Ultrasound-Guided Interventions in Lateral Epicondylitis

Enthesitis in Spondyloarthritis Including Psoriatic Arthritis-To Inject or Not To Inject?: A Narrative Review

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.

Ultrasound-guided versus palpation-guided platelet-rich plasma injection for the treatment of chronic lateral epicondylitis: A prospective, randomized study

OBJECTIVES

This study aims to compare the effectiveness of palpation-guided and ultrasound (US)-guided platelet-rich plasma (PRP) injections in patients with chronic lateral epicondylitis (LE).

PATIENTS AND METHODS

Between January 2021 and August 2021, a total of 60 patients (34 males, 26 females; mean age: 40.5±10.9 years; range, 22 to 64 years) diagnosed with chronic LE were included. The patients were randomly allocated to either the palpation-guided (n=30) or the US-guided injection group (n=30) before they received PRP injection. All patients were assessed using the Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH) scale, and grip strength at baseline and at one, three, and six months after injection.

RESULTS

Baseline sociodemographic and clinical variables were statistically similar between two groups (p>0.05). The VAS and DASH scores improved significantly after the injection at each control, as well as grip strength in both groups (p<0.001). No statistically significant difference was found between the groups regarding VAS and DASH scores, and grip strength at one, three, and six months post-injection (p>0.05). No significant complication related to the injection was observed in any of the groups.

CONCLUSION

This study demonstrates that both palpation-guided and US-guided PRP injection protocols can improve clinical symptoms and functional parameters of patients with chronic LE.

A Guide to Indoor Rock Climbing Injuries

ABSTRACT

Rock climbing is an increasingly popular indoor sport with a sizable risk of overuse injuries. Yet, many medical practitioners have little familiarity with evaluating and treating climbing injuries because of the terminology, biomechanical demands, mechanisms of injury, and return to sport counseling needed, unique to the sport. This review seeks to educate practitioners on these aspects. Upper extremity injuries occur more frequently than lower extremity injuries, with finger injuries being most prevalent. Pulley injuries, consisting of rupture of the A2 or A4 annular pulleys are the most common type of injury. Other finger injuries include tenosynovitis of the flexor tendons, as well as lumbrical muscle tears. Elbow injuries occur frequently, with medial epicondylopathy being most common. Brachialis injuries are seldom seen outside of climbing. Lower-extremity injuries are typically more acute in nature, including ankle injuries from falls and knee injuries from strenuous climbing moves.

Platelet-Rich Plasma Injection Associated With Microtenotomy in Lateral Epicondylitis – is a Tendon Tear Associated with the Therapeutic Response?

Objective

Ultrasound-guided platelet-rich plasma (PRP) injections, as well as needle tenotomy, are becoming increasingly popular in the treatment of epicondylitis. Whether ultrasound (US) findings predict the clinical benefit of these techniques is unclear at the moment. This study aimed to investigate the relationship between the presence of tendon tear assessed by US and the therapeutic response of the PRP injection following needle microtenotomy in patients with epicondylitis.

Methodology

This is a retrospective observational study. Twenty-six patients with chronic (>three months) lateral epicondylitis recalcitrant to conservative treatment or corticosteroid injection. Patients underwent US-guided microtenotomy followed by PRP injection. Data regarding gender, age, US findings at baseline, and numeric pain rating scale (NPRS) scores before and after intervention were collected. Pain improvement rates were calculated at several follow-up time points, namely one, three, six, and 12 months post-intervention. Results are stated as mean ± standard deviation.

Results

At the time of intervention, the mean age was 47.6±6.5 years, and 57.7% of patients were men. Overall, the mean initial NPRS score was 7.5±1.2, and there were no statistically significant differences in mean initial NPRS scores between the groups with or without tendon tear on the US imaging. The mean improvement rate at one, three, and six months was similar between patients with and without tendon tear. However, a statistically significant difference was observed at 12 months (73.1±37.6% vs. 16.0±21.9, p=0.029). 

Conclusions

Patients with tendon tear demonstrated a higher pain improvement rate at 12 months follow-up. This finding could predict the clinical response to this technique, thus allowing a better selection of the candidates.

Ultrasound-guided percutaneous needle tenotomy using Tenex system for refractory lateral epicondylitis; short and long-term effectiveness and contributing factors

BACKGROUND

Ultrasound-guided percutaneous needle tenotomy (USPNT) has been proposed as an alternative treatment to surgical intervention for lateral epicondylitis (LE). The Tenex system (Tenex Health Inc., Lake Forest, CA, USA) for USPNT is an ultrasonic device involving a needle which oscillates at high frequency to debride and aspirate diseased tendon under ultrasound image guidance. This investigation evaluates the efficacy of USPNT using the Tenex system for LE refractory to conservative management. We also seek to evaluate patient-specific factors which may correlate with treatment response.

MATERIALS AND METHODS

PRTEE (Patient-Rated Tennis Elbow Evaluation) and DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaires were completed before performing the Tenex USPNT for all consecutive patients over a course of 38 months (Feb 2015-Mar 2018). Patients were contacted for follow-up evaluations. Paired t test was used to evaluate significant changes in treatment response (p < 0.05). The univariate Tobit regression model was applied followed by multivariate Tobit model with forward selection algorithm. All models were adjusted by preoperative score and follow-up duration.

RESULTS

A total of 37 patients (average age 51± 9 years, M/F:15/22) with refractory LE were included (mean follow-up, 531 days; range, 65-1148 days). Tenex USPNT significantly improved PRTEE and DASH scores (p < 0.001). In some patients, this decrease persisted for up to 3 years after intervention. A significant association between treatment response and post-procedure physical therapy (PT) was present. Post-procedure PT contributes to 60, 68, 59, and 50% of reduction in PRTEE pain, function, total scores, and DASH score, respectively (p < 0.001). No tendon ruptures, post-procedural infections, or other complications were noted.

CONCLUSION

USPNT with Tenex significantly improves symptoms and function in individuals with LE even with long-term follow-up for 3 years. Post-procedure PT is associated with improved treatment response and should be considered after USPNT.

Interrater and Intrarater Reliability of Musculoskeletal Ultrasonographic Findings for the Common Extensor Tendon of the Elbow

Objectives:

This retrospective case study evaluated the interrater and intrarater reliability of seven common extensor tendon pathologic features on musculoskeletal ultrasonography (MSK-US).

Materials and Methods:

A cohort of 50 patients were imaged due to presenting with atraumatic nonradicular lateral elbow pain. Three experienced and two novice readers rated the images on two separate occasions, and AC1 and kappa coefficients were calculated for each feature.

Results:

The interrater reliability was fair with respect to fascial thickening/scarring (AC1 = 0.26), tearing (AC1 = 0.35), tendon thickening (AC1 = 0.38), and intratendinous calcification (AC1 = 0.33); substantial for enthesophytes (AC1 = 0.80); and near complete for hyperemia (AC1 = 0.83) and hypoechogenicity (AC1 = 0.92). Intrarater reliability was moderate for fascial thickening/scarring (κ = 0.48), tearing (κ = 0.41), tendon thickening (0.47), intratendinous calcification (κ = 0.56), and hypoechogenicity (κ = 0.47); substantial for hyperemia (κ = 0.71); and almost perfect for enthesophytes (κ = 0.86).

Conclusion:

MSK-US may be a reliable tool to determine soft tissue changes in common extensor tendon pathology.