Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: a protocol for a randomised control trial with placebo comparison

Interhemispheric Inhibition Between Primary Motor Cortices is Not Altered in Individuals With Chronic Lateral Epicondylalgia

Lateral epicondylalgia (LE), commonly referred to as tennis elbow, is a musculoskeletal condition characterized by pain and sensorimotor dysfunction. In some individuals with chronic unilateral LE, sensorimotor symptoms develop on the unaffected side despite no evidence of tissue damage. Altered interhemispheric inhibition (IHI) is one mechanism that could underpin this phenomenon. The aim of this cross-sectional study was to examine IHI between the primary motor cortices (M1) in individuals with chronic LE and healthy controls. In 20 individuals with chronic LE and 20 healthy participants, transcranial magnetic stimulation was used to assess 1) short and long-latency IHI from the affected (corresponding to the injured side) to the unaffected M1 and 2) corticomotor excitability of the affected and unaffected M1. Sensorimotor function was evaluated bilaterally at the extensor carpi radialis brevis muscle using pressure pain threshold, grip strength, 2-point discrimination, and temporal summation tests. Short- and long-latency IHI from the affected to the unaffected M1 and corticomotor excitability of the affected and unaffected M1 were not altered in individuals with LE compared with healthy participants. No differences in sensorimotor function were observed for the affected or unaffected extensor carpi radialis brevis muscles when individuals with LE were compared with healthy participants. IHI is not altered in individuals with chronic LE. Further studies are required to determine the mechanisms that underpin the development of bilateral sensorimotor symptoms in unilateral LE. PERSPECTIVE: IHI is unaltered from the affected M1 (corresponding to the painful muscle) to unaffected M1 in individuals with LE compared to healthy controls. The absence of bilateral sensorimotor dysfunction and low pain severity in this cohort of individuals with LE may explain this finding.

Clinical and radiological effects of Corticosteroid injection combined with deep transverse friction massage and Mill's manipulation in lateral epicondylalgia-A prospective, randomized, single-blinded, sham controlled trial

BACKGROUND

The knowledge about the effective implementation of corticosteroid injection (CS) with deep transverse friction massage (DTFM) and Mill's manipulation (MM) on clinical and radiological changes (Magnetic resonance imaging-MRI and Ultra sound) in lateral epicondylalgia (LE) is lacking. Therefore, the objective of this study is proposed to find and compare the effects of corticosteroid injection (CS) DTFM and Mill's manipulation on clinical and radiological changes in lateral epicondylalgia.

DESIGN, SETTING, PARTICIPANTS

Randomized, single-blinded, controlled study was conducted on 60 LE participants at university hospital. The active MM group (n = 30) received corticosteroid injection with DTFM and active Mill's manipulation (MM) three sessions a week for 4 weeks and the sham MM group received corticosteroid injection with sham manipulation. The primary outcome was pain intensity, measured with the visual analog scale. The other outcome measures were percentage of injury measured by MRI and ultrasound, functional disability, handgrip strength, patient perception, kinesiophobia, depression status and quality of life which were measured at 4 weeks, 8weeks and at 6 months follow up.

RESULTS

The between-group difference in pain intensity at 4 weeks was 1.6 (CI 95% 0.97 to 2.22), which shows improvement in the active group than sham group. The similar effects have been noted after 8 weeks and at 6 months 2.0 (CI 95% 1.66 to 2.33) follow up in pain intensity. Similar improvements were also found on percentage of injury, functional disability, handgrip strength, patient perception, kinesiophobia, depression status and quality of life (p = 0.001).

CONCLUSION

Corticosteroid injection with DTFM and Mill's manipulation was superior to sham group for improving pain, percentage of injury, functional disability, handgrip strength, patient perception, kinesiophobia, depression status and quality of life in people with lateral epicondylalgia.

TRIAL REGISTRATION

Clinical trial registration: CTRI/2020/05/025135 trial registered prospectively on 12/05/2020. https://trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2020/05/025135.

MRI and Ultrasound Analysis of Corticosteroid Injection Combined with Extracorporeal Shockwave Therapy in Lateral Epicondylitis—A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial

Objective: The knowledge about the effective implementation of corticosteroid injection and extracorporeal shockwave therapy on radiological changes in chronic lateral epicondylitis is lacking. Therefore, the objective of this study is to find and compare the effects of corticosteroid injection and extracorporeal shockwave therapy on radiological changes in chronic lateral epicondylitis. Methods: A randomized, double-blinded controlled study was conducted on 60 LE participants at a university hospital. The active extracorporeal shockwave therapy group (n = 30) received a corticosteroid injection with active extracorporeal shockwave therapy one session a week for 4 weeks, and the placebo extracorporeal shockwave therapy group received a corticosteroid injection with placebo extracorporeal shockwave therapy. The primary outcome was pain intensity, measured with the visual analog scale. The other outcome measures were the percentage of injury measured by magnetic resonance imaging and ultrasound, functional disability, handgrip strength, patient perception, kinesiophobia, depression status, and quality of life. Results: The between-group difference in pain intensity at 4 weeks was 1.4 (CI 95% 0.77 to 2.02), which shows more improvement in the active group than in the placebo group. Improvements in the effects were noted after 8 weeks and at 6 months (1.8; CI 95% 1.50 to 2.09) follow-up. Similar improvements were also found in the percentage of injury, functional disability, handgrip strength, patient perception, kinesiophobia, depression status, and quality of life. Conclusion: Extracorporeal shockwave therapy has added effects on corticosteroid injection for improving pain, percentage of injury, functional disability, handgrip strength, patient perception, kinesiophobia, depression status and quality of life in people with chronic lateral epicondylitis.

Efficacy of ultrasound therapy for the treatment of lateral elbow tendinopathy (the UCICLET Trial): study protocol for a three-arm, prospective, multicentre, randomised controlled trial

INTRODUCTION

Lateral elbow tendinopathy (LET) is a highly prevalent disease among the middle-aged population, with no consensus on optimal management. Non-operative treatment is generally accepted as the first-line intervention. Ultrasound (US) therapy has been reported to be beneficial for various orthopaedic diseases, including tendinopathy. The purpose of this study is to investigate the efficacy of US for LET treatment.

METHODS AND ANALYSIS

This protocol entails a three-arm, prospective, multicentre, randomised controlled trial. Seventy-two eligible participants with clinically confirmed LET will be assigned to either (1) US, (2) corticosteroid injections or (3) control group. All participants will receive exercise-based therapy as a fundamental intervention. The primary outcome is Patient-rated Tennis Elbow Evaluation. The secondary outcomes include Visual Analogue Scale for pain, shortened version of the Disabilities of the Arm, Shoulder and Hand for upper limb disability, pain free/maximum grip strength, Work Limitations Questionnaire-25 for functional limitations at work, EuroQol-5D for general health, Hospital Anxiety and Depression Scale for mental status, Global Rating of Change for treatment success and recurrence rate, and Mahomed Scale for the participant's satisfaction. Adverse events will be recorded. Intention-to-treat analyses will be used.

ETHICS AND DISSEMINATION

Ethics committees of all clinical centres have approved this study. The leading centre is Shanghai Sixth People's Hospital, whose approval number is 2021-153. New versions with appropriate amendments will be submitted to the committee for further approval. Final results will be published in peer-reviewed journals and presented at local, national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100050547.

Early Results of Kinesio Taping and Steroid Injections in Elbow Lateral Epicondylitis: A Randomized, Controlled Study

Background and objectives: This study prospectively compares early results of Kinesio tape (KT) as an alternative method for the treatment of lateral epicondylitis with those of corticosteroid injection and the rest-and-medication group (RMG). Materials and methods: Among the fifty patients (53 elbows), KT was applied to 20 patients (21 elbows), and corticosteroid injection (CSI) was applied to 15 patients (17 elbows). Fifteen patients were included in the RMG. Patients in the RMG were informed about their condition, and necessary warnings were given. No oral or topical treatments were recommended. If needed, paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed. Patients were classified according to the Nirschl scores and evaluated with visual analog scale (VAS); Quick Disability of Arm, Shoulder and Hand (QDASH); and the Turkish version of the Patient Related Elbow Evaluation (PREE-T). Results: Improvements in all scores were statistically significant in all groups at the end of the second week. At the end of the fourth week, there was also a statistically significant improvement in all three groups, but these improvements were not as high as they were in the first 2 weeks. There was a slight deterioration in the functional scores in the RMG and CSI groups, while the improvement in the KT group continued. In the KT group, the average QDASH score was 18.1 (4.5–35), the VAS score was 2 (1–3), the VAS score in resisted wrist extension was 4 (2–5) and the Nirschl score was 2 (1–3) at the fourth week. The KT group had significant superiority in these parameters over the RMG (p = 0.035, p = 0.035, p = 0.029, p = 0.035, respectively). However, there was no significant difference between the KT, the RMG and the CSI groups at the fourth week. Conclusions: CSI, KT and rest-and-medication treatments were all effective in terms of pain reduction and functional scores at the end of week 2, and the only treatment that continued to be effective in the final week was KT.

Prolotherapy injections and physiotherapy used singly and in combination for lateral epicondylalgia: a single-blinded randomised clinical trial

Background

Lateral epicondylalgia (tennis elbow) is a common, debilitating and often treatment-resistant condition. Two treatments thought to address the pathology of lateral epicondylalgia are hypertonic glucose plus lignocaine injections (prolotherapy) and a physiotherapist guided manual therapy/exercise program (physiotherapy). This trial aimed to compare the short- and long-term clinical effectiveness, cost effectiveness, and safety of prolotherapy used singly and in combination with physiotherapy.

Methods

Using a single-blinded randomised clinical trial design, 120 participants with lateral epicondylalgia of at least 6 weeks’ duration were randomly assigned to prolotherapy (4 sessions, monthly intervals), physiotherapy (weekly for 4 sessions) or combined (prolotherapy+physiotherapy). The Patient-Rated Tennis Elbow Evaluation (PRTEE) and participant global impression of change scores were assessed by blinded evaluators at baseline, 6, 12, 26 and 52 weeks. Success rate was defined as the percentage of participants indicating elbow condition was either ‘much improved’ or ‘completely recovered.’ Analysis was by intention-to-treat.

Results

Eighty-eight percent completed the 12-month assessment. At 52 weeks, there were substantial, significant improvements compared with baseline status for all outcomes and groups, but no significant differences between groups. The physiotherapy group exhibited greater reductions in PRTEE at 12 weeks than the prolotherapy group (p = 0.014).

Conclusion

There were no significant differences amongst the Physiotherapy, Prolotherapy and Combined groups in PRTEE and global impression of change measures over the course of the 12-month trial.

Trial registration

ACTRN12612000993897.

The Therapeutic Benefits of Saline Solution Injection for Lateral Epicondylitis: A Meta-analysis of Randomized Controlled Trials Comparing Saline Injections With Nonsurgical Injection Therapies

PURPOSE

To quantify the effect of saline solution injections on patient-reported outcome measures (PROMs) and to determine whether this effect is clinically relevant by comparing it with minimal clinically important difference (MCID) criteria.

METHODS

A systematic search identified randomized controlled trials of lateral epicondylitis interventions comparing saline solution injections with nonsurgical injection therapies. Among included studies, saline solution was compared with platelet-rich plasma, autologous conditioned plasma, corticosteroid, and botulinum toxin injections. By use of data from included studies, a random-effects model was used to calculate overall mean differences (MDs) in pre- and post-injection PROMs in a pair-wise fashion. Calculated MDs were then compared with MCID criteria.

RESULTS

Of 458 identified studies, 10 met the inclusion criteria and encompassed 283 patients. At 1, 3, 6, and 12 months, statistically significant improvements in MDs in visual analog scale (VAS) scores were noted as follows: MD of 16.11 (95% confidence interval [CI], 8.29-23.93) at 1 month; MD of 22.50 (95% CI, 11.45-33.55) at 3 months; MD of 40.40 (95% CI, 27.48-53.32) at 6 months; and MD of 47.04 (95% CI, 39.43-54.66) at 12 months. At 6 months, Disabilities of the Arm, Shoulder and Hand scores showed a statistically significant improvement (MD, 23.92; 95% CI, 9.47-38.37).

CONCLUSIONS

Improvements in Disabilities of the Arm, Shoulder and Hand scores at 6 months (23.92) surpassed MCID criteria for conservatively managed upper-extremity musculoskeletal pathology (10.83)-suggesting that saline solution injections have a clinically relevant effect. VAS MCID criteria are poorly established, but VAS scores at 6 and 12 months surpassed MCID criteria for conservative treatments for common orthopaedic conditions. In all but 1 study, no statistically significant difference in PROMs was found between saline solution and non-saline solution injections.

LEVEL OF EVIDENCE

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

Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All

Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by many proposed interventions and the condition's prognosis, ranging from immediate resolution of symptoms following simple advice in some patients to long-lasting problems, regardless of treatment, in others. This is compounded by our lack of understanding of the complexity of the underlying pathophysiology of LET. In this article, we collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears, or central sensitization, are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. A preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. Further research is needed to evaluate whether such an approach may lead to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.

Ultrasound-guided percutaneous needle electrolysis in chronic lateral epicondylitis: short-term and long-term results

BACKGROUND

Ultrasound (US)-guided percutaneous needle electrolysis (PNE) is a novel minimally invasive approach which consists of the application of a galvanic current through an acupuncture needle.

OBJECTIVE

To evaluate the clinical and ultrasonographic effectiveness of a multimodal programme (PNE, eccentric exercise (EccEx) and stretching) in the short term for patients with chronic lateral epicondylitis, and to determine whether the clinical outcomes achieved decline over time.

METHODS

A one-way repeated measures study was performed in a clinical setting in 36 patients presenting with lateral epicondylitis. The patients received one session of US-guided PNE per week over 4-6 weeks, associated with a home programme of EccEx and stretching. The main outcome measures were severity of pain, disability (Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), structural tendon changes (US), hypervascularity and patients' perceptions of overall outcome. Measurements at 6, 26 and 52 weeks follow-up included recurrence rates (increase in severity of pain or disability compared with discharge), perception of overall outcome and success rates.

RESULTS

All outcome measures registered significant improvements between pre-intervention and discharge. Most patients (n=30, 83.3%) rated the overall outcome as 'successful' at 6 weeks. The ultrasonographic findings showed that the hypoechoic regions and hypervascularity of the extensor carpi radialis brevis changed significantly. At 26 and 52 weeks, all participants (n=32) perceived a 'successful' outcome. Recurrence rates were null after discharge and at follow-up at 6, 26 and 52 weeks.

CONCLUSIONS

Symptoms and degenerative structural changes of chronic lateral epicondylitis are reduced after US-guided PNE associated with EccEx and stretching, with encouragingly low recurrences in the mid to long term.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02085928.

A randomized clinical trial on comparison of corticosteroid injection with or without splinting versus saline injection with or without splinting in patients with lateral epicondylitis

BACKGROUND

Lateral epicondylitis is a common problem affecting 1-3% of the population. There has been much debate about the best treatment modality for this condition. There is, however, no conclusive evidence in support of any of the proposed treatment modalities. In this trial, we have studied the effect of corticosteroid injection (with or without splinting) with normal saline injection (with or without splinting).

MATERIALS AND METHODS

In this double-blind, randomized clinical trial, individuals were randomly assigned to either of four treatment groups and received either 40 mg depomedrol injection alone, 40 mg depomedrol injection with splinting, normal saline injection alone, or normal saline injection with splinting. They were evaluated using the visual analog scale (VAS) at weeks 2, 4 and 24 and with the Oxford elbow scale (OES) at 24 weeks.

RESULTS

A total of 79 patients were participated in the study. The corticosteroid injection groups had better pain relief as measured by VAS at 2 and 4 weeks compared with the two saline injection groups. Mean VAS difference at week 0 versus week 2 was 4.5 ± 0.9 and 2.8 ± 0.6 in corticosteroid injection groups and saline injection groups respectively (P < 0.01) but at 24 weeks, there was only moderate benefit reported for the group which received steroid injection and splinting (P < 0.01) compared to the saline injection groups. The saline injection groups reported better improvement in OES scores (20.1 ± 3.7) at the end of the trial compared corticosteroid injection groups (16.1 ± 2.9) (P < 0.05).

CONCLUSION

Our results indicate that despite the clear pain reduction benefit associated with steroid injection in short term, this benefit in comparison with normal saline injection fades by the 24(th) week of follow-up.

Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report

BACKGROUND

This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report.

METHODS

A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

RESULTS

25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

CONCLUSIONS

Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

Quality measures for the care of patients with lateral epicondylalgia

Background

Lateral epicondylalgia (LE) defines a condition of varying degrees of pain near the lateral epicondyle. Studies on the management of LE indicated unexplained variations in the use of pharmacologic, non-pharmacological and surgical treatments.

The main aim of this paper was to develop and evaluate clinical quality measures (QMs) or quality indicators, which may be used to assess the quality of the processes of examination, education and treatment of patients with LE.

Methods

Different QMs were developed by a multidisciplinary group of experts in Quality Management of Health Services during a period of one year. The process was based following a 3-step model: i) review and proportion of existing evidence-based recommendations; ii) review and development of quality measures; iii) pilot testing of feasibility and reliability of the indicators leading to a final consensus by the whole panel.

Results

Overall, a set of 12 potential indicators related to medical and physical therapy assessment and treatment were developed to measure the performance of LE care. Different systematic reviews and randomized control trials supported each of the indicators judged to be valid during the expert panel process. Application of the new indicator set was found to be feasible; only the measurement of two quality measures had light barriers. Reliability was mostly excellent (Kappa > 0.8).

Conclusions

A set of good practice indicators has been built and pilot tested as feasible and reliable. The chosen 3-step standardized evidence-based process ensures maximum clarity, acceptance and sustainability of the developed indicators.

Relationships between biomechanics, tendon pathology, and function in individuals with lateral epicondylosis

STUDY DESIGN

Single-cohort descriptive and correlational study.

OBJECTIVES

To investigate the relationships between tendon pathology, biomechanical measures, and self-reported pain and function in individuals with chronic lateral epicondylosis.

BACKGROUND

Lateral epicondylosis has a multifactorial etiology and its pathophysiology is not well understood. Consequently, treatment remains challenging, and lateral epicondylosis is prone to recurrence. While tendon pathology, pain system changes, and motor impairments due to lateral epicondylosis are considered related, their relationships have not been thoroughly investigated.

METHODS

Twenty-six participants with either unilateral (n = 11) or bilateral (n = 15) chronic lateral epicondylosis participated in this study. Biomechanical measures (grip strength, rate of force development, and electromechanical delay) and measures of tendon pathology (magnetic resonance imaging and ultrasound) and self-reported pain and function (Patient-Rated Tennis Elbow Evaluation) were performed. Partial Spearman correlations, adjusting for covariates (age, gender, weight, and height), were used to evaluate the relationship between self-reported pain, function, and biomechanical and tendon pathology measures.

RESULTS

Statistically significant correlations between biomechanical measures and the Patient-Rated Tennis Elbow Evaluation ranged in magnitude from 0.44 to 0.68 (P<.05); however, no significant correlation was observed between tendon pathology (magnetic resonance imaging and ultrasound) measures and the Patient-Rated Tennis Elbow Evaluation (r = -0.02 to 0.31, P>.05). Rate of force development had a stronger correlation (r = 0.54-0.68, P<.05) with self-reported function score than with grip strength (r = 0.35-0.47, P<.05) or electromechanical delay (r = 0.5, P<.05).

CONCLUSION

Biomechanical measures (pain-free grip strength, rate of force development, electromechanical delay) have the potential to be used as outcome measures to monitor progress in lateral epicondylosis. In comparison, the imaging measures (magnetic resonance imaging and ultrasound) were useful for visualizing the pathophysiology of lateral epicondylosis. However, the severity of the pathophysiology was not related to pain and function, indicating that imaging measures may not provide the best clinical assessment.

The effects of corticosteroid injection versus local anesthetic injection in the treatment of lateral epicondylitis: a randomized single-blinded clinical trial

INTRODUCTION

This study seeks to compare two treatment methods of lateral epicondylitis: corticosteroid injection (CSI) and a local anesthetic injection (LAI).

MATERIALS AND METHODS

In this single-blinded randomized clinical trial, 138 patients with the diagnosis of lateral epicondylitis were assigned either into CSI group receiving methylprednisolone 1 ml (49 patients) or LAI group (51 patients) receiving procaine 1 ml 2 % in a single dose at the maximal point tenderness site. The primary outcome measure was elbow disability using Quick DASH, and secondary outcome measures were pain intensity using Visual Analogue Scale (VAS) and recurrence rate at pretreatment visit and at 3-, 6- and 12-week post-treatment visits.

RESULTS

There were no significant differences between the patients in both groups for demographic factors including age, gender, dominant hand, involved hand, and work pressure. Before treatment, the patients in both groups were suffering from the same rates of elbow disability and pain as measured by Quick DASH and VAS, respectively, (p > 0.05). In general, the recovery rate (comparison between pretreatment visit and last post-treatment visit) was significantly more effective and higher in CSI than LAI. CSI was dramatically more effective at 3-week visit, but less and less effective at 6- and 12-week visits. At 12-week visit the recurrence rate was 34.7 % (17 patients) in CSI group.

CONCLUSION

For lateral epicondylitis, CSI has the best short-term treatment results yet the highest recurrent rates. The combination of CSI with other treatment option or with a change in injection technique from single injection to peppering injection may be promising.

Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Injection therapy with glucocorticoids has been used since the 1950s as a treatment strategy for lateral epicondylitis (tennis elbow). Lately, several novel injection therapies have become available.

PURPOSE

To assess the comparative effectiveness and safety of injection therapies in patients with lateral epicondylitis.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Randomized controlled trials comparing different injection therapies for lateral epicondylitis were included provided they contained data for change in pain intensity (primary outcome). Trials were assessed using the Cochrane risk of bias tool. Network (random effects) meta-analysis was applied to combine direct and indirect evidence within and across trial data using the final end point reported in the trials, and results for the arm-based network analyses are reported as standardized mean differences (SMDs).

RESULTS

Seventeen trials (1381 participants; 3 [18%] at low risk of bias) assessing injection with 8 different treatments-glucocorticoid (10 trials), botulinum toxin (4 trials), autologous blood (3 trials), platelet-rich plasma (2 trials), and polidocanol, glycosaminoglycan, prolotherapy, and hyaluronic acid (1 trial each)-were included. Pooled results (SMD [95% confidence interval]) showed that beyond 8 weeks, glucocorticoid injection was no more effective than placebo (-0.04 [-0.45 to 0.35]), but only 1 trial (which did not include a placebo arm) was at low risk of bias. Although botulinum toxin showed marginal benefit (-0.50 [-0.91 to -0.08]), it caused temporary paresis of finger extension, and all trials were at high risk of bias. Both autologous blood (-1.43 [-2.15 to -0.71]) and platelet-rich plasma (-1.13 [-1.77 to -0.49]) were also statistically superior to placebo, but only 1 trial was at low risk of bias. Prolotherapy (-2.71 [-4.60 to -0.82]) and hyaluronic acid (-5.58 [-6.35 to -4.82]) were both more efficacious than placebo, whereas polidocanol (0.39 [-0.42 to 1.20]) and glycosaminoglycan (-0.32 [-1.02 to 0.38]) showed no effect compared with placebo. The criteria for low risk of bias were only met by the prolotherapy and polidocanol trials.

CONCLUSION

This systematic review and network meta-analysis of randomized controlled trials found a paucity of evidence from unbiased trials on which to base treatment recommendations regarding injection therapies for lateral epicondylitis.

Effect of lateral epicondylosis on grip force development

STUDY DESIGN

Case-Control.

INTRODUCTION

Although it is well known that grip strength is adversely affected by lateral epicondylosis (LE), the effect of LE on rapid grip force generation is unclear.

PURPOSE OF THE STUDY

To evaluate the effect of LE on the ability to rapidly generate grip force.

METHODS

Twenty-eight participants with LE (13 unilateral and 15 bilateral LE) and 13 healthy controls participated in this study. A multiaxis profile dynamometer was used to evaluate grip strength and rapid grip force generation. The ability to rapidly produce force is composed of the electromechanical delay and rate of force development. Electromechanical delay is defined as the time between the onset of electrical activity and the onset of muscle force production. The Patient-rated Tennis Elbow Evaluation (PRTEE) questionnaire was used to assess pain and functional disability. Magnetic resonance imaging was used to evaluate tendon degeneration.

RESULTS

LE-injured upper extremities had lower rate of force development (50 lb/sec, confidence interval [CI]: 17, 84) and less grip strength (7.8 lb, CI: 3.3, 12.4) than nonnjured extremities. Participants in the LE group had a longer electromechanical delay (- 59% , CI: 29, 97) than controls. Peak rate of force development had a higher correlation (r = 0.56; p<0.05) with PRTEE function than grip strength (r = 0.47; p<0.05) and electromechanical delay (r = 0.30; p>0.05) for participants with LE. In addition to a reduction in grip strength, those with LE had a reduction in rate of force development and an increase in electromechanical delay.

CONCLUSIONS

Collectively, these changes may contribute to an increase in reaction time, which may affect risk for recurrent symptoms. These findings suggest that therapists may need to address both strength and rapid force development deficits in patients with LE.

LEVEL OF EVIDENCE

3B.

Measuring clinically important change with the Patient-rated Tennis Elbow Evaluation

Introduction

The Patient-rated Tennis Elbow Evaluation (PRTEE) enables quantitative rating by the patient of pain and functional impairment associated with tennis elbow or lateral elbow tendinopathy. When used as an outcome measure in trials of therapies, a minimum clinically important difference (MCID) value is required to interpret trial outcomes. This study aimed to calculate the MCID for a sample of patients diagnosed with lateral elbow tendinopathy (LET).

Methods

The PRTEE was used as an outcome measure with participants in a trial of a novel therapy for LET. It was administered at baseline and after treatment, three weeks later. Score changes were compared with patient-rated global change scores using receiver operating curve analysis. MCID values were calculated for two different criteria of clinically important difference and the effects of baseline symptom severity on the MCID were investigated.

Results

Data were available from 57 participants, with PRTEE scores in the range 13–81/100. For clinical significance defined as ‘a little better’ the MCID for the total PRTEE score was 7/100 or 22% of baseline score. For clinical significance defined as ‘much better’ or ‘completely recovered’, the MCID was 11/100 or 37% of baseline score. The MCID value was higher for a subgroup with greater baseline severity.

Conclusions

Substantial changes in the PRTEE scores are required before they can be considered clinically significant. Clinically significant change varies according to the baseline score. The instrument may be less sensitive to change when used by people who are symptomatic in their non-dominant arm.

Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials

BACKGROUND

Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection.

METHODS

We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0-12), intermediate term (26 weeks, 13-26), or long term (52 weeks, ≥52). Adverse events were also reported.

FINDINGS

3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17-1·71, p<0·0001), but no intervention was favoured at intermediate term (-0·40, -0·67 to -0·14, p<0·003) and long term (-0·31, -0·61 to -0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise.

INTERPRETATION

Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy.

FUNDING

None.

Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: a protocol for a randomised, placebo-controlled study

Background

Lateral epicondylitis is a painful condition responsible for loss of function and sick leave for long periods of time. In many countries, the treatment guidelines recommend a wait-and-see policy, reflecting that no conclusions on the best treatment can be drawn from the available research, published studies and meta-analyses.

Methods/Design

Randomized double blind controlled clinical trial in a primary care setting. While earlier trials have either compared corticosteroid injections to physical therapy or to naproxen orally, we will compare the clinical effect of physiotherapy alone or physiotherapy combined with corticosteroid injection in the initial treatment of acute tennis elbow. Patients seeing their general practitioner with lateral elbow pain of recent onset will be randomised to one of three interventions: 1: physiotherapy, corticosteroid injection and naproxen or 2: physiotherapy, placebo injection and naproxen or 3: wait and see treatment with naproxen alone. Treatment and assessments are done by two different doctors, and the contents of the injection is unknown to both the treating doctor and patient. The primary outcome measure is the patient's evaluation of improvement after 6, 12, 26 and 52 weeks. Secondary outcome measures are pain, function and severity of main complaint, pain-free grip strength, maximal grip strength, pressure-pain threshold, the patient's satisfaction with the treatment and duration of sick leave.

Conclusion

This article describes a randomized, double blind, controlled clinical trial with a one year follow up to investigate the effects of adding steroid injections to physiotherapy in acute lateral epicondylitis.

Trial Registration

ClinicalTrials.gov Identifier: NCT00826462