A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma

Use of Ultrasound-Guided Tendon Fenestration and Injection Procedures for Treatment of Tendinosis

Introduction

Overuse injuries such as tendinosis are a common complaint at sports medicine clinics. When conservative management for tendinosis has failed, ultrasound-guided tendon fenestration and injection procedures, such as dry needling, needling tenotomy, autologous whole blood injections, and prolotherapy, can be utilized for treatment. This study examined the effectiveness of these procedures for pain improvement and ability to return to activity for patients with tendinosis.

Methods

This study involved a chart review of patients 15 years or older who underwent at least one treatment for tendinosis at a sports medicine clinic between January 1, 2014 and April 17, 2019. Eligible patients had at least one of the following procedures: 1) percutaneous dry needling, 2) percutaneous needle tenotomy, 3) autologous whole blood injection, and/or 4) prolotherapy. A Current Procedural Terminology (CPT) code query was used to screen patient charts for study inclusion.

Results

In total, 680 patients' data were reviewed, and 343 patients met inclusion criteria. Patients underwent a total of 598 unique procedures. Dry needling represented most procedures (62.8%, n = 375). Most patients reported diminished pain at follow up (73.0%, n = 268). Prolotherapy had the highest percentage among the follow up patients reporting diminished pain (81.0%, n = 17). Most patients were able to return to activity at follow-up (47.4%, n = 172). A greater proportion of patients with autologous whole blood injection were able to return to activity (60.7%, n = 85).

Conclusions

Most patients with tendinosis who underwent tendon fenestration or injection procedures reported diminished pain at follow-up. Autologous whole blood injection may be more likely to diminish patient pain and allow return to activity than other procedure types. More research is needed across all anatomical sites to compare the generalized effectiveness of these procedures.

Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review

Objective

The primary objective of this review was to summarize systematic reviews and meta-analyses reporting on nonoperative management of lateral epicondyle tendinopathy.

Methods

An umbrella review of all published systematic reviews and meta-analyses was performed. Three databases were searched using the key words "tennis elbow," "lateral epicondylitis," "non-operative," and "non-surgical modalities." The search was limited to English-language systematic reviews and meta-analyses between the years of 2000 and 2022.

Results

There were 114 systematic reviews/meta-analyses, of which 35 met our inclusion criteria. These articles reviewed the following nonoperative management strategies: ultrasound, shockwave therapy, injection procedures, low-level laser therapy, joint mobilizations, exercise therapy, and electrophysical modalities. Exercise therapy was beneficial in decreasing pain regardless of dosage or type. Conflicting results were seen with ultrasound, laser, and shockwave therapy. Corticosteroid injections provided the most short-term pain relief, and platelet-rich plasma and autologous blood injections were most effective in the long term.

Conclusion

A variety of nonoperative interventions were found to be effective for short- and long-term pain relief as well as functional improvement, with most interventions indicating mixed results. Due to variations in study populations and study quality, results should be interpreted with caution.

Effects of splinting and three injection therapies (corticosteroid, autologous blood and prolotherapy) on pain, grip strength, and functionality in patients with lateral epicondylitis

Objectives

This study aims to compare the efficacy of the wrist splint and the injection of corticosteroid, autologous blood, and hypertonic dextrose in the treatment of lateral epicondylitis (LE).

Patients and methods

A total of 120 patients (43 males, 77 females; mean age: 45.7±7.7 years; range, 18 to 65 years) diagnosed with LE between December 2013 and June 2015 were included in the study and randomized into four groups. The first group was administered 20 mg methylprednisolone acetate + 2 mL 2% prilocaine, the second group 2 mL venous blood + 0.5 mL prilocaine, and the third group 2 mL 30% dextrose + 0.5 mL prilocaine injections. A second injection was administered to the third group one month later. The fourth group was recommended to use only a wrist splint. Pre-treatment and post-treatment evaluations of the patients were carried out at one and six months by the Visual Analog Scale (VAS) in terms of pain, by Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire in terms of functional level, and by the Jamar dynamometer in terms of grip strength.

Results

In all groups, VAS values at one and six months after treatment were found to be lower in comparison to baseline. Except for the splint group, a significant improvement was observed in all three injection groups in terms of grip strength and PRTEE values at six months compared to the baseline values. In the comparison of the groups, no significant difference was observed in terms of improvement in VAS scores and grip strength. While corticosteroid injection was significantly effective in terms of PRTEE pain, function, and total scores only at one month, the autologous injection was effective in terms of PRTEE function and total scores at only six months after treatment. There were no significant differences for splint and prolotherapy groups in terms of PRTEE scores.

Conclusion

Corticosteroid injection, autologous blood injection, and prolotherapy are effective and safe long-term methods in LE treatment.

Bibliometric analysis of the top 50 highly cited articles on platelet-rich plasma in osteoarthritis and tendinopathy

The primary goal of this study was to compile the top 50 most cited articles on the use of platelet-rich plasma (PRP). A search of relevant studies was performed in accordance with the PRISMA guidelines in Web of Science. The top 25 most cited articles in osteoarthritis and tendinopathy were then compiled and evaluated. Level 1 evidence articles constituted the majority of the studies (64%) and were more likely to have a higher citation density. Altmetric data was highest for level 1 systematic reviews. Of the articles that report a positive outcome for PRP, 13% (2/16) had low risk of bias. This study defines the most cited and influential publications regarding PRP to further research in this area.

Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain

BACKGROUND

Autologous whole blood or platelet-rich plasma (PRP) injections are commonly used to treat lateral elbow pain (also known as tennis elbow or lateral epicondylitis or epicondylalgia). Based on animal models and observational studies, these injections may modulate tendon injury healing, but randomised controlled trials have reported inconsistent results regarding benefit for people with lateral elbow pain.

OBJECTIVES

To review current evidence on the benefit and safety of autologous whole blood or platelet-rich plasma (PRP) injection for treatment of people with lateral elbow pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase for published trials, and Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal for ongoing trials, on 18 September 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs comparing autologous whole blood or PRP injection therapy to another therapy (placebo or active treatment, including non-pharmacological therapies, and comparison between PRP and autologous blood) for lateral elbow pain. The primary comparison was PRP versus placebo. Major outcomes were pain relief (≥ 30% or ≥ 50%), mean pain, mean function, treatment success, quality of life, withdrawal due to adverse events, and adverse events; the primary time point was three months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 32 studies with 2337 participants; 56% of participants were female, mean age varied between 36 and 53 years, and mean duration of symptoms ranged from 1 to 22 months. Seven trials had three intervention arms. Ten trials compared autologous blood or PRP injection to placebo injection (primary comparison). Fifteen trials compared autologous blood or PRP injection to glucocorticoid injection. Four studies compared autologous blood to PRP. Two trials compared autologous blood or PRP injection plus tennis elbow strap and exercise versus tennis elbow strap and exercise alone. Two trials compared PRP injection to surgery, and one trial compared PRP injection and dry needling to dry needling alone. Other comparisons include autologous blood versus extracorporeal shock wave therapy; PRP versus arthroscopic surgery; PRP versus laser; and autologous blood versus polidocanol. Most studies were at risk of selection, performance, and detection biases, mainly due to inadequate allocation concealment and lack of participant blinding. We found moderate-certainty evidence (downgraded for bias) to show that autologous blood or PRP injection probably does not provide clinically significant improvement in pain or function compared with placebo injection at three months. Further, low-certainty evidence (downgraded for bias and imprecision) suggests that PRP may not increase risk for adverse events. We are uncertain whether autologous blood or PRP injection improves treatment success (downgraded for bias, imprecision, and indirectness) or withdrawals due to adverse events (downgraded for bias and twice for imprecision). No studies measured health-related quality of life, and no studies reported pain relief (> 30% or 50%) at three months. At three months, mean pain was 3.7 points (0 to 10; 0 is best) with placebo and 0.16 points better (95% confidence interval (CI) 0.60 better to 0.29 worse; 8 studies, 523 participants) with autologous blood or PRP injection, for absolute improvement of 1.6% better (6% better to 3% worse). At three months, mean function was 27.5 points (0 to 100; 0 is best) with placebo and 1.86 points better (95% CI 4.9 better to 1.25 worse; 8 studies, 502 participants) with autologous blood or PRP injection, for absolute benefit of 1.9% (5% better to 1% worse), and treatment success was 121 out of 185 (65%) with placebo versus 125 out of 187 (67%) with autologous blood or PRP injection (risk ratio (RR) 1.00; 95% CI 0.83 to 1.19; 4 studies, 372 participants), for absolute improvement of 0% (11.1% lower to 12.4% higher). Regarding harm, we found very low-certainty evidence to suggest that we are uncertain whether withdrawal rates due to adverse events differed. Low-certainty evidence suggests that autologous blood or PRP injection may not increase adverse events compared with placebo injection. Withdrawal due to adverse events occurred in 3 out of 39 (8%) participants treated with placebo versus 1 out of 41 (2%) treated with autologous blood or PRP injection (RR 0.32, 95% CI 0.03 to 2.92; 1 study), for an absolute difference of 5.2% fewer (7.5% fewer to 14.8% more). Adverse event rates were 35 out of 208 (17%) with placebo versus 41 out of 217 (19%) with autologous blood or PRP injection (RR 1.14, 95% CI 0.76 to 1.72; 5 studies; 425 participants), for an absolute difference of 2.4% more (4% fewer to 12% more). At six and twelve months, no clinically important benefit for mean pain or function was observed with autologous blood or PRP injection compared with placebo injection.

AUTHORS' CONCLUSIONS

Data in this review do not support the use of autologous blood or PRP injection for treatment of lateral elbow pain. These injections probably provide little or no clinically important benefit for pain or function (moderate-certainty evidence), and it is uncertain (very low-certainty evidence) whether they improve treatment success and pain relief > 50%, or increase withdrawal due to adverse events. Although risk for harm may not be increased compared with placebo injection (low-certainty evidence), injection therapies cause pain and carry a small risk of infection. With no evidence of benefit, the costs and risks are not justified.

Do hand therapists have a role in workplace-based education to manage tennis elbow? Beliefs about effective treatments among Australian hand therapists and medical practitioners

BACKGROUND

Lateral elbow tendinopathy (LET), commonly known as tennis elbow, is a prevalent work-related upper extremity musculoskeletal disorder. Medical practitioners and hand therapists manage LET with commonly available clinic-based treatments, despite no sound evidence to suggest long-term relief and functional restoration for workers with LET. Workplace-based rehabilitation is effective for injured workers with other health conditions, but no studies have investigated this rehabilitation approach in the management of LET.

OBJECTIVES

(i) Identify, compare, and contrast Australian hand therapists' and medical practitioners' perceptions about the effectiveness of common treatments for LET, and (ii) obtain their views towards a hand therapist delivered workplace-based education approach.

METHODS

In this cross-sectional study, 38 medical practitioners from Western Australia and 104 hand therapists around Australia completed online surveys. Independent t-tests were used to identify between-group differences in responses.

RESULTS

Despite some between-group differences regarding the perceived effectiveness of common LET treatments, both groups believed education about LET pathology, activity modification, postures, and workplace recommendations were most effective. Most medical practitioners (81%) and hand therapists (71%) believed workplace-based education delivered by a hand therapist would be beneficial for patients with acute and chronic LET.

CONCLUSION

Australian hand therapists and medical practitioners believed educational approaches were the most important component in the management of LET, and supported workplace-based educational interventions provided by hand therapists in the management of LET.

Prolotherapy for chronic low back pain: a review of literature

INTRODUCTION

Low back pain is common and imposes major societal burdens for patient suffering and costs. Prolotherapy injections are used for musculoskeletal conditions including tendinopathies, osteoarthritis and low back pain to enhance soft-tissue healing. This review aims to clarify the place of prolotherapy in chronic low back pain (CLBP).

SOURCES OF DATA

Using multiple databases, a systematic search was performed to identify studies detailing the use of prolotherapy to manage CLBP. A total of 12 articles was included in the present work.

AREAS OF AGREEMENT

Considering the level of evidence and the quality of the studies assessed using the modified Coleman Score, prolotherapy is an effective management modality for CLBP patients in whom conservative therapies failed.

AREAS OF CONTROVERSY

The presence of co-interventions and the clinical heterogeneity of the work contributes to confound the overall conclusions.

GROWING POINTS AND AREAS FOR RESEARCH

The analysis of the studies included in the review, using appropriate tools, showed how their quality has decreased over the years, reflecting the need for appropriately powered well planned and performed randomized control trials.

Functional and Pain Improvement in Tennis Elbow with Dry Needling as Alternative Treatment: Case Series

Collapse

Platelet-rich plasma injections for hip osteoarthritis: a review of the evidence

Osteoarthritis is a significant cause of chronic pain in the elderly population with hip osteoarthritis as one of the main causes of functional disability and joint pain in adults older than 55 years. Recently, platelet rich plasma (PRP) injections have been introduced for treatment of osteoarthritis. The aim of this systematic review is to assess its effectiveness in the management of hip osteoarthritis. We performed a search of the literature for published prospective studies that assessed the effectiveness of PRP injections in the treatment of hip osteoarthritis, with a minimum follow-up of 3 months. Primary outcome measures were WOMAC and VAS scores. Five trials were identified with 185 patients undergoing treatment with ultrasound-guided intra-articular injections of PRP, compared with patients treated with hyaluronic acid alone (n = 148) or hyaluronic acid combined with PRP (n = 31) in one study. PRP was shown to improve patient outcome scores at follow-up at 6 and 12 months; however, there was no significant difference seen between patients treated with PRP or hyaluronic acid alone. Following this systematic review, we cannot currently recommend the use of intra-articular injections of PRP for the treatment of hip OA. Given that intra-articular steroid injections are the only such injection recommended by international guidelines for the treatment of hip OA, further studies comparing PRP to steroid would be of benefit to determine the value of PRP injections in hip OA.

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

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

Platelet-rich Plasma or Autologous Blood Do Not Reduce Pain or Improve Function in Patients with Lateral Epicondylitis: A Randomized Controlled Trial

BACKGROUND

Platelet-rich plasma (PRP) and autologous blood are commonly used therapies for lateral epicondylitis, but the evidence from randomized, placebo-controlled trials is conflicting. Thus, it is still unclear if patients benefit from these treatments.

QUESTIONS/PURPOSES

In the setting of a randomized, placebo-controlled trial, we compared PRP, autologous blood, and saline injections in the treatment of lateral epicondylitis with respect to: (1) VAS pain scores, and (2) functional outcomes (DASH score and grip strength) 1 year after treatment.

METHODS

We performed a parallel-group, randomized, controlled participant- and assessor-blinded study including adults with clinically diagnosed lateral epicondylitis. We defined lateral epicondylitis as pain in the lateral humeral epicondyle area exacerbated during resisted wrist extension and epicondyle compression. The participants were recruited from a secondary referral center, after not responding to initial nonoperative treatment. Patients with other concomitant upper-limb symptoms and surgical treatment of the elbow were excluded. Randomization sequence was generated with computer software and concealed from the investigators. We randomized 119 participants to receive an injection of PRP, autologous blood, or saline (1:1:1) in the proximal insertion of the extensor carpi radialis brevis muscle; 40 participants received PRP, 40 received autologous blood, and 39 received a saline injection. To prepare the PRP, we collected venous blood with a syringe kit followed by centrifugation, whereas autologous blood group received unprepared blood injection. Two unblinded investigators gave injections while the participant was unable to see the injection. There was no formal postinjection rehabilitation protocol and the use of NSAIDs was similar between different treatment arms. Follow-up visits were at 4, 8, 12, 26, and 52 weeks after the injection. The primary outcome measure was improvement in pain, measured with VAS scale (without specification as to whether the pain was activity related or at rest; range 0-10; a higher score indicates worse pain; the minimum clinically important difference [MCID] on the 10-cm scale was 1.5 cm), from baseline to 52 weeks. The secondary outcomes were the DASH score (range 0-100; a higher indicates a poorer outcome, and the MCID was 10.2 points) and grip strength. All patients were included in the analyses, and analyses were performed using the intention-to-treat principle. There was no crossover between treatment groups. At 52 weeks, nearly all (95% [38 of 40]) participants in autologous blood group were available for analysis whereas 78% (31 of 40) and 82% (32 of 39) were available in PRP and saline groups. This study was registered at ClinicalTrials.gov and funded by the local hospital district. With 40 patients in each group, we had 80% power to detect a clinically important improvement in pain (1.5 cm on the 10-cm VAS pain scale).

RESULTS

There were no clinically important differences in the mean VAS pain or DASH scores among the groups at any timepoint. At 52 weeks, the mean difference in the VAS score for pain was -0.2 (95% CI -1.5 to 1.1; p = 0.75) for PRP versus saline and 0.5 (95% CI -0.7 to 1.7; p = 0.40) for autologous blood versus saline. The corresponding mean differences in the DASH score were 0.0 (95% CI -9.2 to 9.2; p > 0.99) and 7.7 (95% CI -1.3 to 16.7; p = 0.09) and those for grip strength were 1.4 kg (95% CI -3.3 to 6.1; p = 0.56) and -0.2 kg (95% CI -5.0 to 4.5; p = 0.92). No complications occurred because of the injections.

CONCLUSIONS

PRP or autologous blood injections did not improve pain or function at 1 year of follow-up in people with lateral epicondylitis compared with those who were given a saline injection. However, because the 95% CIs did not exclude the MCID in VAS scores for autologous blood versus saline at 52 weeks, it is possible that a larger study could identify a between-group difference that we missed, but the effect size of that difference (based on our findings), even if present, is likely still to be small. Until or unless future randomized trials convincingly show a benefit either to PRP or autologous blood injections, we recommend against their use in patients with lateral epicondylitis.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Prolotherapy: Regenerative Medicine for Lateral Epicondylitis

Lateral epicondylitis (LE) is a degenerative disease of the tendons, spurred by repetitive microtrauma leading to an attempt by the body to heal by upregulating local angiogenesis and fibroblast proliferation. Prolotherapy (PT) is the injection of dextrose around the injured tissues to stimulate their spontaneous regeneration. Herein, we have described a case of lateral epicondylitis, diagnosed with clinical and ultrasound (US) examination, where local steroid injections provided relief only for a limited time. We treated the patient with US-guided PT, following which the pain disappeared and the tendon was restored.

PAST, CURRENT AND FUTURE INTERVENTIONAL ORTHOBIOLOGICS TECHNIQUES AND HOW THEY RELATE TO REGENERATIVE REHABILITATION: A CLINICAL COMMENTARY

Interventional orthobiologics is changing the landscape of orthopedic medicine. Various methods exist for treatment of many different musculoskeletal pathologies. Candidacy for such injections remains a debated topic, and current research is underway for stratifying the patients that would be most successful for certain techniques. Described in this commentary are the various methods of interventional orthobiologic techniques available such as: prolotherapy, platelet rich plasma (PRP), mesenchymal stromal cells (MSCs), culture-expanded MSCs and amniotic-based products. Here we review the healing cascade and how this relates to the application of the various injectates and rehabilitation protocols. In conclusion, there exists orthobiologic techniques for the healing of a multitude of musculoskeletal ailments, from ligamentous instabilities/tears, tendon derangements and osteoarthritis, however candidacy grades continue to be an area for discussion as to which type of treatment is the most beneficial, and which rehabilitation protocols are required. More randomized controlled trials and comparative analyses are needed for direct correlative conclusions for which interventional orthobiologic treatment and rehabilitation protocol is best after each respective treatment.

LEVEL OF EVIDENCE

5.

Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial

BACKGROUND

Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow.

METHOD

Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months.

RESULTS

Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection.

CONCLUSION

L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention.

Is Dextrose Prolotherapy Superior To Corticosteroid Injection In Patients With Chronic Lateral Epicondylitis?: A Randomized Clinical Trial

Purpose

To compare the efficacy of dextrose prolotherapy versus steroid injection in the treatment of patients with chronic lateral epicondylitis.

Methods

Thirty subjects with chronic lateral epicondylitis were randomly assigned into two groups of hypertonic dextrose or methylprednisolone injection. Participants were assessed through Quick DASH and VAS scores, once before injection, and then after 1- and 3-months follow-up. Two patients were excluded due to not completing the follow-up timepoints.

Results

In both groups VAS scores revealed significant improvement during the first month follow-up [mean difference (MD) = 1.9±3.3, versus 1.5±1.9 for the prolotherapy and steroid groups, respectively]. This declining trajectory continued at the third month visit in the prolotherapy group and MD reached 4.4±2.9, while it did not change remarkably in the steroid group (MD=1.9±3.4). In fact, comparing VAS scores between the 1st- and 3rd-month time points did not reveal a significant improvement in the steroid group (p=0.6). Also, the Quick DASH index showed a similar pattern and improved remarkably in both groups during the first visit. However, only the efficacy in the prolotherapy group persisted after 3-month follow-up (MD = 9.5±21.6, p=0.044). One month after injections no preference between the two interventions was observed (p=0.74 for VAS and 0.14 for Quick DASH score). However, the 3rd-month follow-up revealed a meaningful superiority (p=0.03 for VAS and p=0.01 for Quick DASH score) favoring the prolotherapy method.

Conclusion

Both methods were proven to be effective in the short-term treatment of chronic lateral epicondylitis, but dextrose prolotherapy seems to be slightly more efficacious than steroid injection over a longer period.Clinical trial registration: Iranian Registry of Clinical Trials Database: IRCT20170311033000N3.

Ultrasound-Guided Dry Needling of the Healthy Rat Supraspinatus Tendon Elicits Early Healing Without Causing Permanent Damage

Overuse-induced tendinopathy is highly prevalent in the general population. Percutaneous fenestration, or dry needling, techniques have been increasing in popularity, but despite their current use, there are no controlled laboratory studies to provide fundamental support for this practice. The objective of this study was to establish a model for percutaneous needling of the rat supraspinatus tendon using ultrasound guidance and to evaluate the biological response of needling healthy tendon. A total of 44 male Sprague-Dawley rats (477 ± 39 g) were used to evaluate the effect of dry needling on healthy supraspinatus tendon properties. Ten rats were reserved as un-needled control animals, and the remaining animals underwent either mild or moderate bilateral needling protocols and were sacrificed at 1 or 6 weeks post-needling (n = 8-10/group). Color Doppler ultrasound imaging was performed to analyze blood flow within the tendon. Histological and immunohistochemical analyses were used to determine cellular, inflammatory, and extracellular matrix properties of the tissue. Finally, quasi-static tensile mechanical analysis was performed to obtain viscoelastic, structural, and material properties to evaluate the tendon healing outcome. Data were tested for normality, and then two-way analysis of variance tests were performed followed by post hoc tests for multiple comparisons. Both the mild and moderate needling groups caused a transient healing response at early time points as shown by a statistically significant (p < 0.05) reduction in mechanical properties, and increase in blood flow, inflammation, and production of collagen III and glycosaminoglycans as compared to the control. Furthermore, mild needling properties returned to or exceeded pre-needling values at the 6-week time point. Clinical significance: Needling the rat supraspinatus tendon is a feasible technique that causes a transient healing response followed by a return to, or improvement of, normal tendon properties, indicating potential applicability in understanding the effects of current practices utilizing dry needling of tendons in humans. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2035-2042, 2019.

Biologically Enhanced Hamstring Tendon Transfer for Treatment of Acute Rupture of Posterior Tibialis Tendon in an Athlete: Case Report

We report the case of a 32-year-old basketball player who presented with an acute flatfoot deformity after performing a unipodal power jump. Rupture of the posterior tibial tendon within the foot was diagnosed and then treated by hamstring tendon transfer combined with application of autologous biologic preparations. The functional outcome at 18 months was good. To our knowledge, this is the first reported case of posterior tibial tendon rupture treated by hamstring tendon transfer.

Comparison of tetradecyl sulfate versus polidocanol injections for stabilisation of joints that regularly dislocate in an Ehlers-Danlos population

OBJECTIVES

To determine whether there is similarity between tetradecyl sulfate and polidocanol in stabilising a joint from dislocating in patients with Ehlers-Danlos syndrome (EDS).

METHOD

A retrospective analysis of patients with EDS in a sole-practice clinic in New Zealand. Patients must have had the diagnosis of EDS, had easily dislocatable joints, had treatment and at least 3 months' follow-up. 0.11% tetradecyl sulfate solution, or 0.25% polidocanol solution, was injected to ligament attachments (enthesis) on the side of the joints where they dislocated. Patients were deemed successfully treated if their affected joints were no longer dislocated over a minimum of 3 months' follow-up (out to 3 years).

RESULTS

Of 250 patients at the time of the study, 46 fitted the criteria. There were 37 treated with tetradecyl sulfate and nine with polidocanol. For the tetradecyl group there were a total of 305 injections around 97 joints: mean 3.1, range 1-22, median 2. For the polidocanol group there were 36 injections around 19 joints: mean 1.9, range 1-8, median 2. The difference of means between group 1 (tetradecyl) and group 2 (polidocanol) is 1.2, CIs 0.34 to 2.98. All patients had no further dislocations of treated joints unless they had a major new injury (two patients).

CONCLUSION

There was no difference between the two groups for stabilising joints from dislocating. These two agents appear promising for treating patients with recurrent joint dislocations in the setting of EDS. Prospective multicentre randomised controlled trials are needed to confirm these data.

Ethics, Evidence Based Sports Medicine, and the Use of Platelet Rich Plasma in the English Premier League

The use of platelet rich plasma (PRP) as a novel treatment is discussed in the context of a qualitative research study comprising 38 interviews with sports medicine practitioners and other stakeholders working within the English Premier League during the 2013-16 seasons. Analysis of the data produced several overarching themes: conservatism versus experimentalism in medical attitudes; therapy perspectives divergence; conflicting versions of appropriate evidence; subcultures; community beliefs/practices; and negotiation of medical decision-making. The contested evidence base for the efficacy of PRP is presented in the context of a broader professional shift towards evidence based medicine within sports medicine. Many of the participants while accepting this shift are still committed to casuistic practices where clinical judgment is flexible and does not recognize a context-free hierarchy of evidentiary standards to ethically justifiable practice. We also discuss a tendency in the data collected to consider the use of deceptive, placebo-like, practices among the clinician participants that challenge dominant understandings of informed consent in medical ethics. We conclude that the complex relation between evidence and ethics requires greater critical scrutiny for this emerging specialism within the medical community.

Role of a combination dietary supplement containing mucopolysaccharides, vitamin C, and collagen on tendon healing in rats

Objective

The aim of this study was to investigate the effect of mucopolysaccharide, vitamin C, and collagen supplementation on the healing of Achilles tendon in rats.

Methods

Sixteen rats were separated into 2 groups. Both Achilles tendons of all rats were transected 5 mm above the insertion and repaired using a Kessler suture. After the surgical repair, the study group received the daily recommended amount of the supplement by gastric gavage, while the control group received a placebo. At the end of the third week, the animals were sacrificed. The biomechanical properties of the groups were compared with ultimate tensile strength and stiffness tests. The biological properties of the 2 groups were assessed with a histomorphometric comparison to determine the amount of collagen type I (COL1), proliferating cell nuclear antigen (PCNA), and transforming growth factor β1 (TGF-β1) expression in 3 different tissue subgroups (collagen matrix, tenocytes, and endotenon fibroblasts).

Results

Analysis of histomorphometric results revealed that the rats receiving dietary supplements demonstrated a significant increase in PCNA (mean value of 86 in the control group and 168.85 in the trial group; p < 0.05) and TGF-β1 (mean value of 87.57 in the control group and 161.85 in the trial group; p < 0.05) in the endotenon fibroblasts of the repair site. However, there was no difference between the groups in PCNA or TGF-β1 when the collagen matrix and the tenocytes of the repair site were examined. Furthermore, no significant difference could be found between groups in COL1 in any of the 3 tissue subgroups (collagen matrix, tenocytes, and endotenon fibroblasts). The statistical analysis also indicated that the rats receiving supplements did not demonstrate a significant increase in the ultimate tendon tensile strength or stiffness.

Conclusion

The results of this study revealed no advantage to the oral administration of the trial supplement in collagen synthesis or biomechanical properties in rats after 3 weeks using the presented study design. However, the increased expression of PCNA and TGFβ1 seen in the endotenon fibroblasts of the repair site might play a role in the continuum of tendon healing.

Change of site of intra-articular injection of hypertonic dextrose resulted in different effects of treatment

Most minimally invasive treatments for dysfunction of the temporomandibular joint (TMJ) are empirical, and aimed at the painful trigger points with the purpose of preventing muscular spasm and restoring normal function. In this prospective study I investigated whether the choice of site of injection of hypertonic dextrose affected the benefits of treatment of internal derangement and pain. I studied 72 patients with pain and clicking as a result of dysfunction of the TMJ. Patients were divided into four groups with four separate sites for intra-articular injection. Dextrose was injected into the superior joint space, inferior joint space, retrodiscal tissue, and anterior capsule injection. Results showed that the retrodiscal site was the most effective for reducing clicking and subsequently improving derangement, while the inferior joint space was the best site for the relief of pain, and the extracapsular site should be used in cases of hypermobility. In conclusion, the injection site should be selected according to the symptoms being treated, and could be used as an adjunct to other sites to improve outcome.

Alternatives to Biologics in Management of Knee Osteoarthritis: A Systematic Review

BACKGROUND

Knee osteoarthritis (KOA) is a common condition encountered by physicians. KOA is addressed by a wide array of modalities including a number of nonbiological treatments.

METHODS

PubMed, ISI Web of Science, and SPORTDiscus were searched for level 1 to 4 studies published from inception to August 2017.

RESULTS

A total of 18 studies were evaluated and results demonstrated moderate supporting evidence for prolotherapy and limited evidence for botulinum toxin type A, sodium bicarbonate and calcium gluconate, and low-molecular weight fraction of 5% human serum albumin. Evidence for local anesthetic agents was conflicting.

CONCLUSION

There is moderate supportive evidence for the effectiveness of prolotherapy in improving pain and function in both, short-term and long-term. Limited supporting evidence found for botulinum toxin type A, sodium bicarbonate and calcium gluconate, and low-molecular weight fraction of 5% human serum albumin in improving pain and function. There is conflicting evidence for the use of local anesthetic agents in patients with KOA.

Efficacy of platelet-rich plasma injections for symptomatic tendinopathy: systematic review and meta-analysis of randomised injection-controlled trials

Aim

To determine the efficacy of platelet-rich plasma (PRP) injections for symptomatic tendinopathy.

Design

Systematic review of randomised, injection-controlled trials with meta-analysis.

Data sources

Systematic searches of MEDLINE and EMBASE, supplemented by manual searches.

Eligibility criteria for selecting studies

Randomised controlled trials with 3 months minimum follow-up that evaluated pain reduction with PRP versus control (saline, local anaesthetic, corticosteroid) injections in patients with symptomatic tendinopathy.

Results

A total of 16 randomised controlled trials (18 groups) of PRP versus control were included. Median sample size was 35 patients, a study size that would require an effect size ≥1.0 to achieve statistical significance. PRP was more efficacious than control in reducing tendinopathy pain, with an effect size of 0.47 (95% CI 0.22 to 0.72, p<0.001), signifying a moderate treatment effect. Heterogeneity among studies was moderate (I²=67%, p<0.001). In subgroup analysis and meta-regression, studies with a higher proportion of female patients were associated with greater treatment benefits with PRP.

Conclusions

Injection of PRP is more efficacious than control injections in patients with symptomatic tendinopathy.

Randomised, prospective, non-blinded pilot study comparing the effect of intramuscular steroid injections and intralesional steroid injections in the management of tennis elbow

Background

Tennis elbow is an overuse injury affecting people performing repetitive forearm movements. It is a soft tissue disorder that causes significant disability and pain.

The aim of the study was to establish that an intramuscular steroid injection is effective in the short-term pain relief and functional improvement of tennis elbow. The severity of pain at the injection site was monitored to determine whether the intramuscular injection is better tolerated than the intralesional injection.

Methods and results

19 patients, who had no treatment for tennis elbow in the preceding 3 months, were recruited from Whipps Cross University Hospital, London, and were randomised to receive either 80 mg of intramuscular Depo-Medrone or 40 mg of intralesional Depo-Medrone injection. Blinding proved difficult as the injection sites differed and placebo arms were not included in the study. A Patient-Rated Tennis Elbow Evaluation (PRTEE) Questionnaire and a 10-point Likert scale were used to assess primary outcome. Six weeks after the treatment, there was a reduction in pain, improvement in function and total PRTEE scores in both intramuscular and intralesional groups (p=0.008) using a 95% CI for mean treatment difference of −26 to +16 points. A statistically significant result (p=0.001) in favour of intramuscular causing less pain at the injection site was noted.

Conclusion

Non-inferiority of intramuscular to intralesional injections was not confirmed; however, the intramuscular injection proved to be effective in reducing tennis elbow-related symptoms and was found less painful at the site of injection at the time of administration.

Trial registration number

EUDRACT Number: 2010-022131-11.

REC Number: 10/H0718/76 (NRES, Central London REC 1).

Injection of tennis elbow: Hit and miss? A cadaveric study of injection accuracy

PURPOSE

Different injection therapies are used in the treatment of lateral epicondylitis (LE). Usually, the extensor carpi radialis brevis (ECRB) tendon is affected. Therefore, an injection should be aimed at the origin of this tendon. This study demonstrates the accuracy of manual injections in the treatment of LE.

METHODS

Ten surgeons have injected a cadaver elbow with acrylic paint, using the same injection technique (i.e. number of perforations, amount of injected fluid) that they in daily practice would use in the treatment of LE. After the injection, an arthroscopy and dissection of the elbow were performed. The injection technique and localization of acrylic paint were reported.

RESULTS

Only a third of the injections were (partially) localized in the ECRB tendon; 60 % were localized intra-articular.

CONCLUSION

Injections carried out manually for the treatment of LE are not accurate, resulting in the majority being localized intra-articular. For future research to the effect of injection therapy in the treatment of LE, it is important that injections should be performed in a reproducible and standardized way.

The effectiveness of prolotherapy in treating knee osteoarthritis in adults: a systematic review

INTRODUCTION

Osteoarthritis (OA) often leads to symptoms such as pain, stiffness and decreased function. OA is treated with a wide range of modalities, both conservatively and surgically. Prolotherapy has been used to treat various musculoskeletal problems and has shown some promise.

SOURCES OF DATA

Searches of the electronic databases, PubMed, ISI web of science, PEDro and SPORTDiscus, were conducted for all Level 1-4 studies published from inception through to December 2016.

AREAS OF AGREEMENT

Ten studies were evaluated and results show significant improvement in scores for pain, function and range of motion, both in the short term and long term. Patient satisfaction was also high in these patients (82%).

AREAS OF CONTROVERSY

Meta-analysis was not possible due to heterogeneity of outcome measures and populations.

GROWING POINTS

Moderate evidence suggests that prolotherapy is safe and can help achieve significant symptomatic control in individuals with OA.

AREAS FOR DEVELOPING RESEARCH

Future research should focus on larger sample size, standardization of treatment protocol and basic science evidence.

Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series

BACKGROUND

The intra-tendinous tear is a new pathology that is defined as a discontinuity of fibres situated entirely within the tendon. Prolotherapy involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain.

METHODS

43 consecutive patients diagnosed with an intra-tendinous tear were included (27 males: 16 females, mean (SD) age 41 (11.3). Patients were injected with 0.4ml-1.5ml (mean 0.8ml) of 50% dextrose and 0.5% marcaine mixed in a 1:1 ratio. A 4-6 week period of walking boot immobilisation was followed by progressive rehabilitation (6-8 weeks). Outcomes were assessed with a VISA-A questionnaire at baseline, 3 months and a mean 12.6 (7.0) months post-treatment. Ultrasound scans were conducted before treatment and 5.2 (2.3) weeks later to assess sonographic changes.

RESULTS

30 patients (70%) responded with VISA-A scores increasing by 31 (30.5) points after 3 months (f=0.62, p<0.05) and by 40 (29.3) points after 12.60 (7.0) months (f=0.87, p<0.05). After 5.2 (2.3) weeks, echogenicity was significantly reduced (p<0.05) and 27% of tears were no longer detectable. No significant differences were observed in remaining tears with respect to tear size, tendon thickness or neovascularisation.

CONCLUSION

Treatment resulted in clinically significant improvements and controlled trials are warranted.

LEVEL OF EVIDENCE

IV.

Orthopaedic management of the Ehlers-Danlos syndromes

The role of orthopedic surgery in Ehlers-Danlos syndrome is inherently controversial, opaque to most patients and many medical providers, and difficult to discern from available medical literature. Non-operative treatment is preferable, but for carefully selected patients, specific joint stabilization and nerve decompression procedures can provide symptomatic relief when conservative measures fail. © 2017 Wiley Periodicals, Inc.

Current use of autologous adipose tissue-derived stromal vascular fraction cells for orthopedic applications

Autologous adipose stromal vascular fractions (SVFs) containing adipose tissue-derived stem cells (ASCs) are currently being used in clinical settings for various orthopedic applications for human patients. Due to its potential capability of regenerating cartilage, bone, and tendons, autologous adipose SVFs are being tried in treating patients with osteoarthritis (OA), chondromalacia, meniscus tear, osteonecrosis of the femoral head, and tendon injuries. Here, we have reviewed available human clinical studies with regard to patient applications of autologous adipose SVF containing ASCs, specifically assessing effectiveness and safety in the field of orthopedic disorders. All studies reviewed in this article presents potential benefits of autologous adipose SVF in various orthopedic applications without any serious side effects.

Comparative effectiveness of dextrose prolotherapy versus control injections and exercise in the management of osteoarthritis pain: a systematic review and meta-analysis

BACKGROUND

Increasing evidence has supported the use of dextrose prolotherapy for patients with osteoarthritis. However, the real benefits may be affected by differences in injection protocols, comparative regimens, and evaluation scales.

METHODS

PubMed and Scopus were searched from the earliest record until February 2016. One single-arm study and five randomized controlled trials were included, comprising 326 participants. We estimated the effect sizes of pain reduction before and after serial dextrose injections and compared the values between dextrose prolotherapy, comparative regimens, and exercise 6 months after the initial injection.

RESULTS

Regarding the treatment arm using dextrose prolotherapy, the effect sizes compared with baseline were 0.65 (95% confidence interval [CI], 0.14-1.17), 0.84 (95% CI, 0.40-1.27), 0.85 (95% CI, 0.60-1.10), and 0.87 (95% CI, 0.53-1.21) after the first, second, third, and fourth or more injections, respectively. The overall effect of dextrose was better than control injections (effect size, 0.36; 95% CI, 0.10-0.63). Dextrose prolotherapy had a superior effect compared with local anesthesia (effect size, 0.38; 95% CI, 0.07-0.70) and exercise (effect size, 0.71; 95% CI, 0.30-1.11). There was an insignificant advantage of dextrose over corticosteroids (effect size, 0.31; 95% CI, -0.18 to 0.80) which was only estimated from one study.

CONCLUSION

Dextrose injections decreased pain in osteoarthritis patients but did not exhibit a positive dose-response relationship following serial injections. Dextrose prolotherapy was found to provide a better therapeutic effect than exercise, local anesthetics, and probably corticosteroids when patients were retested 6 months following the initial injection.

A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain

OBJECTIVE

The aim of this study was to systematically review dextrose (d-glucose) prolotherapy efficacy in the treatment of chronic musculoskeletal pain.

DATA SOURCES

Electronic databases PubMed, Healthline, OmniMedicalSearch, Medscape, and EMBASE were searched from 1990 to January 2016.

STUDY SELECTION

Prospectively designed studies that used dextrose as the sole active prolotherapy constituent were selected.

DATA EXTRACTION

Two independent reviewers rated studies for quality of evidence using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs, for level of evidence using a modified Sackett scale, and for clinically relevant pain score difference using minimal clinically important change criteria. Study population, methods, and results data were extracted and tabulated.

DATA SYNTHESIS

Fourteen RCTs, 1 case–control study, and 18 case series studies met the inclusion criteria and were evaluated. Pain conditions were clustered into tendinopathies, osteoarthritis (OA), spinal/pelvic, and myofascial pain. The RCTs were high-quality Level 1 evidence (Physiotherapy Evidence Database ≥8) and found dextrose injection superior to controls in Osgood–Schlatter disease, lateral epicondylitis of the elbow, traumatic rotator cuff injury, knee OA, finger OA, and myofascial pain; in biomechanical but not subjective measures in temporal mandibular joint; and comparable in a short-term RCT but superior in a long-term RCT in low back pain. Many observational studies were of high quality and reported consistent positive evidence in multiple studies of tendinopathies, knee OA, sacroiliac pain, and iliac crest pain that received RCT confirmation in separate studies. Eighteen studies combined patient self-rating (subjective) with psychometric, imaging, and/or biomechanical (objective) outcome measurement and found both positive subjective and objective outcomes in 16 studies and positive objective but not subjective outcomes in two studies. All 15 studies solely using subjective or psychometric measures reported positive findings.

CONCLUSION

Use of dextrose prolotherapy is supported for treatment of tendinopathies, knee and finger joint OA, and spinal/pelvic pain due to ligament dysfunction. Efficacy in acute pain, as first-line therapy, and in myofascial pain cannot be determined from the literature.

Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis

Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi-randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.

The effect of platelet-rich plasma injection on lateral epicondylitis following failed conservative management

OBJECTIVE

We assessed the effect PRP injection on pain and function in patients with lateral epicondylitis where conservative management had failed.

METHODS

We prospectively reviewed 34 patients. The mean follow-up was 26 weeks (range 6-114 weeks). We used the Oxford Elbow Score (OES) and progression to surgery to assess outcomes.

RESULTS

88.2% improved their OES. 8.8% reported symptom progression. One patient had no change. No patients suffered adverse reactions. Two patients underwent an open release procedure. One had the injection repeated.

CONCLUSION

An injection of PRP improves pain and function in patients suffering from LE where conservative management has failed.

What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations

BACKGROUND

Lateral elbow tendinopathy (LET) is a common complaint causing characteristic pain in the lateral elbow and upper forearm, and tenderness of the forearm extensor muscles. It is thought to be an overuse injury and can have a major impact on the patient's social and professional life. The condition is challenging to treat and prone to recurrent episodes. The average duration of a typical episode ranges from 6 to 24 months, with most (89%) reporting recovery by 1 year.

OBJECTIVES

This systematic review aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for LET.

DATA SOURCES

A comprehensive search was conducted from database inception to 2012 in a range of databases including MEDLINE, EMBASE and Cochrane Databases.

METHODS AND OUTCOMES

We conducted an overview of systematic reviews to summarise the current evidence concerning the clinical effectiveness and a systematic review for the cost-effectiveness of conservative interventions for LET. We identified additional randomised controlled trials (RCTs) that could contribute further evidence to existing systematic reviews. We searched MEDLINE, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Web of Science, The Cochrane Library and other important databases from inception to January 2013.

RESULTS

A total of 29 systematic reviews published since 2003 matched our inclusion criteria. These were quality appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist; five were considered high quality and evaluated using a Grading of Recommendations, Assessment, Development and Evaluation approach. A total of 36 RCTs were identified that were not included in a systematic review and 29 RCTs were identified that had only been evaluated in an included systematic review of intermediate/low quality. These were then mapped to existing systematic reviews where further evidence could provide updates. Two economic evaluations were identified.

LIMITATIONS

The summary of findings from the review was based only on high-quality evidence (scoring of > 5 AMSTAR). Other limitations were that identified RCTs were not quality appraised and dichotomous outcomes were also not considered. Economic evaluations took effectiveness estimates from trials that had small sample sizes leading to uncertainty surrounding the effect sizes reported. This, in turn, led to uncertainty of the reported cost-effectiveness and, as such, no robust recommendations could be made in this respect.

CONCLUSIONS

Clinical effectiveness evidence from the high-quality systematic reviews identified in this overview continues to suggest uncertainty as to the effectiveness of many conservative interventions for the treatment of LET. Although new RCT evidence has been identified with either placebo or active controls, there is uncertainty as to the size of effects reported within them because of the small sample size. Conclusions regarding cost-effectiveness are also unclear. We consider that, although updated or new systematic reviews may also be of value, the primary focus of future work should be on conducting large-scale, good-quality clinical trials using a core set of outcome measures (for defined time points) and appropriate follow-up. Subgroup analysis of existing RCT data may be beneficial to ascertain whether or not certain patient groups are more likely to respond to treatments.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003593.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review

Introduction

The aim of this review was to identify and evaluate existing research to determine the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy.

Review

Nine databases were searched (Medline, Science Direct, AMED, Australian Medical Index, APAIS-Health, ATSIhealth, EMBASE, Web of Science, OneSearch) without language, publication or data restrictions for all relevant articles between January 1960 and September 2014. All prospective randomised and non-randomised trials, cohort studies, case-series, cross-sectional studies and controlled trials assessing the effectiveness of one or more prolotherapy injections for tendinopathy or fasciopathy at or below the superior aspect of the tibia/fibula were included. Methodological quality of studies was determined using a modified evaluation tool developed by the Cochrane Musculoskeletal Injuries Group. Data analysis was carried out to determine the mean change of outcome measure scores from baseline to final follow-up for trials with no comparative group, and for randomised controlled trials, standardised mean differences between intervention groups were calculated. Pooled SMD data were calculated where possible to determine the statistical heterogeneity and overall effect for short-, intermediate- and long-term data. Adverse events were also reported.

Two hundred and three studies were identified, eight of which met the inclusion criteria. These were then grouped according to tendinopathy or fasciopathy being treated with prolotherapy injections: Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease. The methodological quality of the eight included studies was generally poor, particularly in regards to allocation concealment, intention to treat analysis and blinding procedures. Results of the analysis provide limited support for the hypothesis that prolotherapy is effective in both reducing pain and improving function for lower limb tendinopathy and fasciopathy, with no study reporting a mean negative or non-significant outcome following prolotherapy injection. The analysis also suggests prolotherapy injections provide equal or superior short-, intermediate- and long-term results to alternative treatment modalities, including eccentric loading exercises forAchilles tendinopathy, platelet-rich plasma for plantar fasciopathy and usual care or lignocaine injections for Osgood-Schlatter disease. No adverse events following prolotherapy injections were reported in any study in this review.

Conclusions

The conclusions of this review were derived from the best available scientific evidence. It is intended that the results of this study will assist clinical decision-making by practitioners. The results of this review found limited evidence that prolotherapy injections are a safe and effective treatment for Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease, however more robust research using large, methodologically-sound randomised controlled trials is required to substantiate these findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-015-0114-5) contains supplementary material, which is available to authorized users.

Efficacy of physical therapy for the treatment of lateral epicondylitis: a meta-analysis

Background

Physical therapy for the treatment of lateral epicondylitis (LE) often comprises movement therapies, extracorporeal shockwave therapy (ECSWT), low level laser therapy (LLLT), low frequency electrical stimulation or pulsed electromagnetic fields. Still, only ECSWT and LLLT have been meta-analytically researched.

Methods

PUBMED, EMBASE and Cochrane database were systematically searched for randomized controlled trials (RCTs). Methodological quality of each study was rated with an adapted version of the Scottish Intercollegiate Guidelines Network (SIGN) checklist. Pain reduction (the difference between treatment and control groups at the end of trials) and pain relief (the change in pain from baseline to the end of trials) were calculated with mean differences (MD) and 95 %-Confidence intervals (95 % CI).

Results

One thousand one hundred thirty eight studies were identified. One thousand seventy of those did not meet inclusion criteria. After full articles were retrieved 16 studies met inclusion criteria and 12 studies reported comparable outcome variables. Analyses were conducted for overall pain relief, pain relief during maximum handgrip strength tests, and maximum handgrip strength. There were not enough studies to conduct an analysis of physical function or other outcome variables.

Conclusions

Differences between treatment and control groups were larger than differences between treatments. Control group gains were 50 to 66 % as high as treatment group gains. Still, only treatment groups with their combination of therapy specific and non-therapy specific factors reliably met criteria for clinical relevance. Results are discussed with respect to stability and their potential meaning for the use of non-therapy specific agents to optimize patients’ gain.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0665-4) contains supplementary material, which is available to authorized users.

Image-guided elbow interventions: a literature review of interventional treatment options

Over the years, a wide range of image-guided interventional therapies have been used in treating different elbow pathologies, many of which are predominantly based on anecdotal and low-level study findings. This article critically assesses the existing literature and discusses the efficacy of the most commonly utilized interventional procedures for elbow pathology.

Treatment of Lateral Epicondylosis by Using Allogeneic Adipose-Derived Mesenchymal Stem Cells: A Pilot Study

Mesenchymal stem cell therapy is a novel regenerative approach for treating tendinopathy. Here, we evaluated the safety and efficacy of allogeneic adipose-derived mesenchymal stem cells (allo-ASC) in treating lateral epicondylosis (LE). Under ultrasound guidance, allo-ASCs mixed with fibrin glue were injected into the hypoechoic common extensor tendon lesions of 12 participants with chronic LE; 6 subjects each were administered 10(6) or 10(7) cells in 1 ml. Safety was evaluated at day 3 and weeks 2, 6, 12, 26, and 52 post-injection. Efficacy was assessed by measuring patients' visual analog scale (VAS) score for elbow pain, modified Mayo clinic performance index for the elbow, and by evaluating longitudinal and transverse ultrasound images of tendon defect areas after 6, 12, 26, and 52 weeks. No significant adverse effects of allo-ASC injection were observed through 52 weeks of follow-up. From baseline through 52 weeks of periodic follow-up, VAS scores progressively decreased from 66.8 ± 14.5 mm to 14.8 ± 13.1 mm and elbow performance scores improved from 64.0 ± 13.5 to 90.6 ± 5.8. Tendon defects also significantly decreased through this period. Allo-ASC therapy was thus safe and effective in improving elbow pain, performance, and structural defects for 52 weeks. This clinical study is the first to reveal therapeutic value of mesenchymal stem cell injection for treating chronic tendinopathy.

Platelet-rich plasma for osteoarthritis treatment

We conducted a comprehensive and systematic search of the literature on the use of platelet-rich plasma (PRP) in the treatment of osteoarthritis, using the Medline, Lilacs, Cochrane and SciELO databases, from May 2012 to October 2013. A total of 23 studies were selected, with nine being controlled trials and, of these, seven randomized, which included 725 patients. In this series, the group receiving PRP showed improvement in pain and joint function compared to placebo and hyaluronic acid. The response lasted up to two years and was better in milder cases. However it was found that there is no standardization in the PRP production method, neither in the number, timing, and volume of applications. Furthermore, the populations studied were not clearly described in many studies. Thus, these results should be analyzed with caution, and further studies with more standardized methods would be necessary for a more consistent conclusion about the PRP role in osteoarthritis.