ArticlePublisher preview available

The Use of Ultrasound-Guided Injections for Tendinopathies

August 2018
Current Radiology Reports 6(10)

Authors:

Sportdoctorlondon

Purpose of Review The purpose of the study was to review the efficacy and safety of common ultrasound-guided injections for tendinopathy conditions. Corticosteroid injections have historically been the most common injection used for tendinopathy; however, there are an increasing number of injections including platelet-rich plasma, hyaluronan, polidocanol, botulinum toxin, and high volume saline injections. Recent Findings There is growing evidence that while corticosteroid injections for tendinopathies usually have short-term efficacy, they may result in medium-term harm, particularly for tennis elbow (lateral epicondylitis). Corticosteroid injections appear to have more clinical utility for tenosynovitis conditions. There is insufficient evidence regarding other injection options to make a broad recommendation in favour, although individual trials for certain tendons illustrate benefits for some of the non-corticosteroid options. Summary When considering the use of ultrasound-guided corticosteroid injections for tendinopathies, the risk of possible medium-term harm must be weighed up against any short-term efficacy. Other injection-based therapies may be appropriate in certain clinical situations; however, the evidence and clinical circumstances must be considered for the particular tendon and patient. Load-based rehabilitation remains the cornerstone of tendinopathy management.

Injection of common extensor origin at elbow under ultrasound guidance

…

A small supraspinatus tear, such as that visualised, might be a relative contraindication for corticosteroid injection in shoulder pain

…

Injection of subacromial bursa above supraspinatus tendon under ultrasound guidance

…

Injection of superficial trochanteric bursa over gluteus medius tendon under ultrasound guidance

…

injection of Achilles tendon under ultrasound guidance

…

Figures - available from: Current Radiology Reports

This content is subject to copyright. Terms and conditions apply.

A preview of this full-text is provided by Springer Nature.

Learn more

Content available from Current Radiology Reports

This content is subject to copyright. Terms and conditions apply.

SPORTS IMAGING (J LINKLATER, SECTION EDITOR)

The Use of Ultrasound-Guided Injections for Tendinopathies

John W. Orchard

•Richard Saw

•Lorenzo Masci

Published online: 10 August 2018

Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract

Purpose of Review The purpose of the study was to review

the efﬁcacy and safety of common ultrasound-guided

injections for tendinopathy conditions. Corticosteroid

injections have historically been the most common injec-

tion used for tendinopathy; however, there are an increas-

ing number of injections including platelet-rich plasma,

hyaluronan, polidocanol, botulinum toxin, and high volume

saline injections.

Recent Findings There is growing evidence that while

corticosteroid injections for tendinopathies usually have

short-term efﬁcacy, they may result in medium-term harm,

particularly for tennis elbow (lateral epicondylitis). Corti-

costeroid injections appear to have more clinical utility for

tenosynovitis conditions. There is insufﬁcient evidence

regarding other injection options to make a broad recom-

mendation in favour, although individual trials for certain

tendons illustrate beneﬁts for some of the non-corticos-

teroid options.

Summary When considering the use of ultrasound-guided

corticosteroid injections for tendinopathies, the risk of

possible medium-term harm must be weighed up against

any short-term efﬁcacy. Other injection-based therapies

may be appropriate in certain clinical situations; however,

the evidence and clinical circumstances must be considered

for the particular tendon and patient. Load-based rehabili-

tation remains the cornerstone of tendinopathy

management.

Keywords Tendinopathy Tenosynovitis Ultrasound-

guided Injection Corticosteroid Platelet-rich-plasma

Introduction

Injections for tendinopathies (and related conditions) have

been common practice in musculoskeletal medicine for the

past 60 years, ever since injectable corticosteroid prepa-

rations become readily available [1]. Injections have the

attraction of being ‘‘minimally invasive’’ management with

relatively low risk of complications compared to surgical

interventions. In the last 20 years, ultrasound guidance has

also been regularly used, in theory to improve the accuracy

of injection location. However, the evidence-base both for

the efﬁcacy of injections is not always consistent with

common practice and even to a standard set of guidelines.

For example, the most recent Australian edition of Thera-

peutic Guidelines: Rheumatology [2] recommends corti-

sone injections for almost every common tendinopathy (for

example, rotator cuff tendinopathy, tennis elbow, De

Quervain’s tenosynovitis), whereas the evidence for efﬁ-

cacy is not nearly as prescriptive. This narrative review

aims to summarise the best evidence with respect to

ultrasound-guided injections for the most common

tendinopathy conditions, for both corticosteroid injections

(CSIs) and other commonly used injection options.

This article is part of the Topical collection on Sports Imaging.

&John W. Orchard

john.orchard@sydney.edu.au

School of Public Health, University of Sydney, Physics Rd.,

Western Avenue, Sydney, NSW 2006, Australia

Olympic Park Sports Medicine Centre, Melbourne, VIC,

Australia

Pure Sports Medicine Clinic, Cabot Place West, London

E14 4QS, UK

123

Curr Radiol Rep (2018) 6:38(0123456789().,-volV)(0123456789().,-volV)

https://doi.org/10.1007/s40134-018-0296-2

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Current trends in tendinopathy management

Article

Mar 2019
BEST PRACT RES CL RH

Tendinopathy (pain and dysfunction in a tendon) is a prevalent clinical musculoskeletal presentation across the age spectrum, mostly in active and sporting people. Excess load above the tendon's usual capacity is the primary cause of clinical presentation. The propensity towards chronicity and the extended times for recovery and optimal function and the challenge of managing tendinopathy in a sporting competition season make this a difficult condition to treat. Tendinopathy is a heterogeneous condition in terms of its pathology and clinical presentation. Despite ongoing research, there is no consensus on tendon pathoetiology and the complex relationship between tendon pathology, pain and function is incompletely understood. The diagnosis of tendinopathy is primarily clinical, with imaging only useful in special circumstances. There has been a surge of tendinopathy treatments, most of which are poorly supported and warrant further exploration. The evidence supports a slowly progressive loading program, rather than complete rest, with other treatment modalities used as adjuncts mainly targeted at achieving pain relief.

The Effectiveness of Hyaluronic Acid Injection in the Treatment of Lateral Epicondylitis among Adults: A Systematic Review

Article

Full-text available

Oct 2021

Background: Lateral epicondylitis is common and may negatively impact activities of daily living. Currently, various conservative treatments are available including physiotherapy, pharmacotherapy, and interventional physiatry. Among the interventional procedures, periarticular hyaluronic acid (HA) injection is an emerging treatment option, but it lacks firm evidence to support its use. Objective: The objective of the study was to determine the effectiveness and safety of HA in reducing pain and improving function of patients with lateral epicondylitis. Methods: We conducted a systematic review in January 2020. Randomized controlled trials identified from various electronic databases were included if they involved the following: Adults with lateral epicondylitis, periarticular injection of HA with or without other medications, and reported outcomes on pain, function, and adverse effects. Assessment of risk of bias was performed using the Cochrane Collaboration Tool. Pertinent data were extracted from the eligible studies for data analysis. Results: Among the 42 studies identified, we included two trials with a total of 388 participants followed up within 6–12 months. The trials employed similar techniques in administering HA, although they used different doses and preparations. The control groups used either normal saline or corticosteroid. In both trials, there were statistically significant improvements in pain and function in favor of HA. No serious adverse event was reported. Conclusion: Albeit with promising intermediate and long‑term effects for lateral epicondylitis, HA remains to have limited evidence regarding its effectiveness and safety. We recommend further research to determine the most optimal HA preparation, dosage, and technique for lateral epicondylitis that will help standardize our procedures.

Proximal Hamstring Tendinopathy: A Systematic Review of Interventions

Article

Full-text available

Apr 2021
Int J Sports Phys Ther

Background: Proximal hamstring tendinopathy affects athletic and non-athletic populations and is associated with longstanding buttock pain. The condition is common in track and field, long distance running and field-based sports. Management options need to be evaluated to direct appropriate clinical management. Purpose/hypothesis: To evaluate surgical and non-surgical interventions used in managing proximal hamstring tendinopathy. Study design: Systematic review. Methods: Electronic databases were searched to January 2019. Studies (all designs) investigating interventions for people with proximal hamstring tendinopathy were eligible. Outcomes included symptoms, physical function, quality of life and adverse events. Studies were screened for risk of bias. Reporting quality was assessed using the Cochrane Risk of Bias Tool (Randomized Controlled Trials [RCT]) and the Joanna Briggs Institute Checklist (Case Series). Effect sizes (Standard mean difference or Standard paired difference) of 0.2, 0.5 and 0.8 were considered as small, medium and large respectively. Overall quality of evidence was rated according to GRADE guidelines. Results: Twelve studies (2 RCTs and 10 case series) were included (n=424; males 229). RCTs examined the following interventions: platelet-rich plasma injection (n=1), autologous whole-blood injection (n=1), shockwave therapy (n=1) and multi-modal intervention (n=1). Case series included evaluation of the following interventions: platelet-rich plasma injection (n=3), surgery (n=4), corticosteroid injection (n=2), multi-modal intervention + platelet-rich plasma injection (n=1). Very low-level evidence found shockwave therapy was more effective than a multi-modal intervention, by a large effect on improving symptoms (-3.22 SMD; 95% CI -4.28, -2.16) and physical function (-2.42 SMD; 95% CI-3.33, -1.50) in the long-term. There was very low-level evidence of no difference between autologous whole-blood injection and platelet-rich plasma injection on physical function (0.17 SMD; 95% CI -0.86, 1.21) to (0.24 SMD; 95% CI -0.76, 1.24) and quality of life (-0.04 SMD; 95%CI -1.05, 0.97) in the medium-term. There was very low-quality evidence that surgery resulted in a large reduction in symptoms (-1.89 SPD; 95% CI -2.36, -1.41) to (-6.02 SPD; 95% CI -8.10, -3.94) and physical function (-4.08 SPD; 95%CI -5.53, -2.63) in the long-term. Conclusions: There is insufficient evidence to recommend any one intervention over another. A pragmatic approach would be to initially trial approaches proven successful in other tendinopathies. Level of evidence: Level 2a.

Clinical efficacy of botulinum toxin in lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials

Article

Oct 2023

Ultrasound‐guided versus landmark‐guided subacromial corticosteroid injections for rotator cuff related shoulder pain: A systematic review of randomised controlled trials

Article

May 2022

Introduction: Rotator cuff related shoulder pain (RCRSP) is the most common presentation of shoulder pain within physiotherapy. Corticosteroid injections (CSI) have become increasingly popular to reduce pain, increase range of motion (ROM) and improve shoulder function. Evidence around the use of ultrasound-guided (USG) versus landmark-guided (LMG) CSIs remains controversial. Objective: The objective of this appraisal was to compare the effectiveness of each approach in the management of RCRSP. Methods: Cochrane, PubMed and CINAHL electronic databases were searched (from January 2014 to February 2021). Randomised controlled trials (RCTs) were included comparing USG to LMG CSIs for RCRSP. An independent reviewer selected the studies, extracted and synthesised the data. Two reviewers carried out a quality appraisal. Outcome measures were pain, function and ROM. Results: Four RCTs (n = 179 participants, n = 184 shoulders) were reviewed. Both USG and LMG groups showed statistically significant within group improvements in clinical outcomes. There were no significant differences between groups. Three studies were identified as being a 'low' risk of bias (RoB) and did not favour the use of ultrasound. One study did favour the use of ultrasound for improving function, although it was found to have 'high' RoB. Adverse events were seldom reported. Conclusion: There is limited evidence to suggest using USG CSIs has a superior effect on clinical outcomes compared to LMG, though small sample sizes and lack of long-term follow-up limit the generalisability of the findings.

Article

Jul 2021
CLIN J SPORT MED

Objective: To compare the outcomes for patients with chronic plantar fasciitis after extracorporeal shockwave therapy (ESWT) or autologous blood injection (ABI). Design: Cohort study-retrospective analysis of prospectively collected data. Setting: Hospital-based Sports Medicine Outpatient Clinic. Patients: One hundred two consecutive patients with chronic plantar fasciitis, treated with either radial-ESWT (rESWT) (n = 54) or ABI (n = 48), with minimum 3-month follow-up and 96% (98/102) having 6-month follow-up. Mean age 49.5 years and mean duration of symptoms 37.5 months before treatment. Interventions: Patients received either 3 sessions of radial ESWT (one session per week for 3 weeks), or a single ultrasound-guided dry needling and ABI (3 mL whole autologous blood). All patients received standardized after-care, including progressive structured home exercise program of flexibility, strengthening, and proprioception exercises. Main outcome measures: 0 to 10 numerical rating scale (NRS) for self-reported "average pain" and "average stiffness" values. Secondary outcome measures included assessments of local foot function [including Manchester-Oxford Foot Questionnaire (MOXFQ), revised-Foot Function Index] as well as markers of mental health functioning (HAD), global health (EQ-5D-5L), and physical activity (International Physical Activity Questionnaire). Results: This study demonstrated statistically significant improvements in self-reported measures of pain and local foot function after either procedure at 6 weeks, 3 months, and 6 months, but no statistically significant differences were seen between groups at any time-period studied. At 6 months, the average pain using a 0 to 10 NRS was improved from 6.8 ± 1.8 to 4.0 ± 2.7 (P < 0.001) after ESWT and from 7.1 ± 1.6 to 3.8 ± 2.7 (P < 0.001) after ABI. At 6 months, significant improvements were seen following either group using a number of different validated patient-rated outcome measures assessing local foot pain and function, eg, the total score for MOXFQ improved from 56.1 ± 12.8 to 42.5 ± 16.6 (P < 0.001) after ESWT and from 58.8 ± 13.2 to 44.2 ± 19.2 (P < 0.001) after ABI. However, measures of physical activity or wider aspects of patient functioning did not consistently improve from baseline values to follow-up periods. Conclusions: Patients with chronic plantar fasciitis improved to statistically significant extent after either rESWT or ABI procedures, with no significant differences seen between groups. The lack of randomization in this pragmatic study is noted, which may have influenced the outcome seen. Potentially larger and more robust studies are required to investigate this treatment comparison further.

Image guided injection therapies in athletes—Do they work and what should we be using?

Article

Dec 2018
EUR J RADIOL

In the modern management of the injured elite athlete, the goals of guided injection therapies have extended beyond simple reduction of pain to enhancement of tissue healing and accelerated return to competition, faster than natural healing can allow. This article will review the injection therapies which are frequently used in elite sports injury management and describe other less commonly used injection therapies that are available to the treating clinician and athlete. The evidence base, where available, for each treatment option will be summarised.

Shoulder Injection Prior to Rotator Cuff Repair is Associated with Increased Risk of Subsequent Surgery

Article

Full-text available

Jul 2018

Objectives Corticosteroid injections (CSI) are frequently utilized in the nonoperative management of rotator cuff tears. However, recent literature suggests that injections may reduce biomechanical strength of tendons and ligaments in animal models and increase the risk of postoperative infections following surgery. The goal of this study was to determine if the timing of CSI is associated with an increased risk of reoperation following primary rotator cuff repair (RCR). Methods A retrospective analysis of claims data of privately-insured subjects from the MarketScan® database for the years 2010-2014 was conducted. A cohort of subjects aged 18-64 who were diagnosed with a rotator cuff tear and underwent repair in 2011 was identified. Multivariable logistic regression models were used to compare the odds of reoperation between groups. Results A total of 4,959 subjects with an arthroscopic RCR were identified. Of this, 550 subjects required reoperation within the following 3 years. Patients who had a CSI within 6 months preceding the RCR were at a much higher risk of undergoing reoperation: 0-3 months prior, AOR 1.536 (95% CI: 1.201 -1.965); 3-6 months, AOR 1.843 (95% CI: 1.362-2.494); and 6-12 months AOR 1.339 (95% CI: 0.914 -1.962). Of those patients that underwent a reoperation, the most common surgery performed was revision rotator cuff repair followed by arthroscopic debridement (48.5% versus 38.9%, respectively). Conclusion Patients who had received a CSI within 6 months prior to RCR were much more likely to undergo a subsequent reoperation within the following 3 years. These odds diminished as more time passed between CSI and primary repair. Consideration should therefore be given to delaying primary rotator cuff repair for 6 months following injection. [Table: see text][Figure: see text]

Ultrasound-guided subacromial-subdeltoid bursa corticosteroid injections: a study of short- and long-term outcomes

Article

Full-text available

May 2018

Aim: To assess shoulder pain and disability in patients undergoing corticosteroid injection into the subacromial-subdeltoid (SA-SD) bursa under ultrasound guidance, evaluating both short and long-term outcomes. Materials and methods: In this prospective, longitudinal, analytical study 376 patients referred for SA-SD bursa injection during a 6 month period were asked to complete a questionnaire assessing shoulder pain and disability in the form of the Shoulder Pain and Disability Index (SPADI). Patients were reassessed at 6 weeks and 12 months post-injection. Data were collated and analysed based on the diagnosis made at ultrasound. Results: Almost two-thirds (63.6%) of patients irrespective of the underlying diagnosis showed improvement in pain and disability 6 weeks after injection, but this figure decreased significantly after 12 months to 27.3%. There was no significant difference in outcome between patients with a rotator cuff tendon tear and without a tear at 6 weeks; however, there was a difference between these two groups at 12 months with significantly fewer patients with a tear receiving benefit. Conclusion: The pattern of good short-term, but poorer long-term outcomes from SA-SD bursa injection is in line with previous studies; however, this study provides additional information on the effect of the underlying diagnosis on the potential outcome, specifically the presence or absence of a rotator cuff tendon tear.

Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial

Article

Full-text available

May 2018

Objective To compare the effects of a programme of load management education plus exercise, corticosteroid injection use, and no treatment on pain and global improvement in individuals with gluteal tendinopathy. Design Prospective, three arm, single blinded, randomised clinical trial. Setting Brisbane and Melbourne, Australia. Participants Individuals aged 35-70 years, with lateral hip pain for more than three months, at least 4/10 on the pain numerical rating scale, and gluteal tendinopathy confirmed by clinical diagnosis and magnetic resonance imaging; and with no corticosteroid injection use in previous 12 months, current physiotherapy, total hip replacement, or neurological conditions. Interventions A physiotherapy led education and exercise programme of 14 sessions over eight weeks (EDX; n=69), one corticosteroid injection (CSI; n=66), and a wait and see approach (WS; n=69). Main outcomes Primary outcomes were patient reported global rating of change in hip condition (on an 11 point scale, dichotomised to success and non-success) and pain intensity in the past week (0=no pain, 10=worst pain) at eight weeks, with longer term follow-up at 52 weeks. Results Of 204 randomised participants (including 167 women; mean age 54.8 years (standard deviation 8.8)), 189 (92.6%) completed 52 week follow-up. Success on the global rating of change was reported at eight weeks by 51/66 EDX, 38/65 CSI, and 20/68 WS participants. EDX and CSI had better global improvement scores than WS (risk difference 49.1% (95% confidence interval 34.6% to 63.5%), number needed to treat 2.0 (95% confidence interval 1.6 to 2.9); 29.2% (13.2% to 45.2%), 3.4 (2.2 to 7.6); respectively). EDX had better global improvement scores than CSI (19.9% (4.7% to 35.0%); 5.0 (2.9 to 21.1)). At eight weeks, reported pain on the numerical rating scale was mean score 1.5 (standard deviation 1.5) for EDX, 2.7 (2.4) for CSI, and 3.8 (2.0) for WS. EDX and CSI participants reported less pain than WS (mean difference −2.2 (95% confidence interval −2.89 to −1.54); −1.2 (−1.85 to −0.50); respectively), and EDX participants reported less pain than CSI (−1.04 (−1.72 to −0.37)). Success on the global rating of change was reported at 52 weeks by 51/65 EDX, 36/63 CSI, and 31/60 WS participants; EDX was better than CSI (20.4% (4.9% to 35.9%); 4.9 (2.8 to 20.6)) and WS (26.8% (11.3% to 42.3%); 3.7 (2.4 to 8.8)). Reported pain at 52 weeks was 2.1 (2.2) for EDX, 2.3 (1.9) for CSI, and 3.2 (2.6) for WS; EDX did not differ from CSI (−0.26 (−1.06 to 0.55)), but both treatments did better than WS (1.13 (−1.93 to −0.33); 0.87 (−1.68 to −0.07); respectively). Conclusions For gluteal tendinopathy, education plus exercise and corticosteroid injection use resulted in higher rates of patient reported global improvement and lower pain intensity than no treatment at eight weeks. Education plus exercise performed better than corticosteroid injection use. At 52 week follow-up, education plus exercise led to better global improvement than corticosteroid injection use, but no difference in pain intensity. These results support EDX as an effective management approach for gluteal tendinopathy. Trial registration Prospectively registered at the Australian New Zealand Clinical Trials Registry (ACTRN12612001126808).

A Survey of Fellowship-Trained Upper Extremity Surgeons on Treatment of Lateral Epicondylitis

Article

Full-text available

Apr 2018
Hand

Background: The aim of the study is to investigate current management strategies for lateral epicondylitis by fellowship-trained upper extremity surgeons. Methods: A 17-question survey of treatment approaches and outcomes related to lateral epicondylitis was sent to 3354 surgeons using the American Society for Surgery of the Hand and American Shoulder and Elbow Surgeons member databases. Results: Six hundred twelve upper extremity surgeons completed the survey. The 6 most frequently prescribed nonoperative treatments for lateral epicondylitis were home exercise program/stretching (81%), nonsteroidal anti-inflammatory drugs (75%), steroid injection (71%), counterforce bracing (68%), formal physical therapy (65%), and wrist brace (47%). Less commonly performed nonoperative treatment measures included platelet-rich plasma injection (16%), Tenex procedure (6%), and iontophoresis (2%). Conclusions: There is a lack of consensus in the literature for the management of lateral epicondylitis, which is reflected by individual variation in clinical treatment among the experts. Future prospective randomized control studies are needed to establish evidence-based practice standards for this common diagnosis.

Local application of tranexamic acid affects tendon healing negatively in the late period

Article

Full-text available

Apr 2018
EKLEM HAST CERRAHISI

Objectives: This study aims to evaluate the potential adverse effects of tranexamic acid (TA) on tendon healing. Materials and methods: Twelve male Wistar-Albino rats (weighing 300 g to 350 g) were used in the study. Rats were divided into two groups. Right legs of the rats were determined as the TA group and left legs as the serum physiologic (SP) group. Bilateral Achilles tenotomy was performed and surgically repaired. For the right side, 1 mL of TA and for the left side, 1 mL of SP were applied. Half of the rats were sacrificed at the third week and the other half at the sixth week and tendon samples were collected from the extremities. Histological analyses were performed according to the tendon scoring system (Bonar classification). Results: Tenocyte cell morphology was better in the third week in TA group than in SP group. In terms of colloidal organization, SP groups gave superior results in all weeks. An analysis of total tendon healing scores revealed that the results of the third week TA groups were superior to the results of the sixth week TA groups. Tenocyte morphology and total tendon healing scores of rats in the sixth week TA group were statistically significantly lower compared to the third week TA group (tenocyte morphology p=0.009, total score p=0.041). Conclusion: In this study, we detected that locally administered TA has an adverse effect on tendon healing in late period. However, further immunohistochemical and biomechanical studies are needed to support these results.

Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial

Article

Full-text available

Mar 2018
AM J SPORT MED

Background: A number of surgical techniques for managing tennis elbow have been described. One of the most frequently performed involves excising the affected portion of the extensor carpi radialis brevis (ECRB). The results of this technique, as well as most other described surgical techniques for this condition, have been reported as excellent, yet none have been compared with placebo surgery. Hypothesis: The surgical excision of the degenerative portion of the ECRB offers no additional benefit over and above placebo surgery for the management of chronic tennis elbow. Study design: Randomized controlled trial; Level of evidence, 2. Methods: This study investigated surgical excision of the macroscopically degenerated portion of the ECRB (surgery; n = 13) as compared with skin incision and exposure of the ECRB alone (sham; n = 13) to treat patients who had tennis elbow for >6 months and had failed at least 2 nonsurgical modalities. The primary outcome measure was defined as patient-rated frequency of elbow pain with activity at 6 months after surgery. Secondary outcome measures included patient-rated pain and functional outcomes, range of motion, epicondyle tenderness, and strength at 6 months and 2.5 years. All outcome measures up to and including the 6-month follow-up were measured in person; the longer-term questionnaire was conducted in person or over the phone. Results: The 2 groups, surgery and sham, were similar for age, sex, hand dominance, and duration of symptoms. Both procedures improved patient-rated pain frequency and severity, elbow stiffness, difficulty with picking up objects, difficulty with twisting motions, and overall elbow rating >6 months and at 2.5 years ( P < .01). Both procedures also improved epicondyle tenderness, pronation-supination range, grip strength, and modified Orthopaedic Research Institute-Tennis Elbow Testing System at 6 months ( P < .05). No significant difference was observed between the groups in any parameter at any stage. No side effects or complications were reported. The study was stopped before the calculated number of patients were enrolled (40 per group); yet, a post hoc futility analysis was conducted that showed, based on the magnitude of the differences between the groups, >6500 patients would need to be recruited per group to see a significant difference between the groups at 26 weeks in the primary outcome (patient-rated frequency of elbow pain with activity). Conclusion: With the number of available participants, this study failed to show additional benefit of the surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow.

Existing Evidence on Ultrasound-Guided Injections in Sports Medicine

Article

Full-text available

Feb 2018

Office-based ultrasonography has become increasingly available in many settings, and its use to guide joint and soft tissue injections has increased. Numerous studies have been conducted to evaluate the use of ultrasound-guided injections over traditional landmark-guided injections, with a rapid growth in the literature over the past few years. A comprehensive review of the literature was conducted to demonstrate increased accuracy of ultrasound-guided injections regardless of anatomic location. In the upper extremity, ultrasound-guided injections have been shown to provide superior benefit to landmark-guided injections at the glenohumeral joint, the subacromial space, the biceps tendon sheath, and the joints of the hand and wrist. Ultrasound-guided injections of the acromioclavicular and the elbow joints have not been shown to be more efficacious. In the lower extremity, ultrasound-guided injections at the knee, ankle, and foot have superior efficacy to landmark-guided injections. Conclusive evidence is not available regarding improved efficacy of ultrasound-guided injections of the hip, although landmark-guided injection is performed less commonly at the hip joint. Ultrasound-guided injections are overall more accurate than landmark-guided injections. While current studies indicate that ultrasound guidance improves efficacy and cost-effectiveness of many injections, these studies are limited and more research is needed.

Efficacy Of A Single-Injection Sodium Hyaluronate Treatment In Lateral Epicondylitis

Article

Jan 2018

Background: Lateral epicondylitis or tennis elbow is a disease of tendons arising from common extensor origin at the lateral epicondyle of elbow and is commonly characterized by pain on supination of forearms as well as extension of fingers and wrists. Methods: This descriptive case series aims to determine the efficacy of a single-injection sodium hyaluronate treatment for lateral epicondylitis. The study was conducted at the Department of Orthopaedics. Ayub Teaching Hospital Abbottabad. From February 1 to August 31, 2014. Patients diagnosed with lateral epicondylitis were administered 1 cc of 1% Sodium hyaluronate 1 cm from the lateral epicondyle into the soft tissue. Results: Hyaluronic acid is more effective in patients with moderate pain of lateral epicondylitis (VAS score ≤7 than in patients with severe pain (VAS score >7). Paired sample t-test was used to compared the means of the pre- and post-procedure VAS score and the difference was found to be statistically very significant (p=0.00) with a mean±SD change in VAS of 2.31±1.35 at 4 weeks. Conclusions: A single injection of sodium hyaluronate is effective in management of moderate, but not severe pain of lateral epicondylitis.

Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review

Article

Jan 2018

Objective To compare the effectiveness of corticosteroid injections to local anaesthetic injections in the management of rotator cuff-related shoulder pain (RCRSP). Design Systematic review with best evidence synthesis. Data sources The Cochrane, PubMed, CINAHL Plus, PEDro and EMBASE electronic databases were searched (inception until 8 June 2017). Reference lists of included articles were also hand searched. Eligibility criteria Two reviewers independently evaluated eligibility. Randomised controlled trials (RCTs) were included if they compared subacromial injections of corticosteroid with anaesthetic injections. Two reviewers independently extracted data regarding short-term, midterm and long-term outcomes for pain, self-reported function, range of motion and patient-perceived improvement. Results Thirteen RCTs (n=1013) were included. Four trials (n=475) were judged as being at low risk of bias. Three studies of low risk of bias favoured the use of corticosteroid over anaesthetic-only injections in the short term (up to 8 weeks). There was strong evidence of no significant difference between injection types in midterm outcomes (12–26 weeks). There was limited evidence of no significant difference between injection types in long-term outcomes. Conclusion Corticosteroid injections may have a short-term benefit (up to 8 weeks) over local anaesthetic injections alone in the management of RCRSP. Beyond 8 weeks, there was no evidence to suggest a benefit of corticosteroid over local anaesthetic injections. Trial registration number PROSPERO CRD42016033161.

The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy A Randomized, Double-Blind Controlled Trial Comparing a Single Platelet-Rich Plasma Injection With a Single Corticosteroid Injection

Article

Jan 2018
AM J SPORT MED

Background: Gluteus medius/minimus tendinopathy is a common cause of lateral hip pain or greater trochanteric pain syndrome. Hypothesis: There would be no difference in the modified Harris Hip Score (mHHS) between a single platelet-rich plasma (PRP) injection compared with a corticosteroid injection in the treatment of gluteal tendinopathy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: There were 228 consecutive patients referred with gluteal tendinopathy who were screened to enroll 80 participants; 148 were excluded (refusal: n = 42; previous surgery or sciatica: n = 50; osteoarthritis, n = 17; full-thickness tendon tear, n = 17; other: n = 22). Participants were randomized (1:1) to receive either a blinded glucocorticoid or PRP injection intratendinously under ultrasound guidance. A pain and functional assessment was performed using the mHHS questionnaire at 0, 2, 6, and 12 weeks and the patient acceptable symptom state (PASS) and minimal clinically important difference (MCID) at 12 weeks. Results: Participants had a mean age of 60 years, a ratio of female to male of 9:1, and mean duration of symptoms of .14 months. Pain and function measured by the mean mHHS showed no difference at 2 weeks (corticosteroid: 66.95 6 15.14 vs PRP: 65.23 6 11.60) or 6 weeks (corticosteroid: 69.51 6 14.78 vs PRP: 68.79 6 13.33). The mean mHHS was significantly improved at 12 weeks in the PRP group (74.05 6 13.92) compared with the corticosteroid group (67.13 6 16.04) (P = .048). The proportion of participants who achieved an outcome score of �74 at 12 weeks was 17 of 37 (45.9%) in the corticosteroid group and 25 of 39 (64.1%) in the PRP group. The proportion of participants who achieved the MCID of more than 8 points at 12 weeks was 21 of 37 (56.7%) in the corticosteroid group and 32 of 39 (82%) in the PRP group (P = .016). Conclusion: Patients with chronic gluteal tendinopathy .4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection. Registration: ACTRN12613000677707 (Australian New Zealand Clinical Trials Registry) Keywords: platelet-rich plasma; gluteal tendinopathy; leukocyte

The Use of Ultrasound-Guided Injections for Tendinopathies

Abstract and Figures

Recommended publications

Myths and Facts of In-Office Regenerative Procedures for Tendinopathy: Literature Review

Treatment of athletic tendonopathy

Spor Yaralanmalarında Plateletten Zengin Plazma Uygulamaları

[Research advancement of the tennis elbow]