Comparison Between Corticosteroid and Lidocaine Injection in the Treatment of Tennis Elbow: A Randomized, Double-Blinded, Controlled Trial

Effects of hyaluronic acid injections on pain and functioning in patients affected by tendinopathies: A narrative review

BACKGROUND

Tendinopathies are overuse tendon injuries showing load-dependant pain, stiffness, weakness of movement in the affected area, and impairment in the movements. The scientific interest on the role of Hyaluronic Acid (HA) for the management of tendinopathies has been increased due to its anti-inflammatory and lubricative properties.

OBJECTIVE

To collect evidence regarding the effectiveness and safety of HA injections in reducing pain in patients affected by tendinopathies.

METHODS

A scientific literature search was conducted using the PubMed, Medline and PEDro electronic databases. The databases were searched since their inception until July 2021. The search was limited to English language articles. Different combinations of the terms and MeSH terms "tendinopathy", "tendinosis", "tendinitis", "hyaluronic acid", "hyaluronate", "infiltration", "hyaluronic injections", "viscosupplementation" connected with various boolean operators were used for other electronic databases.

RESULTS

One hundred and one records were identified from the selected databases plus three additional papers identified by the authors through other sources. After removing duplicated papers and title/abstract screening, 19 studies were included in our review (eight papers on shoulder, three on elbow, four on hand, one on knee, and three on ankle).

CONCLUSION

The results showed that none of the studies report severe adverse effects and most of them support the use of HA injections in tendinopathies, with a special attention to pain reduction and functional assessment. Further studies are warranted to better investigate effects and methods of administration of HA in tendinopathies.

Extracorporeal Shock Wave Therapy Shows Superiority Over Injections for Pain Relief and Grip Strength Recovery in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis

PURPOSE

To examine the efficacy of extracorporeal shock wave therapy (ESWT) and injection therapies by synthesizing direct and indirect evidence for all pairs of competing therapies for lateral epicondylitis.

METHODS

PubMed, EMBASE, and Web of Science databases were searched for all appropriate randomized controlled trials (RCTs), assessing the effect of ESWT or injection therapies. The primary outcome was short-term (≤3 months) and medium-term (>3 months but ≤12 months) pain, while the secondary outcomes were grip strength and patient-reported outcome measures. All outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs) and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to determine a hierarchy of treatments. Sensitivity analysis was performed to eliminate potential therapeutic effects of normal saline (NS) and exclude trials that included patients with acute lateral epicondylitis (LE).

RESULTS

40 RCTs were included to evaluate ESWT and five different injection therapies, including corticosteroids (CSs), autologous whole blood, platelet-rich plasma (PRP), botulinum toxin A (BoNT-A), and dextrose prolotherapy (DPT). DPT (-.78 [-1.34 to -.21]), ESWT (.57 [-.89 to -.25]), PRP (-.48 [-.85 to -.11]), and BoNT-A (-.43 [-.84 to -.02]) outperformed placebo for short-term pain relief; ESWT (-.44 [-.85 to -.04]) outperformed placebo for medium-term pain relief. DPT was ranked as the most optimal short-term and medium-term pain reliever (SUCRA, 87.3% and 98.6%, respectively). ESWT was ranked as the most optimal short-term and medium-term grip strength recovery (SUCRA; 79.4% and 86.4%, respectively).

CONCLUSIONS

DPT and ESWT were the best two treatment options for pain control and ESWT was the best treatment option for grip strength recovery. CSs were not recommended for the treatment of LE. More evidence is required to confirm the superiority in pain control of DPT among all these treatment options on LE.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I randomized controlled trials.

Lateral epicondylitis: New trends and challenges in treatment

Lateral epicondylitis (LE) is a chronic aseptic inflammatory condition caused by repetitive microtrauma and excessive overload of the extensor carpi radialis brevis muscle. This is the most common cause of musculoskeletal pain syndrome in the elbow, inducing significant pain and limitation of the function of the upper limb. It affects approximately 1-3% of the population and is frequently seen in racquet sports and sports associated with functional overload of the elbow, such as tennis, squash, gymnastics, acrobatics, fitness, and weight lifting. Typewriters, artists, musicians, electricians, mechanics, and other professions requiring frequent repetitive movements in the elbow and wrists are also affected. LE is a leading causation for absence from work and lower sport results in athletes. The treatment includes a variety of conservative measures, but if those fail, surgery is indicated. This review summarizes the knowledge about this disease, focusing on risk factors, expected course, prognosis, and conservative and surgical treatment approaches.

Comparison of the efficacy of corticosteroid, dry needling, and PRP application in lateral epicondylitis

PURPOSE

The aim of this study was to compare the short-term efficacy of dry needling, corticosteroids, and platelet-rich plasma application (PRP) in the management of lateral epicondylitis.

METHODS

The study included 72 patients diagnosed with lateral epicondylitis divided into three groups of 24 individuals using the sealed envelope method. Group 1 underwent dry needling, Group 2 received 40 mg methylprednisolone acetate, and Group 3 received PRP treatment. Patients were assessed using the visual analog scale (VAS) and the Disabilities of the Shoulder, Arm, and Hand (DASH) score, and Jamar grip strength before treatment and 3rd week and 3rd month.

RESULTS

At the 3rd month, the mean VAS score was 1.16 ± 0.56 in dry needling group and 0.75 ± 0.60 in corticosteroids group, showing a statistically significant difference between dry needling and corticosteroids group, and between corticosteroids and PRP group (p = 0.015 and p = 0.000, respectively). At the 3rd week and 3rd month, VAS scores decreased in each treatment modality group, showing a statistically significant difference between the groups (p < 0.01). Jamar grip strength increased over time in all groups. There were no significant differences between the DASH scores of all groups at the 3rd week (p > 0.05). DASH scores decreased significantly from the 3rd week to the 3rd month in dry needling and corticosteroids group (p < 0.01), while it increased slightly in PRP group during the same period with a statistically insignificant change (p > 0.05). DASH scores decreased significantly at the 3rd month for all groups (p = 0.014).

CONCLUSION

Dry needling is an effective and safe application for the short-term treatment of lateral epicondylitis.

Comparative outcomes of combined corticosteroid with low volume compared to high volume of local anesthetic in subacromial injection for impingement syndrome: systematic review and meta-analysis of RCTs

Subacromial impingement syndrome (SIS) is one of the most frequent pathologies of the shoulder, which may cause serious restriction of daily activities and lifestyle changes. Corticosteroid injection (CI) into the subacromial space is a palliative treatment option. Currently, there have been no studies that compare between the different volumes of CI injection. We have conducted a systematic review and meta-analysis to answer our specific study questions: Are high volume (< 5 ml) better than low volume (≥ 5 ml) of CI injection with respect to pain reduction? This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Relevant studies were identified from Medline and Scopus from inception to May 11, 2017 that reported American shoulder and elbow surgeons (ASES) function score, pain visual analog score (VAS), and postoperative complications of either group. Fifteen studies were included for the analysis of high volume (more than or equal 5 ml), and 5 studies were included for analysis of low volume (less than 5 ml). Overall, there were 1101 patients (732 in the high-volume group and 369 in the low-volume group). A pooling of mean VAS and ASES function score was (N = 557) 2.02 (95% CI 1.52, 2.53), (N = 190) 82.59 (95% CI 76.92, 88.27) in high-volume group and (N = 179) 2.60 (95% CI 1.94, 3.26), (N = 95) 84.65 (95% CI 81.64, 86.82) in low-volume group, respectively. The unstandardized mean difference of ASES and VAS of high volume was - 0.58 (95% confidence interval (CI): - 1.38, 0.22) and - 2.06 (95% CI - 8.35, 4.23) scores lower than low-volume CI in SIS patients, but without statistical significance. A total of 11 studies in the high-volume group and 4 studies in the low-volume group reported adverse effects. The total complication rate per patient was 6.2% (2.3, 10.1%) in the high-volume group and 11.7% (0.3, 12%) in the low-volume group (p = 0.091). No significant differences were noted for complications. In subacromial impingement syndrome, the corticosteroid injection had acceptable pain and functional outcomes. Higher volume had a lower ASES, VAS, and risk of having complication when compared to lower volume. However, there are no statistically significant differences between groups. Larger, randomized noninferiority or equivalent trial studies are needed to confirm these findings as the current literature is still insufficient. Level of evidence I.