Is Chronic Tendon Pain Caused by Neuropathy? Exciting Breakthroughs may Direct Potential Treatment

BACKGROUND

Tendinopathy significantly impacts the quality of life and imposes a high economic burden, accounting for a large proportion of sports and musculoskeletal injuries. Traditionally considered a collagen-related inflammatory disorder, emerging evidence suggests a critical role of neuropathic processes in chronic tendon pain.

OBJECTIVE

This review aims to evaluate the neuropathic mechanisms in tendinopathy and discuss innovative treatments targeting these pathways.

METHODS

We analyze recent studies highlighting the tendon innervation, pathological nerve sprouting neuronal ingrowth in tendinopathy, and the associated increase in pain and neuronal mediators.

RESULTS

Chronic tendinopathy exhibits nociceptive sprouting from paratenon into the fibrous tendon proper. Innovative treatments such as Percutaneous Ultrasound-Guided Tenotomy (PUT) or high-frequency ultrasound interventions show promise in targeting these neuropathic components by paratenon separation. These approaches focus on disrupting the pathological innervation cycle.

CONCLUSION

Chronic tendon pain may be predominantly neuropathic, driven by pathologic neuronal ingrowth from paratenon into the tendon proper. Interventions that accurately target and disrupt these nerve pathways could revolutionize the treatment of tendinopathy. Further research is required to validate these findings and refine treatment modalities to ensure safety and efficacy.

Retrospective Evaluation of Ultrasound Guided Percutaneous Plantar Fasciotomy With and Without Platelet Rich Plasma

Plantar fasciitis is one of the most common foot conditions presenting to a foot and ankle specialist. Surgical treatment outcomes following plantar fasciotomy vary but short-term studies have reported excellent early pain relief and significant improvements in symptoms. This study evaluates patient reported pain scores collected pre- and post-op for patients who underwent percutaneous ultrasonic microtenotomy (PUT) plantar fasciotomy with PRP injection vs without the use of PRP. We compared pain visual analog scale (VAS) scores, for patients treated surgically by Orthopedic Surgery department of foot and ankle faculty members between December 2007 and December 2022. A total of 30 patients were identified that met inclusion and exclusion criteria. Our results showed that there was a significant decrease in pain VAS scores from pre-op visit (at least 1 month prior to operation) to post-op visit (at least 1 month following operation) for both groups, with a paired t test (p value <.0001). However, patients who received PRP had a statistically significant decrease in pain level compared to the group who did not receive PRP. Statistical analysis completed with a 2-sample t test (p-value <.0325). Our results found the mean time between the initial pre-op visit and last post-op follow-up visit was 19 months. The mean for time following surgical intervention was 10 months. The findings of our study suggest that the dual use of PUT and PRP to treat plantar fasciitis, could potentially lead to an improvement in pain reduction and longevity of pain relief.

Tips and tricks in ultrasound-guided musculoskeletal interventional procedures

Ultrasound visualization affords proceduralists versatile and accurate guidance for a variety of percutaneous, minimally invasive procedures in the musculoskeletal system including joint (intra-articular) injections or aspirations, intra-bursal injections, peritendinous, and perineural injections. A variety of percutaneous procedures are traditionally performed blindly, but may be more easily or more accurately performed with the real-time assistance of ultrasound guidance. Other procedures are only possible utilizing image-guidance, due to the required precision of the injection because of delicate local anatomy or depth of the injection; ultrasound is a safe, portable, and widespread modality that can be used to assist the proceduralist in localizing the needle tip in such cases, to ensure safe and accurate delivery of the medication, most frequently a solution of steroid and anesthetic. This review aims to provide a foundational approach to ultrasound-guided procedures in the musculoskeletal system, offering tips and tricks that can be employed in many different procedures including intra-articular, juxta-articular, and perineural injections for a multitude of clinical scenarios. Technical considerations regarding ultrasound transducer selection, sonographic technique, as well as common indications, contraindications, and complications of these procedures, are presented. Additionally, a variety of pharmacologic considerations for proceduralists contemplating ultrasound-guided injections are discussed.

Tendon injections - upper extremity

Imaging-guided tendon procedures aim to reduce pain and increase function by controlling inflammation and stimulating healing. Ultrasound is the preferable guiding modality due to its high resolution and real-time demonstration of the tendinous anatomy and needle positioning. The technique includes appropriate patient positioning, which varies depending on the targeted tendon, as well as sterile and proper draping. For most procedures, we prefer the "in-plane" approach, which demonstrates the entire needle as it advances through different tissue layers. Upper limb injections commonly use corticosteroids and anesthetics with different reported short- and long-term results depending on the tendon treated; better results are obtained in the treatment of tenosynovitis (sliding tendons such as trigger finger and De Quervain's tenosynovitis). Shoulder and elbow tendinopathies (anchor tendons) may also benefit from injections containing irritants or healing stimulants such as dextrose (prolotherapy) and platelet-rich plasma or by the stimulation of healing via tendon perforations (fenestration). The hyaluronic acid injection has also been used in the treatment of both tenosynovitis and tendinopathies. For tendons passing through osteofibrous tunnels, an additional release may be performed, and the techniques are discussed in this review. Therefore, this article provides practicing musculoskeletal radiologists and trainees with a comprehensive review of tendon injection musculoskeletal image-guided procedures.

Interventional Imaging Techniques as Alternative to Surgery of the Foot and Ankle

A variety of foot and ankle pathologies can impair patient's daily activities, ultimately requiring surgical management. However, with improvements in image-guided intervention, the joints, soft tissues, and osseous structures may be accessible using various percutaneous techniques as a potential alternative therapeutic tool, avoiding the need for surgery with its associated risks and morbidity. This article discusses the potential range of image-guided interventional treatments. Injections, aspiration, biopsies, cryoablation, and radiofrequency ablation are described. Newer novel treatments are also covered. Finally, the common pathologies of Morton's neuroma, Achilles tendinopathy, and plantar fasciitis are addressed.

Validation of a novel magnetic resonance imaging classification and recommended treatment for lateral elbow tendinopathy

BACKGROUND

Lateral epicondylitis is one of the most common upper extremity problems presented to orthopedic surgeons. Despite a rapid and accurate arrival at a diagnosis by clinical examination, there exists no consensus classification for this condition, which hampers clinical approaches for treatment of the disease based on its severity. Thus, the aim of this study was to propose and valiadate a new magnetic resonance imaging (MRI) classification of lateral epicondylitis, staging by tendinosis, the degree of thickness tears of the common extensor tendon (CET) and bone bruise lesion.

METHOD

MRI assessment of the elbow of 75 patients (57 women and 18 men; mean age:51.4 years (range,34-73) from Jan 2014 to Jan 2021 who were diagnosed with lateral epicondylitis were included in the study. MR images were reviewed retrospectively by two independent upper extremities orthopedists and one musculoskeletal radiologist. Inter- and intra-observer reliabilities for the classification were calculated using kappa statistics for the analysis of interrater agreement. Correlation between the stage of the disease and the duration of symptom before MRI was calculated using Kruskal-wallis test.

RESULTS

Various degrees of CET lesions were demonstrated in this population (Stage I-17, IIA-7, IIB-22 and III-29). Intra-observer agreements of MRI staging were substantial to satisfactory. Inter-observer agreements were moderate to substantial. There was no significant correlation between the disease stage and the patient age or the duration of symptom before MRI.

CONCLUSION

Our MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis. At the end, we have suggeted a clearer direction for understanding the disease pathology as well as an appropriate management protocol for each stage of the disease in line with the recent body of literature.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Ultrasound-Guided Musculoskeletal Injections

Musculoskeletal injections serve a variety of diagnostic and therapeutic purposes, with ultrasonography (US) guidance having many advantages: no ionizing radiation, real-time guidance, high spatial resolution, excellent soft tissue contrast, and the ability to identify and avoid critical structures. Sonography can be cost effective and afford flexibility in resource-constrained settings. This article describes US-guided musculoskeletal injections relevant to many radiology practices and provides experience-based suggestions. Structures covered include multiple joints (shoulder, hip), bursae (iliopsoas, subacromial-subdeltoid, greater trochanteric), peripheral nerves (sciatic, radial), and tendon sheaths (posterior tibial, peroneal, flexor hallucis longus, Achilles, long head of the biceps). Trigger point and similar targeted steroid injections, as well as calcific tendinopathy barbotage, are also described.

Ultrasound-guided versus blind interventions in patellar tendon lesions: a cadaveric study

PURPOSE

The present study aims to analyze the accuracy of injections aimed to hit the proximal and depth part of the patellar tendon "target point" in patellar tendinopathy, comparing ultrasound-guided or non-ultrasound-guided (blind) injections.

METHODS

A cadaver randomized study was carried out. Injections were performed under ultrasound control, as well as blinded. There were 26 knees from fresh cadavers and injections were placed by 26 practitioners with experience in the use of musculoskeletal ultrasound and injection treatment. Each participant performed 6 ultrasound-guided and 6 blind punctures in different cadaveric specimens. This provided 312 injections that were analyzed in 2 different anatomical cuts, thus providing a database of 624 measurements for statistical analysis.

RESULTS

Statistically significant differences were observed (p < 0.0001) in the distance from the target point between the ultrasound-guided and the non-guided infiltrations. The "unguided" injections were considered to have been performed on average 10 mm away from the target point compared to the "ultrasound-guided" injections. The ultrasound-guided injections obtained an accuracy of 74.36% while the "non-ultrasound-guided" injections obtained an accuracy of 11.54% (p < 0.0001).

CONCLUSION

The use of ultrasound to guide the positioning of injections on the dorsal side of the proximal patellar tendon had a significantly higher accuracy compared to blind injections. The finding provides knowledge of importance for injection treatment.

Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review

CONTEXT

Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results.

OBJECTIVE

To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure.

DATA SOURCES

PubMed, MEDLINE, EMBASE, and Google Scholar.

STUDY SELECTION

The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected.

RESULTS

There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking.

CONCLUSION

PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.

Influence of Acromial Morphologic Characteristics and Acromioclavicular Arthrosis on the Effect of Platelet-Rich Plasma on Partial Tears of the Supraspinatus Tendon

OBJECTIVE. The purposes of this study were to determine the medium-term effect of ultrasound-guided infiltration of platelet-rich plasma (PRP) on partial tears of the supraspinatus tendon (SST) and to identify prognostic indicators of an unfavorable outcome. SUBJECTS AND METHODS. Over a period of 4 years, patients with a partial SST tear smaller than 1.5 cm referred for ultrasound-guided PRP infiltration (1 mL) for shoulder pain lasting more than 3 months were recruited consecutively. MRI was used to analyze the type of acromion and presence of acromioclavicular (AC) arthrosis. Primary (size of the tear and associated bursitis) and secondary (mobility and pain) results were collected at 3 months. RESULTS. The study included 128 patients (66 men, 62 women; mean age, 48.3 years; range, 20-59 years). At 3 months, favorable evolution of the tear repair was recorded in 71.1% (91/128) of patients and resolution of bursitis in 66.7% (42/63). Changes in tear size had large effect sizes (Cohen d ≥ 1.16), as did pain and shoulder mobility (Cohen d ≥ 0.95). The strongest predictors of unfavorable evolution of tear and bursitis were type 3 acromion and types 1 and 2 acromion with AC arthrosis (p < 0.001; β = 20.412). CONCLUSION. Ultrasound-guided PRP infiltration of partial tears of the SST relieves pain and improves shoulder mobility, but its effect on the size of the tear is influenced by the morphologic characteristics of the acromion and the presence of AC arthrosis. The effect of PRP is insufficient in patients with a type 3 acromion or severe AC arthrosis.

Shoulder MR Imaging Versus Ultrasound: How to Choose

Imaging evaluation of the shoulder is performed using multiple modalities, including ultrasound (US) and MR imaging. Clinicians often wonder which modality to use to work up their patients with shoulder pain. Although MR imaging has remained the workhorse of shoulder imaging, US has increased in popularity among academic and private institutions. Both modalities offer similar diagnostic information in regards to rotator cuff pathology and other soft tissues, although they differ in their technique, indications, and interpretation. A thorough understanding of these differences is imperative to appropriately use these modalities in clinical practice, including the unique interventional opportunities available with US.

Interventional therapeutic procedures to treat degenerative and inflammatory musculoskeletal conditions: state of the art

Imaging-guided interventional procedures have become increasingly popular in the treatment of several pathologic conditions in the musculoskeletal system. Besides oncological treatments, musculoskeletal procedures can be performed to treat different degenerative or inflammatory conditions. This paper is aimed to review clinical indications and technical aspects of these kinds of procedures. In particular, we revise the general aspects common to most procedures and the different imaging-guided interventions which can be performed around joints, soft tissues, and spine.

Variables affecting the potential efficacy of PRP in providing chronic pain relief

Although chronic pain affects about 1% of the US population, it remains largely resistant to treatment. Despite great variability in pain outcomes, the application of autologous platelet-rich plasma (PRP) has become increasingly popular in attempts to reduce chronic pain. The variability in PRP efficacy raises the question of whether PRP actually has an analgesic capacity, and if so, can that capacity be made consistent and maximized. The best explanation for the variability in PRP analgesic efficacy is the failure during PRP preparation and application to take into account variables that can increase or eliminate its analgesic capabilities. This suggests that if the variables are reduced and controlled, a PRP preparation and application protocol can be developed leading to PRP inducing reliable, complete, and long-term pain relief. The goal of this study was to examine some of the variables that influence platelets and see how they might be controlled to increase the analgesic potential of PRP. Among the variables examined are the physiological status of the patient, methods used to prepare PRP, and methods of PRP application. The goal of modifying these variables is to minimize platelet serotonin content, maximize platelet content of factors that reduce inflammation and pain, while maintaining their bioactivity, maximize platelet capacity to aggregate at injury sites, induce rapid and simultaneous release of their contents, and optimize PRP application protocols. It is concluded that controlling some or many of these variables will lead to PRP that induces reliable, maximum, and long-term relief of chronic pain.

Differing efficacies of autologous platelet-rich plasma treatment in reducing pain following rotator-cuff injury in a single patient

Rotator-cuff tears (RCTs) are typically associated with chronic pain. The most common treatment for reducing pain is the injection of cortisone into the injury site. An alternative and increasingly used technique is the injection of autologous platelet-rich plasma (PRP). A limitation of cortisone is its pain relief is short-lived, while PRP has the limitation of providing pain relief to only about 50% of patients, making its efficacy questioned, although when it is effective, its efficacy is longer than cortisone. Little is known about what accounts for these limitations. This paper presents results from a patient with RCTs causing excruciating pain who received an injection of PRP into that shoulder resulting in complete pain elimination that was ongoing at 2 years and 2 months. When 7-month severe posttrauma pain associated with the RCT developed in the contralateral shoulder, PRP prepared the same way and injected by the same person who performed the first injection provided no pain relief. However, a subsequent single cortisone injection resulted in complete pain elimination, which was ongoing at >15 months. These observations indicate that PRP can have inconsistent effects in reducing pain, not only between patients but also within the same patient. Further, although the pain relief induced by cortisone is normally not long-lasting, when given following a PRP injection, it can induce complete pain relief lasting >15 months. This paper discusses possible reasons for the variability in PRP efficacy on pain relief and addresses the possibility that when administered together, PRP and cortisone may act in a complementary manner, leading to significantly greater and longer-lasting pain relief.

Lateral epicondylitis: Associations of MR imaging and clinical assessments with treatment options in patients receiving conservative and arthroscopic managements

OBJECTIVES

We assessed the implications of MR imaging with clinical history in lateral epicondylitis management by evaluating imaging and clinical features in patients with lateral epicondylitis treated conservatively or operatively.

METHODS

Sixty patients with lateral epicondylitis treated conservatively (n = 38) or operatively (n = 22) from 2011-2015 were included. MR imaging findings of common extensor tendon (CET), lateral collateral ligament (LCL) complex, muscle oedema, ulnar nerve and elbow joint were reviewed. Clinical data recorded were frequency, duration and intensity of pain, history of trauma and injection therapy, range of motion.

RESULTS

MRI-assessed CET and LCL complex abnormalities, muscle oedema, radiocapitellar joint widening, joint effusion/synovitis, pain frequency and intensity differed significantly between the two groups (p < .05) with increased severity in operative group. Persistent pain (OR 12.2, p < .01), CET abnormality on longitudinal plane (OR 7.5, p = .03 for grade 2; OR 22.4, p < .01 for grade 3) and muscle oedema (OR 6.7, p = .03) were major factors associated with operative treatment. Area under the ROC curve of predicted probabilities for combination of these factors was 0.83.

CONCLUSION

MR imaging, combined with clinical assessment, could facilitate appropriate management planning for patients with lateral epicondylitis.

KEY POINTS

• MRI can reflect different disease severity between patients treated conservatively/operatively. • CET abnormality, muscle oedema were major MRI findings with operative treatment. • Patients in operative group were more likely to experience persistent pain. • MRI plus clinical symptoms could facilitate appropriate management for lateral epicondylitis.