Department of Radiology, University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
| | - Majid Chalian
- Musculoskeletal Imaging and Intervention, Department of Radiology, University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA.
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14
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Stewart ZE, Lee K. Lower extremity ultrasound-guided interventions: tendon, ligament, and plantar fascia. Skeletal Radiol 2023; 52:991-1003. [PMID: 36326878 DOI: 10.1007/s00256-022-04212-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
Lower extremity tendinopathy and soft tissue injury are common clinical problems that can cause significant disability. Ultrasound-guided minimally invasive treatments using orthobiologics and image-guided percutaneous treatments continue to gain relevance with an ever-growing body of literature. We review the indications, technique, risks, and benefits according to the literature of common ultrasound-guided interventions utilized in the lower extremities.
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Affiliation(s)
- Zachary E Stewart
- Department of Radiology - Musculoskeletal Imaging and Intervention, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Yawkey Bldg Room 6033, Boston, MA, 02114, USA.
| | - Kenneth Lee
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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15
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Rhim HC, Borg-Stein J, Sampson S, Tenforde AS. Utilizing Extracorporeal Shockwave Therapy for in-Season Athletes. Healthcare (Basel) 2023; 11:healthcare11071006. [PMID: 37046934 PMCID: PMC10093829 DOI: 10.3390/healthcare11071006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
An athlete’s health and availability to train and compete at an optimal performance level is a growing focus for professional sports organizations [...]
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Affiliation(s)
- Hye Chang Rhim
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA 02115, USA
| | - Joanne Borg-Stein
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA 02115, USA
| | - Steven Sampson
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Adam S. Tenforde
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA 02115, USA
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16
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Feng S, Li H, Zhong Y, Xie Y, Chen J, Chen Y, Chen S. Functional and Structural Outcomes After Arthroscopic Rotator Cuff Repair With or Without Preoperative Corticosteroid Injections. Am J Sports Med 2023; 51:733-742. [PMID: 36734466 DOI: 10.1177/03635465221145949] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Corticosteroid injections (CSIs) are effective in alleviating pain in patients with rotator cuff tears, but controversy still exists regarding their potential adverse effects on clinical outcomes after rotator cuff repair. PURPOSE To compare both the functional and the structural outcomes in patients who underwent arthroscopic rotator cuff repair with or without preoperative CSIs. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective cohort study was carried out among patients who underwent arthroscopic rotator cuff repair for partial- and full-thickness tears between 2015 and 2019. The patients who received preoperative CSIs were included in the CSI group and compared with a group without preoperative CSIs (non-CSI group), matched at a ratio of 1:2 based on tear size, age, and follow-up time. Both functional evaluation and structural assessments using magnetic resonance imaging (MRI) were performed at the final follow-up. Clinical outcomes-including retear rate as the primary outcome; pain; functional scores including the Constant-Murley score, American Shoulder and Elbow Surgeons score, and Fudan University Shoulder Score; range of motion (ROM); tendon integrity; tendon healing type; and cartilage thickness-were compared between the 2 groups with a statistical significance of P < .05 and power of 0.9. RESULTS Thirty-one patients were included in the CSI group, and 62 were included in the non-CSI group. After a mean 3-year follow-up, the 2 groups demonstrated no significant differences in retear rate; visual analog scale for pain; shoulder functional scores; and active ROM including forward flexion, abduction, external rotation, and internal rotation. No significant differences were observed on postoperative MRI scans of the rotator cuff tendon (tendon integrity, healing type, residual tendon attachment area, etc), cartilage thickness, and muscle atrophy. CONCLUSION No significant differences were found at a mean 3-year follow-up in the retear rates, pain, ROM, and glenohumeral structure on postoperative MRI scans after arthroscopic rotator cuff repair with or without preoperative CSIs.
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Affiliation(s)
- Sijia Feng
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Huizhu Li
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuting Zhong
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuxue Xie
- Department of Radiology and Institute of Medical Functional and Molecular Imaging, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuzhou Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Shiyi Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
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17
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National Benchmarks for the Efficacy of Trigger Finger and the Risk Factors Associated With Failure. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202302000-00002. [PMID: 36745544 PMCID: PMC9902002 DOI: 10.5435/jaaosglobal-d-22-00198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 12/10/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to compare the efficacy of single and multiple corticosteroid injections used for symptomatic trigger finger. The rates of subsequent injections and the rate of tendon sheath release are reported along with the identification of risk factors correlated with failure of injection. METHODS A retrospective review of a national healthcare database was conducted identifying patients with a diagnosis of trigger finger or thumb. Inclusion required a tendon sheath injection on the same day or within six weeks of diagnosis. Patient cohorts were further stratified based on treatment success and those requiring additional injections within 6 months or surgery within 1 year of initial diagnosis. RESULTS Thirty-one thousand seven hundred fifty-one patients met inclusion criteria and underwent an initial injection within the study period. The efficacy of initial, second, and third injection was 66.3%, 79.4%, and 79.6%, respectively. Of the patients who failed an injection, 9.4% had tendon sheath release after a primary injection, 23.1% had surgery after a second injection, and 30.4% had surgery after a third injection. Only obesity (OR 1.2; P < 0.0001) and concomitant diagnosis of carpal tunnel syndrome (OR 1.4; P < 0.0001) were found to be significant for injection failure on multivariate logistic regression analysis. DISCUSSION Overall corticosteroid injections were effective in greater than 65% of patients. This information may help guide treatment practice because there seems to be continued additional benefit to repeat corticosteroid injections after injection failure.
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18
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Samson JY, Anderson DN, Hooper TL, Sizer PS, Hando BR, Brismée JM. Safe Administration and Low Healthcare Utilization Following Musculoskeletal Corticosteroid Injections by U. S. Military Physical Therapists. Mil Med 2023; 188:e326-e332. [PMID: 36135723 DOI: 10.1093/milmed/usaa556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/04/2020] [Accepted: 12/12/2020] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Musculoskeletal (MSK) injuries make up a significant proportion of conditions treated by military healthcare providers during wartime. Though many common MSK injuries may benefit from corticosteroid injection (CSI), a shortage of qualified military clinicians has led to diminished access to appropriate care. Longer wait times to receive treatment pose detrimental effects on military readiness and have garnered the attention of military leaders. One solution was the development of advanced training for United States Air Force physical therapists (USAF PTs) to gain clinical privileges in administering CSI. The objectives of this study were to determine in USAF PTs (1) the prevalence of those with privileges to administer CSI; (2) the type and (3) safety of MSK CSI administered; (4) incidence of CSI complications; (5) healthcare utilization following CSI; and (6) barriers to obtaining and practicing CSI privileges. MATERIALS AND METHODS United States Air Force PTs with CSI privileges received instructions to follow a link to an anonymous Google survey. Electronic medical record reviews were conducted by three USAF PTs to determine the occurrence and severity of CSI complications provided by USAF PTs and advanced healthcare providers (AHPs). The principal investigator conducted further review of the patients' electronic medical records to calculate healthcare utilization following CSI administered by USAF PTs. A hospital administrator selected cases of similar diagnoses treated with CSI by USAF AHPs. The number selected cases treated by AHPs are similar to the number of CSI cases treated by USAF PTs. RESULTS Eleven USAF PTs held CSI privileges. No major complications associated with CSI were recorded. Of the 95 CSI cases treated by USAF PTs, 27 (28.4%) reported increased pain compared to 24 (27.9%) of 86 CSI cases treated by AHPs (P = .94). Healthcare utilization for the number of follow-up visits, imaging, and additional laboratory tests following CSI by USAF PTs was lower compared to AHPs (chi-square; P < .0069). CONCLUSION Nine percentage of USAF PTs held CSI privileges. United States Air Force PTs were equally safe as AHPs who administered CSI and associated with a lower rate of healthcare utilization following the intervention. Training USAF PTs to administer CSI could be the standard for all USAF PTs who meet qualification requirements. Adoption of similar training and credentialing policies for civilian PTs warrants further exploration.
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Affiliation(s)
- Jeremiah Y Samson
- Wilford Hall Ambulatory Surgical Center, Lackland, TX 78236, USA.,Department of Physical Therapy Education, Western University of Health Sciences, College of Health Sciences, Lebanon, OR 97355, USA
| | | | - Troy L Hooper
- Center of Rehabilitation Research, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Phillip S Sizer
- Center of Rehabilitation Research, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Benjamin R Hando
- US Air Force Special Warfare Training Wing, Lackland, TX 78242, USA
| | - Jean-Michel Brismée
- Center of Rehabilitation Research, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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19
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Wang JC, Hsu PC, Wang KA, Wu WT, Chang KV. Comparative Effectiveness of Corticosteroid Dosages for Ultrasound-Guided Glenohumeral Joint Hydrodilatation in Adhesive Capsulitis: A Randomized Controlled Trial. Arch Phys Med Rehabil 2022; 104:745-752. [PMID: 36521580 DOI: 10.1016/j.apmr.2022.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To investigate the efficacy of hydrodilatation with 40 mg triamcinolone acetonide (TA) compared with the same procedure with 10 mg TA in patients with adhesive capsulitis (AC) of the shoulders. DESIGN Prospective, double-blind, randomized controlled trial with 12 weeks of follow-up. SETTING Tertiary care rehabilitation center. PARTICIPANTS Eighty-four patients diagnosed with AC (N=84). INTERVENTIONS Ultrasound guidance using (A) hydrodilatation with 4 mL of TA (40 mg)+4 mL 2% lidocaine hydrochloride+12 mL normal saline or (B) hydrodilatation with 1 mL of TA (10 mg)+4 mL 2% lidocaine hydrochloride+15 mL normal saline through the posterior glenohumeral recess. MAIN OUTCOME MEASURES Shoulder Pain and Disability Index (SPADI), visual analog scale (VAS) for pain, and range of motion (ROM) at baseline and at 6 and 12 weeks after injection. RESULTS Both groups experienced improvements in the SPADI score, VAS scores for pain, and ROM throughout the study period. However, group-by-time interactions were not significant for any outcome measurement at any follow-up time point. No adverse events were reported in either group. CONCLUSION Ultrasound-guided hydrodilatation with 40 and 10 mg TA yielded similar improvements in SPADI, VAS score, and ROM at the 12-week follow-up. Considering the potential detrimental effects of corticosteroids on the adjacent cartilage and tendons, a low dose of TA would be preferable for ultrasound-guided hydrodilatation for AC.
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Affiliation(s)
- Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Cheng Hsu
- Department of Physical Medicine and Rehabilitation, West Garden Hospital, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kevin A Wang
- Division of General Surgery, Department of Surgery, Shin-Kong Memorial Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan; Center for Regional Anesthesia and Pain Medicine, Wang-Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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20
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Wolfarth B, Speed C, Raymuev K, Vanden Bossche L, Migliore A. Managing pain and inflammation associated with musculoskeletal disease: time for a change? Curr Med Res Opin 2022; 38:1695-1701. [PMID: 35916625 DOI: 10.1080/03007995.2022.2108618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Bernd Wolfarth
- Department of Sports Medicine, Charité University Hospital and Professor, Humboldt University, Berlin, Germany
| | - Cathy Speed
- Department of Rheumatology, Sport & Exercise Medicine, Spire Cambridge Lea Hospital, Cambridge, UK
| | - Kirill Raymuev
- Department of Rheumatology, North-Western State Medical University I.I. Mechnikov, St Petersburg, Russia
| | - Luc Vanden Bossche
- Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Alberto Migliore
- Department of Medicine, St Peter Fatebenefratelli Hospital, Rome, Italy
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21
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Bourgonjon B, Vermeylen K, Tytgat N, Forget P. Anaesthesia for elite athletes. Eur J Anaesthesiol 2022; 39:825-834. [PMID: 35943185 DOI: 10.1097/eja.0000000000001719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sports participation has been growing rapidly since the 1960s. Anaesthesiologists are increasingly confronted with athletes in a peri-operative setting. The right choice of type of anaesthesia technique, pain management of injuries, specific physiologic adaptations of the athlete and knowledge of prohibited substances are eminent for a correct approach of this subpopulation. PURPOSE This review aims to give an overview of athletes' specific anaesthetic management in peri-operative and postoperative settings and to guide the nonspecialised anaesthetist. METHODS We comprehensively reviewed the literature, gathered all the information available on, and synthesised it in a narrative way, regarding preoperative evaluation, intraoperative implications and postoperative pain management of the elite athlete undergoing a surgical procedure. RESULTS An anaesthesiologist should recognise the most common benign ECG findings in athletes like bradycardia, isolated left ventricle hypertrophy on voltage criteria and early repolarisation as normal features in the athlete's heart. Isotonic physiology typically produces four-chamber dilation. In contrast, isometric stress creates high intravascular pressure leading to left ventricular hypertrophy. Pre-operative evaluation should also identify possible consumers of performance-enhancing drugs. Intraoperative points of interest for the anaesthesiologist is mainly avoiding drugs on the prohibited list of the World Anti-Doping Agency (WADA). Postoperative and chronic pain management are still developing fields in this population. The International Olympic Committee (IOC) proposed treating acute pain with a combination of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, injectable NSAIDs and local anaesthetics. It may be suggested that chronic pain management in elite athletes could benefit from treatment in specialised multidisciplinary pain clinics. CONCLUSION This literature review aims to serve as a guide for the anaesthesiologist taking care of the elite athlete.
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Affiliation(s)
- Bram Bourgonjon
- From the Department of Anaesthesiology, GZA Antwerpen (BB), Department of Anaesthesiology, AZ Turnhout, Turnhout (KV), Department of Anaesthesiology, ASZ Aalst, Aalst, Belgium (NT) and Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen; Department of Anaesthesia, NHS Grampian, Aberdeen, UK (PF)
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22
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Methylprednisolone as an Adjunct to Local Infiltration on Laminoplasty or Laminectomy before Wound Closure: A Randomized Controlled Trial. Pain Res Manag 2022; 2022:2274934. [PMID: 35966574 PMCID: PMC9366200 DOI: 10.1155/2022/2274934] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/15/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022]
Abstract
TrialDesign. Patients undergoing laminoplasty and laminectomy often experience severe postoperative pain. Local infiltration analgesia during spine surgery significantly reduces postoperative pain, which only upholds for a short time. Whether methylprednisolone and local anaesthetics are better than local anaesthetics alone in postoperative analgesia is yet to be determined. The primary aim of this research was the postoperative evaluation of efficacy and safety of methylprednisolone when used as an adjunct to local anaesthesia, ropivacaine, before wound closure after surgical procedures, laminoplasty or laminectomy. Methods. 132 patients were divided with a ratio of 1 : 1 into methylprednisolone-ropivacaine and ropivacaine alone groups. Every 30 ml of local infiltration solution consisted of 15 ml of 1% ropivacaine with 14 ml of saline along with 1 ml of 40 mg methylprednisolone and 15 ml of 1% ropivacaine with 15 ml of saline in methylprednisolone-ropivacaine group and ropivacaine group, respectively. The standardization of the study solution depended on the number of levels involved in surgery. Primary outcome was the 48-hour cumulative sufentanil demand. Results. Demographic characters and surgical variables among the groups were identical. The average 48-hour cumulative sufentanil demand was 32.5 ± 20.6 μg in the methylprednisolone-ropivacaine group and 50.9 ± 27.2 μg in the ropivacaine group (
). The estimated median time of demand of the first analgesia via patient-controlled analgesia (PCA) pump was 2.5 hours and 2 hours in the methylprednisolone-ropivacaine group and the ropivacaine group, respectively (hazard ratio (HR) was 0.53, with 95% Cl 0.33 to 0.87 and Log-rank of
). Conclusion. The infiltration of methylprednisolone as adjunct ropivacaine before wound closure is a safe and efficient strategy for pain management following laminoplasty or laminectomy.
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23
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Iannella L, Comunità F, Botrè F, Colamonici C, Curcio D, de la Torre X, Mazzarino M. Urinary excretion profile of prednisolone and prednisone after rectal administration: significance in antidoping analysis. Drug Test Anal 2022; 14:2007-2016. [PMID: 35921255 PMCID: PMC10087643 DOI: 10.1002/dta.3352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022]
Abstract
The rectal administration of glucocorticoids, as well as any injectable, and oral ones, is currently prohibited by the World Anti-Doping Agency when occurs "in competition". A reporting level of 100 ng/mL for prednisolone and 300 ng/mL for prednisone was established to discriminate the allowed and the prohibited administration. Here, the urinary excretion profiles of prednisone and prednisolone were evaluated in five volunteers in therapy with glucocorticoid-based rectal formulations containing prednisone or prednisolone caproate. The urinary levels of the excreted target compounds were determined by LC-MS/MS following the procedure validated and currently in use in our laboratory to detect and quantitate glucocorticoids in urine. Predictably, the excretion trend of the analytes of interest were generally comparable to those obtained after oral administration, even if the excretion profile showed a broad inter-individual variability, with the absorption rate and the systemic bioavailability after rectal administration being strongly influenced by the type of formulations (suppository or rectal cream, in our case) as well as the physiological conditions of the absorption area. Results showed that the target compounds were detectable for at least 30 hours after drug administration. After suppository administration, prednisolone levels reached the maximum after 3 hours from drug administration, and then dropped below the reporting level after 15-21 hours; prednisone reached the maximum after 3 hours from drug administration, and then dropped below the reporting level after 12-15 hours. After cream administration both prednisone and prednisolone levels remained in a concentration below the reporting level throughout the entire monitored period.
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Affiliation(s)
- Loredana Iannella
- Laboratorio Antidoping, Federazione Medico Sportiva Italiana, Rome, Italy
| | - Fabio Comunità
- Laboratorio Antidoping, Federazione Medico Sportiva Italiana, Rome, Italy
| | - Francesco Botrè
- Laboratorio Antidoping, Federazione Medico Sportiva Italiana, Rome, Italy.,REDs - Research and Expertise in anti-Doping sciences, ISSUL - Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | | | - Davide Curcio
- Laboratorio Antidoping, Federazione Medico Sportiva Italiana, Rome, Italy
| | - Xavier de la Torre
- Laboratorio Antidoping, Federazione Medico Sportiva Italiana, Rome, Italy
| | - Monica Mazzarino
- Laboratorio Antidoping, Federazione Medico Sportiva Italiana, Rome, Italy
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24
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Marcoux JT, Tong L. Fibrocartilaginous Tissue: Why Does It Fail to Heal? Clin Podiatr Med Surg 2022; 39:437-450. [PMID: 35717061 DOI: 10.1016/j.cpm.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tendons and ligaments are critical components in the function of the musculoskeletal system, as they provide stability and guide motion for the biomechanical transmission of forces into bone. Several common injuries in the foot and ankle require the repair of ruptured or attenuated tendon or ligament to its osseous insertion. Understanding the structure and function of injured ligaments and tendons is complicated by the variability and unpredictable nature of their healing. The healing process at the tendon/ligament to bone interface is challenging and often frustrating to foot and ankle surgeons, as they have a high failure rate necessitating the need for revision.
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Affiliation(s)
- John T Marcoux
- Division of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Span 3, Boston, MA 02215, USA.
| | - Lowell Tong
- Division of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Span 3, Boston, MA 02215, USA
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25
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Novel Motor-Sparing Ultrasound-Guided Neural Injection in Severe Carpal Tunnel Syndrome: A Comparison of Four Injectates. BIOMED RESEARCH INTERNATIONAL 2022; 2022:9745322. [PMID: 35224104 PMCID: PMC8872692 DOI: 10.1155/2022/9745322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/30/2021] [Indexed: 11/17/2022]
Abstract
Nerve hydrodissection uses fluid injection under pressure to selectively separate nerves from areas of suspected entrapment; this procedure is increasingly viewed as potentially useful in treating carpal tunnel syndrome (CTS). The usage of normal saline (NS), 5% dextrose water (D5W), platelet-rich plasma (PRP), and hyaluronic acid (HA) as primary injectates for hydrodissection without an anesthetic can limit anesthetic-related toxicity and preserve the motor functions of the median nerve. Here, we describe a novel motor-sparing neural injection and compare the effect of these four injectates for severe CTS. We retrospectively reviewed the outcomes of 61 severe CTS cases after a single neural injection with NS, D5W, PRP, or HA. Outcomes were evaluated on the 1st and 6th months postinjection, including the Boston Carpal Tunnel Questionnaire (BCTQ) scores and the nerve cross-sectional area (CSA). The results revealed that PRP, D5W, and HA were more efficient than NS at all measured time points (
), except for CSA at the 1st month between the NS and D5W groups. Single-injections of PRP and D5W seemed more effective than that of HA within 6 months postinjection for symptom and functional improvement (6th-month BCTQ-symptom, D5W vs. HA,
; 1st-month BCTQ-symptom, PRP vs. HA,
; 1st- and 6th-month BCTQ-function, D5W vs. HA,
and 0.016, respectively; 1st-month BCTQ-function, PRP vs. HA,
). For reducing CSA, PRP and HA seemed more effective than D5W (
on the 1st month and HA vs. D5W,
;
on the 6th month and PRP vs. D5W,
).
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26
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Poor AE, Warren A, Zoga AC, Meyers WC, Roedl JB. Ultrasound-guided Procedures Allow Delay of Definitive Treatment for Core Muscle Injuries. Med Sci Sports Exerc 2022; 54:206-210. [PMID: 34559722 DOI: 10.1249/mss.0000000000002785] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Core muscle injuries (CMI) are common in every sport. To minimize lost playing time, providers apply various nonsurgical treatments, including platelet-rich plasma, corticosteroids, ultrasound (US)-guided percutaneous tenotomy, and prolotherapy. Limited data exist with regard to their effectiveness. We chose to review a cohort of consecutive professional and collegiate athletes who sustained CMI at various points within their seasons and underwent a combination of US-guided percutaneous needle "tenotomy" and corticosteroid injections to complete the remainder of their seasons. METHODS Twenty-five consecutive collegiate or professional athletes with CMI involving the rectus abdominis-adductor aponeurotic plate were included in this retrospective study. Athletes with concomitant symptomatic hip femoroacetabular impingement were included in the study. The primary outcome measure was whether athletes completed their seasons. Secondary measures were weeks played after the procedures (delay until surgery), need for repeat procedures, and outcomes after eventual surgery. Postoperative performance was assessed via interviews at 6 wk and 6 months postoperatively. RESULTS Twenty-one of 25 (84%) athletes completed their seasons. On average, athletes returned to play 3 d (range, 1-9 d) after the procedures. Surgical repair was delayed a mean of 18 wk (range, 2-44 wk). Seven athletes had concomitant symptomatic femoroacetabular impingement and six underwent combined hip arthroscopy and core muscle repairs. Among 17 patients who eventually had core muscle surgery alone (no hip surgery), 82% (14 of 17) reported performing at their preinjury level at 6 wk. At 6 months, 96% of postop athletes (22 of 23) reported performing at their preinjury level. CONCLUSIONS Temporizing CMI with US-guided percutaneous tenotomy and corticosteroid injections is effective in allowing continued sport participation among high-level athletes and does not negatively affect postoperative outcomes.
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Affiliation(s)
| | | | - Adam C Zoga
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Johannes B Roedl
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
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Lalehzarian SP, Agarwalla A, Liu JN. Management of proximal biceps tendon pathology. World J Orthop 2022; 13:36-57. [PMID: 35096535 PMCID: PMC8771414 DOI: 10.5312/wjo.v13.i1.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/10/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.
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Affiliation(s)
- Simon P Lalehzarian
- The Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, United States
| | - Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Joseph N Liu
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA 90033, United States
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Hynes JP, Kavanagh EC. Complications in image-guided musculoskeletal injections. Skeletal Radiol 2022; 51:2097-2104. [PMID: 35622087 PMCID: PMC9463191 DOI: 10.1007/s00256-022-04076-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/17/2022] [Accepted: 05/17/2022] [Indexed: 02/02/2023]
Abstract
Complications in musculoskeletal interventions are rare and where they do occur tend to be minor, and often short-lived or self-limiting. Nonetheless, the potential for significant complications exists, and a thorough understanding of both the mechanisms which contribute and the manner in which they may clinically present is of critical importance for all musculoskeletal radiologists involved in performing procedures, both to mitigate against the occurrence of complications and to aid rapid recognition. The purpose of this review is to analyse the relevant literature to establish the frequency with which complications occur following musculoskeletal intervention. Furthermore, we highlight some of the more commonly discussed and feared complications in musculoskeletal intervention, such as the risk of infection, potential deleterious articular consequences including accelerated joint destruction and the poorly understood and often underestimated systemic effects of locally injected corticosteroids. We also consider both extremely rare but emergent scenarios such as anaphylactic reactions to medications, and much more common but less significant complications such as post-procedural pain. We suggest that meticulous attention to detail including strict adherence to aseptic technique and precise needle placement may reduce the frequency with which complications occur.
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Affiliation(s)
- John P. Hynes
- Department of Radiology, National Orthopaedic Hospital Cappagh, Finglas, Dublin 11, Republic of Ireland
| | - Eoin C. Kavanagh
- Department of Radiology, National Orthopaedic Hospital Cappagh, Finglas, Dublin 11, Republic of Ireland
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Bedrin MD, Putko RM, Dickens JF. Analgesia in Athletes: A Review of Commonly Used Oral and Injectable Modalities. Sports Med Arthrosc Rev 2021; 29:e71-e76. [PMID: 34730120 DOI: 10.1097/jsa.0000000000000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pain is common among athletes at all levels and the treatment of pain can be a challenging and frustrating task. The team physician needs a fundamental knowledge of analgesic strategies as it relates to athletes. It is important to understand the mechanism of action, side effect profile/associated complications, incidence of and indications for use, as well as the controversies associated with the most common analgesic medications used in sports medicine. Several "in vogue" treatment modalities, including cannabidiol, are also becoming more commonly used and are worth discussion.
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de Sire A, Marotta N, Lippi L, Scaturro D, Farì G, Liccardi A, Moggio L, Letizia Mauro G, Ammendolia A, Invernizzi M. Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111208. [PMID: 34833426 PMCID: PMC8618079 DOI: 10.3390/medicina57111208] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 12/14/2022]
Abstract
Pain management is a crucial issue for athletes who train and compete at the highest performance levels. There are still evidence gaps for the use of analgesics for sports injuries despite the growing interest in training and competition settings. However, high-quality research is needed to determine the most appropriate and optimal timing and formulations in non-steroidal anti-inflammatory drug and opioid management, particularly given the strictness of anti-doping regulations. Indeed, the role of pharmacological therapy in reducing acute traumatic pain in athletes should still be addressed to minimize the timing of return to sport. Therefore, the aim of this comprehensive review was to summarize the current evidence about pain management in the setting of acute injury in elite athletes, providing the most informed strategy for pain relief and performance recovery.
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Affiliation(s)
- Alessandro de Sire
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (N.M.); (L.M.); (A.A.)
- Correspondence: ; Tel.: +39-0961712819
| | - Nicola Marotta
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (N.M.); (L.M.); (A.A.)
| | - Lorenzo Lippi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont, 28100 Novara, Italy; (L.L.); (M.I.)
| | - Dalila Scaturro
- Physical and Rehabilitative Medicine, Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, 90100 Palermo, Italy; (D.S.); (G.L.M.)
| | - Giacomo Farì
- Motor and Sports Sciences, Department of Sciences and Biological and Environmental Technologies, Salento University, 73100 Lecce, Italy;
| | - Alfonso Liccardi
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy;
| | - Lucrezia Moggio
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (N.M.); (L.M.); (A.A.)
| | - Giulia Letizia Mauro
- Physical and Rehabilitative Medicine, Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, 90100 Palermo, Italy; (D.S.); (G.L.M.)
| | - Antonio Ammendolia
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (N.M.); (L.M.); (A.A.)
| | - Marco Invernizzi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont, 28100 Novara, Italy; (L.L.); (M.I.)
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
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Schiffke-Juhász B, Knobloch K, Vogt PM, Hoy L. Proprioceptive elbow training reduces pain and improves function in painful lateral epicondylitis-a prospective trial. J Orthop Surg Res 2021; 16:468. [PMID: 34315508 PMCID: PMC8314578 DOI: 10.1186/s13018-021-02602-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In painful epicondylitis, previous studies reported deficiencies in elbow proprioception. In line, proprioceptive training of the lower limb has been reported substantial beneficial in a number of indications. Therefore, we have asked if a specified proprioceptive training using training devices that are capable of activating the deep musculature in the upper limb is able to reduce the symptoms of epicondylitis. MATERIALS AND METHODS We included 71 patients with painful lateral epicondylitis > 3 months. INTERVENTIONS Group A: Proprioceptive training intervention with a Flexibar® (9 min daily for 12 weeks). Group B: at least 40 min running or walking/week with the XCO® in addition to the proprioceptive training with the Flexibar® (9 min daily for 12 weeks), follow-up for 12 weeks. Primary end point: Pain on visual analogue scale (VAS, 0-10); secondary end points: DASH-Score (0 = very good, 100 = very poor), grip strength according to Jamar dynamometer (kg), vibration sensation measured with a 128 Hz tuning fork. RESULTS The pain on VAS in group A was reduced significantly. 3.6 ± 2.0 to 2.4 ± 2.1 (-33%, p = 0.013), and from 3.7 ± 2.4 to 2.2 ± 1.9 (-41%, p = 0.004) in group B after 12 weeks. There was no significant difference between A and B (p = 0.899). In both groups, there was a significant improvement of the DASH-Score (A: 32 ± 15 to 14 ± 12, -56%, p < 0.001; B: 27 ± 12 to 12 ± 11, -55%, p = 0.001) without any difference between groups A and B (p = 0.339). Grip strength improvement in group A from 24 ± 12 to 33 ± 11 kg (+38%, p < 0.001), and from 29 ± 14 to 34 ± 11 kg (+15%, p < 0.001) in group B. In line, vibration sensation improved in both groups (A: 6.3 ± 0.6 to 6.5 ± 0.5, p = 0.0001; B: 6.3 ± 0.7 to 6.6 ± 0.5, p = 0.003). CONCLUSION A 12-week proprioceptive training with the Flexibar® improves pain, quality of life, grip strength and vibration sensation in patients with painful lateral epicondylitis. LEVEL OF EVIDENCE Ib, randomised clinical trial TRIAL REGISTRATION: German Clinical Trials Register, DRKS00024857 , registered on 25 March 2021-retrospectively registered, http://apps.who.int/trialsearch/.
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Affiliation(s)
| | | | - P M Vogt
- Formerly Medizinische Hochschule Hannover, Hannover, Germany
| | - L Hoy
- Medizinische Hochschule Hannover, Hannover, Germany
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Goh TS, Ahn TY, Kim K, Shin WC, Moon NH, Woo SH. Outcome of triamcinolone acetonide injection for lateral malleolar bursitis. J Orthop Surg (Hong Kong) 2021; 28:2309499020952893. [PMID: 32873149 DOI: 10.1177/2309499020952893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE This study aimed to evaluate the feasibility and effect of triamcinolone acetonide (TA) injection for lateral malleolar (LM) bursitis. METHODS We retrospectively reviewed data of 49 consecutive patients (49 ankles) who received TA injection between March 2016 and March 2019. All cases received 1 ml (40 mg) of TA injection after aspiration of fluid in the LM bursal sac. Subsequently, the ankle was compressed with an elastic cohesive bandage for 2 weeks. Treatment responses were assessed according to the degree of fluctuation, shrinkage of the bursal sac, and soft tissue swelling. We used the Medical Outcomes Study Short Form Health Survey (SF-36) and complications at 2 and 4 weeks and at 3 and 6 months after TA injection. RESULTS Forty-four patients (89.8%) experienced complete resolution, four (8.2%) had partial resolution, and one (2.0%) had no resolution after the first or second TA injection. The physical component scores of SF-36 improved from 72.8 ± 6.0 to 82.3 ± 6.5 at the last follow-up (p < 0.001). Associated complications included skin atrophy in three patients (6.1%) and transient hyperglycemia in four (8.2%). CONCLUSION TA injection is an effective and safe procedure for LM bursitis. It should be considered as a primary treatment method.
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Affiliation(s)
- Tae Sik Goh
- Department of Orthopedic Surgery and Biomedical Research Institute, 220312Pusan National University Hospital, Seo-gu, Busan, Republic of Korea
| | - Tae Young Ahn
- Department of Orthopedic Surgery and Biomedical Research Institute, 220312Pusan National University Hospital, Seo-gu, Busan, Republic of Korea
| | - Kyeongbaek Kim
- Department of Orthopedic Surgery, 194197Pusan National University Yangsan Hospital, Mulgeum-eup, Yangsan, Republic of Korea
| | - Won Chul Shin
- Department of Orthopedic Surgery, 194197Pusan National University Yangsan Hospital, Mulgeum-eup, Yangsan, Republic of Korea
| | - Nam Hoon Moon
- Department of Orthopedic Surgery and Biomedical Research Institute, 220312Pusan National University Hospital, Seo-gu, Busan, Republic of Korea
| | - Seung Hun Woo
- Department of Orthopedic Surgery, 194197Pusan National University Yangsan Hospital, Mulgeum-eup, Yangsan, Republic of Korea
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Abstract
CONTEXT Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety. EVIDENCE ACQUISITION An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections, athletes, sports, foot and ankle, corticosteroids, platelet-rich plasma, and placental tissue. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results. CONCLUSIONS Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.
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Affiliation(s)
- Jonathan K Ochoa
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, California
| | - Christopher E Gross
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - Robert B Anderson
- Bellin Health Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin
| | - Andrew R Hsu
- Department of Orthopaedic Surgery, University of California-Irvine, Orange, California
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Haunschild ED, Gilat R, Fu MC, Condron N, Cole BJ. Biologics in shoulder and elbow pathology. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:1-6. [PMID: 37588635 PMCID: PMC10426570 DOI: 10.1016/j.xrrt.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
In recent years, orthobiologics have been of increasing clinical interest in the treatment of shoulder and elbow pathology. In some conditions, such as rotator cuff injury and lateral epicondylitis, there have been high-quality trials that support the use of platelet-rich plasma in reducing pain, restoring functionality, and improving clinical outcomes. However, as the numbers of both cellular-based biologics and the conditions being augmented by biologics continue to expand, there is a substantial need for high-quality investigations to support their routine use in most shoulder and elbow conditions. The purpose of this review is to summarize the current evidence of orthobiologics in the management of shoulder and elbow injury, as nonoperative treatment and as augments to operative treatment.
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Affiliation(s)
| | - Ron Gilat
- Midwest Orthopaedics at Rush, Chicago, IL, USA
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Giovannetti de Sanctis E, Franceschetti E, De Dona F, Palumbo A, Paciotti M, Franceschi F. The Efficacy of Injections for Partial Rotator Cuff Tears: A Systematic Review. J Clin Med 2020; 10:jcm10010051. [PMID: 33375716 PMCID: PMC7795404 DOI: 10.3390/jcm10010051] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 01/10/2023] Open
Abstract
(1) Background: Even though rotator cuff tears are the most frequent tendon injuries in adults, the effectiveness of conservatively treated partial-thickness tears still remains a matter of debate. The purpose of this review is to compare corticosteroid injections to other drugs in the treatment of partial rotator cuff tears, focusing on the effectiveness of this therapeutic modality in terms of pain and shoulder functionality. (2) Methods: A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. All studies comparing the use of corticosteroids and other infiltrative techniques in the treatment of partial lesions (excluding studies that considered subacromial impingement as inclusion criteria) were pooled, data were extracted and statistically analyzed. (3) Results: Nine studies were included in this systematic review. Those studies, composed by a total of 494 shoulders treated, have been published from 1985 to 2019. All compared techniques have shown a significant improvement over baseline condition. PRP (Platelet Rich Plasma) injections have been shown to be significantly more effective in both functional and pain control only in the long term. (4) Conclusions: None of the techniques prevail indisputably on the others. Anyway, the treatment of partial rotator cuff tears with PRP injections seems to lead to significantly better outcomes in terms of pain and shoulder function in long term follow up. Whereas in short and medium term follow up, PRP injections was superior only in terms of shoulder function. The small number of studies on prolotherapy did not enable us to provide an opinion on the outcomes of this technique.
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Affiliation(s)
- Edoardo Giovannetti de Sanctis
- Department of Orthopaedics and Traumatology, Catholic University, Agostino Gemelli Hospital, 00164 Rome, Italy
- Correspondence: ; Tel.: +39-331-963-1117
| | - Edoardo Franceschetti
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128 Rome, Italy; (E.F.); (F.D.D.); (A.P.); (M.P.)
| | - Ferdinando De Dona
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128 Rome, Italy; (E.F.); (F.D.D.); (A.P.); (M.P.)
| | - Alessio Palumbo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128 Rome, Italy; (E.F.); (F.D.D.); (A.P.); (M.P.)
| | - Michele Paciotti
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128 Rome, Italy; (E.F.); (F.D.D.); (A.P.); (M.P.)
| | - Francesco Franceschi
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy;
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[Etiology, pathogenesis, clinical features, diagnostics and conservative treatment of adult flatfoot]. DER ORTHOPADE 2020; 49:942-953. [PMID: 33034668 DOI: 10.1007/s00132-020-03995-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND On average, one in six adults is affected by an acquired flatfoot. This foot deformity is characterized by its progression of stages and in 10% of cases causes complaints that require treatment. Untreated, the loss of walking ability may result in the final stage. Correct staging is crucial to being able to offer a specific course of therapy including a wide spectrum of conservative and operative treatments. MATERIAL AND METHODS This review is based on pertinent publications retrieved from a selective search in PubMed and Medline and on the authors' clinical experience. DIAGNOSTICS The loss of function of static (spring ligament complex) and dynamic (tibialis posterior tendon) stabilizers causes the characteristic deformity with loss of the medial arch, hind foot valgus and forefoot abduction. In the late stage, severe secondary osteoarthritis in upper and lower ankle joints occurs and impedes walking ability. The essential physical examination is supplemented by weight-bearing dorsoplantar and lateral radiographs, which provide further information about axial malalignment (Meary's angle, Kite's angle). The long axis hind foot view allows analysis of the hindfoot valgus. MRI provides further information about the integrity of the tibialis posterior tendon, spring ligament complex and cartilage damage. THERAPY The therapy aims to reduce pain, regain function and avoid development of secondary osteoarthritis and degenerative tendon disorders. Progress of the deformity should be stopped. Therefore, the main aspects of the deformity-loss of medial arch, hindfoot valgus and forefoot abduction should be addressed and corrected. In the acute phase, tendovaginitis of the tibialis posterior tendon can be treated sufficiently by anti-inflammatory measures, relieving mechanical loads on the tendon and muscle and physiotherapy.
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Wojtys EM. Drugs in Sports. Sports Health 2020; 12:516-517. [DOI: 10.1177/1941738120963385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair. Orthop Traumatol Surg Res 2020; 106:1159-1166. [PMID: 32826188 DOI: 10.1016/j.otsr.2020.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Multimodal analgesic (MMA) injections combined with corticosteroids have recently been shown to be effective for managing pain after arthroscopic rotator cuff repair. HYPOTHESIS The goal of this study was to analyze the effects of corticosteroid injections on the integrity of tendon repairs using magnetic resonance imaging (MRI). The hypothesis was that MMA injections combined with corticosteroids have no deleterious effects on functional outcomes and tendon healing 1 year after surgical rotator cuff repair. METHODS This was a prospective, double-blind study of 50 patients undergoing arthroscopic rotator cuff repair who were randomized into two groups. The study group (n=25) received a periarticular injection of a mixture of ropivacaine, morphine and methylprednisolone at the end of the procedure. The control group (n=25) received a placebo injection. The clinical outcomes were the pain level and complications, while the functional outcomes consisted of the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder (ASES) score and Simple Shoulder Test (SST). The structural integrity of the operated tendons was analyzed on MRI at a mean follow-up of 15.1±1.3 months for the study group and 15.2±1.1 for the control group (p=0.848). RESULTS Pain on a visual analog scale was significantly reduced in both groups after the surgery. Nevertheless, there was no significant difference between groups at the final follow-up visit (p=0.803). Compared to the preoperative values, the CMS, ASES and SST significantly improved in both groups after surgery but were not significantly different between groups at the final assessment (p=0.801, 0.869 and 0.769, respectively). MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group (p=0.107). There were no infections in the study group as of the final assessment. Advanced age (p=0.049), diabetes (p<0.01) and posterior extension of the tear (p=0.039) negatively impact healing. Corticosteroid injection did not negatively impact healing (p=0.197). CONCLUSION This study shows that MMA injection combined with corticosteroids does not alter the tendon healing, clinical outcomes, or functional outcomes 1 year after arthroscopic rotator cuff repair. It remains a safe and effective analgesia method during rotator cuff repair surgery. LEVEL OF EVIDENCE II, low-powered placebo-controlled, randomized study.
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Mao LJ, Crudup JB, Quirk CR, Patrie JT, Nacey NC. Impact of fluoroscopic injection location on immediate and delayed pain relief in patients with greater trochanteric pain syndrome. Skeletal Radiol 2020; 49:1547-1554. [PMID: 32361853 DOI: 10.1007/s00256-020-03451-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECT The purpose of this study was to assess whether fluoroscopically guided corticosteroid injections into the extrabursal tissues, trochanteric (subgluteus maximus) bursa, or subgluteus medius bursa provide better immediate and short-term pain relief. MATERIALS AND METHODS All fluoroscopically guided corticosteroid injections performed over a 67-month period for greater trochanteric pain syndrome were retrospectively reviewed. Procedural images were reviewed by two musculoskeletal radiologists to determine the dominant injection site based on final needle positioning and contrast spread pattern, with discrepancies resolved by consensus. Statistical analysis of the association between pain score reduction and dominant injection site was performed. RESULTS One hundred forty injections in 121 patients met the inclusion criteria. The immediate and 1-week post-injection pain reduction was statistically significant for trochanteric bursa, subgluteus medius bursa, and non-bursal injections. However, there was no statistically significant difference in the degree of pain reduction between the groups. There was statistically significant increase in the 1-week post-injection mean pain score compared with immediate post-injection mean pain score in the subgluteus medius bursa and non-bursal injection groups (p < 0.01) but not in the trochanteric bursa group. CONCLUSION Fluoroscopy is frequently chosen over blind injection or ultrasound guidance for trochanteric steroid injections in patients with a high body mass index. Our results indicate that fluoroscopically guided steroid injections into the trochanteric bursa and subgluteus medius bursa significantly reduced immediate and 1-week post-injection pain scores, as do non-bursal injections. Steroid injection into the subgluteus medius bursa and non-bursal sites may be less effective in maintaining pain reduction at 1-week post-injection.
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Affiliation(s)
- Lisa J Mao
- Kaiser Permanente Northern California, Sacramento, CA, USA
| | | | - Cody R Quirk
- Medical University of South Carolina, Charleston, SC, USA
| | - James T Patrie
- University of Virginia Public Health Sciences, Charlottesville, VA, USA
| | - Nicholas C Nacey
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
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Abstract
The Gaelic sports of hurling and football, native to Ireland, are increasing in popularity worldwide. The injury profile of these sports requires multidisciplinary management by sports physicians, orthopaedic surgeons, and musculoskeletal (MSK) radiologists, among others. Advances in imaging modalities and interventional techniques have aided the diagnosis and treatment of sport injuries. In this article, we review the literature and our own institutional experience to describe common injury patterns identified in Gaelic games athletes, their main imaging features and relevant therapeutic interventions. We discuss the increasing prevalence of imaging services at sporting events and the central role of MSK radiologists in sports injury management.
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Affiliation(s)
- Charles J Sullivan
- Department of Radiology, National Orthopaedic Hospital Cappagh, Finglas, Dublin, Ireland
| | - Eoin C Kavanagh
- Department of Radiology, National Orthopaedic Hospital Cappagh, Finglas, Dublin, Ireland.,Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
| | - Stephen J Eustace
- Department of Radiology, National Orthopaedic Hospital Cappagh, Finglas, Dublin, Ireland.,Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
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Jelsema TR, Tam AC, Moeller JL. Injectable Ketorolac and Corticosteroid Use in Athletes: A Systematic Review. Sports Health 2020; 12:521-527. [PMID: 32877323 DOI: 10.1177/1941738120946008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT The use of injectable medications to help athletes quickly return to the field of play after injury is common. Understanding the effects and risks of these medications will help providers make informed decisions regarding their use in this patient population. OBJECTIVE To evaluate the utilization, efficacy, and adverse effects of injectable ketorolac and corticosteroids in athletes. DATA SOURCES This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search of the literature was performed using multiple databases (PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov). Secondary references were appraised for relevant articles. No randomized controlled trials or other prospective studies were identified. Articles included retrospective database reviews and physician survey studies. STUDY SELECTION A total of 6 studies met the inclusion and exclusion criteria and were reviewed by 2 independent reviewers with a third consulted in the case of disagreement, which was not needed. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 5. DATA EXTRACTION Two reviewers recorded rate of use, effectiveness of treatment, and reported side effect data. RESULTS Most studies centered around the football athlete, either professional or collegiate. Professional football game day use of intramuscular ketorolac declined from 93.3% (28/30) in 2002 to 48% in 2016. Collegiate football game day use of intramuscular ketorolac declined from 62% in 2008 to 26% in 2016. Game day corticosteroid injection was far lower than ketorolac usage. Both medications were reported to be effective with few adverse events. CONCLUSION Use of injectable ketorolac is common but declining in professional and college football. Pain control efficacy is good, and risk of adverse events is low. The incidence of injectable corticosteroid use in athletes is unknown. Use of injectable corticosteroids in athletes allows for early return to sport activities with no reported complications.
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Affiliation(s)
- Timothy R Jelsema
- Division of Sports Medicine, Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Anthony C Tam
- Division of Sports Medicine, Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - James L Moeller
- Division of Sports Medicine, Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
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Auriemma MJ, Tenforde AS, Harris A, McInnis KC. Platelet-rich plasma for treatment of chronic proximal hamstring tendinopathy. Regen Med 2020; 15:1509-1518. [PMID: 32419631 DOI: 10.2217/rme-2019-0105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Aim: To determine whether platelet-rich plasma (PRP) can successfully treat symptoms associated with proximal hamstring tendinopathy. Materials & methods: Charts were retrospectively reviewed of patients with a diagnosis of chronic proximal hamstring tendinopathy who underwent an ultrasound-guided leukocyte-rich PRP injection to assess reported outcomes at baseline and final follow-up post-intervention. Results: In 22 patients with a mean age of 48.7 years and mean symptom duration of 26.5 months, mean Numeric Pain Rating Scale and Victorian Institute of Sport Assessment Scale for Proximal Hamstring Tendinopathy subscores demonstrated statistically significant improvements (p < 0.05) at a mean of 7.91 months follow-up. Sixty-eight percent of patients demonstrated ≥50% reduction of pain. Conclusion: Pain and functional outcomes improved following injection of PRP.
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Affiliation(s)
- Michael J Auriemma
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.,Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, USA
| | - Adam S Tenforde
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.,Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, USA
| | - Adam Harris
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.,Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, USA
| | - Kelly C McInnis
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.,Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, USA.,Department of Sports Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
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Gerhardt MB, Robinson S. Editorial Commentary: Intra-articular Injection for Osteoarthritis-Is It Hip or Not? Arthroscopy 2020; 36:1465-1467. [PMID: 32370907 DOI: 10.1016/j.arthro.2020.03.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023]
Abstract
Intra-articular injections are commonly used in the treatment algorithm for osteoarthritis of the hip. A number of different adjuvants can be used, such as corticosteroids, hyaluronic acid, and platelet-rich plasma, but there is no consensus regarding indications for or anticipated outcomes of each of these interventions. Recent data suggest that corticosteroids provide the best relief in the short term whereas platelet-rich plasma may be more beneficial in the mid term, but the results are variable. Ultimately, more rigorous studies are needed to evaluate these adjuvants, in particular biologics, while remaining fastidious with our indications for injection therapy.
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Glucocorticoid prescribing habits of sports medicine physicians working in high-performance sport: a 30-nation survey. Br J Sports Med 2020; 54:402-407. [DOI: 10.1136/bjsports-2019-101175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2020] [Indexed: 11/03/2022]
Abstract
ObjectivesGlucocorticoids are commonly prescribed in medicine. When administered via certain routes, glucocorticoids are prohibited for incompetition use by WADA. The glucocorticoid prescribing habits of sports medicine doctors have not been reported.MethodsAn online survey was distributed internationally to physicians working in high-performance sports. The survey queried the doctors about their use of glucocorticoids with athletes and their understanding of WADA’s regulations regarding glucocorticoid use in competition.Results603 sports medicine doctors from 30 different countries participated. The majority (>85%) routinely injected glucocorticoids and/or prescribed glucocorticoids by other routes. There were substantial differences in the common routes of injection as well as types of glucocorticoid used among the physicians from various countries. A relatively small percentage of sports doctors (<25%) accurately identified which routes of glucocorticoid administration are prohibited in competition by WADA. There was a great variation in how long before competition the use of glucocorticoids would cause the doctor to consider applying for a therapeutic use exemption (TUE). A better understanding of the clearance rates of glucocorticoids from athletes’ bodies would greatly aid sports medicine doctors’ decisions on how and when to apply for a TUE. A small number of doctors had observed side effects of glucocorticoid administration, with the majority of side effects being minor in nature.ConclusionGlucocorticoids are widely prescribed by sports physicians. There is a need to better educate sports physicians on the current WADA regulations in relation to glucocorticoid administration.
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Bedi A, Trinh TQ, Olszewski AM, Maerz T, Ramme AJ. Nonbiologic Injections in Sports Medicine. JBJS Rev 2020; 8:e0052. [PMID: 32224626 DOI: 10.2106/jbjs.rvw.19.00052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Nonbiologic medications (local anesthetics, corticosteroids, and nonsteroidal anti-inflammatory drugs) are commonly administered to athletes for analgesia after injury. However, the risks of nonbiologic injections often are overlooked simply because of their long-term market availability.
A thorough understanding of the mechanism of action, the reported benefits, and the potential risks of nonbiologic medications is crucial prior to their use, especially in the treatment of young athletes. Sports medicine physicians and surgeons must be aware of the systemic and local effects of these medications to ensure an appropriate drug choice that minimizes side effects and avoids recently reported toxicity to myocytes, tenocytes, and chondrocytes.
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Affiliation(s)
- Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Thai Q Trinh
- Department of Orthopaedic Surgery, Genesis Healthcare, Zanesville, Ohio
| | - Adam M Olszewski
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Tristan Maerz
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Austin J Ramme
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.,Steindler Orthopedic Clinic, Iowa City, Iowa
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Stenroos AJ, Brinck T. Achilles Tendon Reconstruction with Semitendinous Tendon Grafts Is Associated with a High Complication Rate. J Am Podiatr Med Assoc 2020; 110:436389. [PMID: 32556230 DOI: 10.7547/18-014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND In the presence of a large gap where end-to-end repair of the torn Achilles tendon is difficult and V-Y advancement would likely be insufficient, augmentation is sometimes required. At our institute we have used primarily the hamstring autograft augmentation technique for the past two decades. The aim of this study was to analyze the complications after surgical treatment of Achilles tendon rupture with semitendinous tendon augmentation. METHODS We retrospectively analyzed 58 consecutive patients treated with semitendinous tendon autograft augmentation at the Helsinki University Hospital between January 1, 2006, and January 1, 2016. RESULTS During the study period, 58 patients were operated on by six different surgeons. Of 14 observed complications (24%), seven were major and seven were minor. Most of the complications were infections (n = 10 [71%]) The infections were noted within a mean of 62 days postoperatively (range, 22-180 days). Seven patients with a complication underwent repeated operation because of skin edge necrosis and deep infection (five patients), hematoma formation (one patient), and a repeated rupture (one patient). CONCLUSIONS In light of the experience we have had with autologous semitendinous tendon graft augmentation, we cannot recommend this technique, and, hence, we should abandon reconstruction of Achilles tendon ruptures with autologous semitendinous tendon grafts at our institute. Instead, other augmentation techniques, such as flexor hallucis longus tendon transfer, should be used.
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Affiliation(s)
- Antti J Stenroos
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
| | - Tuomas Brinck
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
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Desai MJ, Mansfield JT, Robinson DM, Miller BC, Borg-Stein J. Regenerative Medicine for Axial and Radicular Spine-Related Pain: A Narrative Review. Pain Pract 2020; 20:437-453. [PMID: 31869517 DOI: 10.1111/papr.12868] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/03/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Regenerative injection-based therapy has established itself as a therapeutic option for the management of a variety of painful musculoskeletal conditions. The aim of this work was to review the current literature regarding regenerative injection therapy for axial/radicular spine pain. METHODS A comprehensive literature review was conducted on the use of regenerative medicine for axial/radicular spine pain. Eligible articles analyzed the therapeutic injection effects of platelet-rich plasma (PRP), prolotherapy, or mesenchymal signaling cells (MSCs) via intradiscal, facet joint, epidural, or sacroiliac joint delivery. RESULTS Regarding intradiscal PRP, there are level I/IV studies supporting its use. Regarding intradiscal prolotherapy, there are level III to IV studies supporting its use. Regarding intradiscal MSCs, there are level I/IV studies supporting its use with the exception of one level IV study that found no significant improvement at 12 months. Regarding facet joint injections with PRP, there are level I/IV studies supporting its use. Regarding facet joint injections with prolotherapy, there are level IV studies supporting its use, though the one level I study did not demonstrate any statistical significance supporting its use. Regarding epidural injections with PRP, there are level I/IV studies supporting its use. Regarding epidural injections with prolotherapy, there are level IV studies supporting its use, though the one level I study did not demonstrate statistical significance beyond 48 hours. Regarding sacroiliac joint injections with PRP, there are level I/IV studies supporting its use. Regarding sacroiliac joint injections with prolotherapy, there are level I/III studies supporting its use. CONCLUSIONS Currently, there are level I studies to support the use of PRP and MSC injections for discogenic pain; facet joint injections with PRP; epidural injections of autologous conditioned serum and epidural prolotherapy; and PRP and prolotherapy for sacroiliac joint pain. One level I study showed that facet joint prolotherapy has no significant benefit. Notably, no intervention has multiple published level I studies.
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Affiliation(s)
- Mehul J Desai
- International Spine, Pain & Performance Center, Washington, DC, U.S.A.,George Washington University, Washington, DC, U.S.A.,Division of Pain Medicine, Virginia Hospital Center, Arlington, Virginia, U.S.A
| | - John Taylor Mansfield
- Department of Physical Medicine and Rehabilitation, MedStar Georgetown University Hospital, Washington, DC, U.S.A
| | - David M Robinson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, U.S.A
| | - Benjamin C Miller
- Department of Physical Medicine and Rehabilitation, MedStar Georgetown University Hospital, Washington, DC, U.S.A
| | - Joanne Borg-Stein
- Division of Sports and Musculoskeletal Rehabilitation, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, U.S.A
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Sindhupakorn B, Jomkoh D, Namkuntee T. Randomized, double-blind, Placebo-Controlled Study to Compare the Efficacy of Combination of Lidocaine with ketorolac or triamcinolone versus Lidocaine Alone for Soft Tissue Injuries. J Orthop 2020; 20:135-143. [PMID: 32025137 DOI: 10.1016/j.jor.2020.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/26/2020] [Indexed: 01/22/2023] Open
Abstract
Background Corticosteroid and Ketorolac tromethamine is a pain reducing. Objective The primary objective was pain intensity scores (VAS) in 10, 30, 60 min, 2, 6 h, 1, and 7 days. Method 120 patients were randomized. The placebo group (normal saline) and experimental groups (ketorolac 30 mg, 60 mg, triamcinolone 10 mg, 20 mg, and 40 mg, respectively) were compared. Result VAS at 60 min, 2, 6 h, 1 and 7 days was significantly different (P < 0.05). Ketorolac 30 mg, 60 mg, and triamcinolone 10 mg shown non inferiority to triamcinolone 40 mg. Conclusions ketorolac was considered equal to triamcinolone.
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Affiliation(s)
- Bura Sindhupakorn
- Orthopedic Department, School of Medicine, Suranaree Medical Institute, Suranaree University of Technology, 111 University Ave, Muang District, Nakhon Ratchasima Province, 30000, Thailand
| | - Darawan Jomkoh
- Orthopedic Department, School of Medicine, Suranaree Medical Institute, Suranaree University of Technology, 111 University Ave, Muang District, Nakhon Ratchasima Province, 30000, Thailand
| | - Theeranit Namkuntee
- Orthopedic Department, School of Medicine, Suranaree Medical Institute, Suranaree University of Technology, 111 University Ave, Muang District, Nakhon Ratchasima Province, 30000, Thailand
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Therapeutic Efficacy of Intratendinous Delivery of Dexamethasone Using Porous Microspheres for Amelioration of Inflammation and Tendon Degeneration on Achilles Tendinitis in Rats. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5052028. [PMID: 32090096 PMCID: PMC6996678 DOI: 10.1155/2020/5052028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/24/2019] [Indexed: 11/17/2022]
Abstract
Achilles tendinitis caused by overuse, aging, or gradual wear induces pain, swelling, and stiffness of Achilles tendon and leads to tendon rupture. This study was performed to investigate the suppression of inflammation responses in interleukin-1β- (IL-1β-) stimulated tenocytes in vitro and the suppression of the progression of Achilles tendinitis-induced rat models in vivo using dexamethasone-containing porous microspheres (DEX/PMSs) for a sustained intratendinous DEX delivery. DEX from DEX/PMSs showed the sustained release of DEX. Treatment of IL-1β-stimulated tenocytes with DEX/PMSs suppressed the mRNA levels for COX-2, IL-1β, IL-6, and TNF-α. The intratendinous injection of DEX/PMSs into Achilles tendinitis rats both decreased the mRNA levels for these cytokines and increased mRNA levels for anti-inflammatory cytokines IL-4 and IL-10 in tendon tissues. Furthermore, DEX/PMSs effectively prevented tendon degeneration by enhancing the collagen content and biomechanical properties. Our findings suggest that DEX/PMSs show great potential as a sustained intratendinous delivery system for ameliorating inflammation responses as well as tendon degeneration in Achilles tendinitis.
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Mazzarino M, Piantadosi C, Comunità F, Torre X, Botrè F. Urinary excretion profile of prednisone and prednisolone after different administration routes. Drug Test Anal 2019; 11:1601-1614. [DOI: 10.1002/dta.2733] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/02/2019] [Accepted: 11/04/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Monica Mazzarino
- Laboratorio Antidoping Federazione Medico Sportiva Italiana, Largo Giulio Onesti, 1, 00197 Rome Italy
| | - Chiara Piantadosi
- Laboratorio Antidoping Federazione Medico Sportiva Italiana, Largo Giulio Onesti, 1, 00197 Rome Italy
| | - Fabio Comunità
- Laboratorio Antidoping Federazione Medico Sportiva Italiana, Largo Giulio Onesti, 1, 00197 Rome Italy
| | - Xavier Torre
- Laboratorio Antidoping Federazione Medico Sportiva Italiana, Largo Giulio Onesti, 1, 00197 Rome Italy
| | - Francesco Botrè
- Laboratorio Antidoping Federazione Medico Sportiva Italiana, Largo Giulio Onesti, 1, 00197 Rome Italy
- Dipartimento di Medicina Sperimentale“Sapienza” Università di Roma Viale Regina Elena 324, 00161 Rome Italy
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