Eva Zeisig

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

Objective: To appraise existing evidence for prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injection therapies for lateral epicondylosis (LE). Design: Systematic review. Data sources: Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine. Search strategy: names and descriptors of the therapies and LE. Study Selection: All human studies assessing the four therapies for LE. Main results: Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. In follow-up periods ranging from 9 to 108 weeks, studies reported sustained, statistically significant (p<0.05) improvement in visual analogue scale primary outcome pain score measures and disease-specific questionnaires; relative effect sizes ranged from 51% to 94%; Cohen’s d ranged from 0.68 to 6.68. Secondary outcomes also improved, including biomechanical elbow function assessment (polidocanol and prolotherapy), presence of abnormalities and increased vascularity on ultrasound (autologous whole blood and polidocanol). Subjects reported satisfaction with therapies on single-item assessments. All studies were limited by small sample size. Conclusions: There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.

Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study

Background: “Tennis elbow” is a difficult condition to treat. Ultrasonography (US) and colour Doppler (CD) guided injections with polidocanol targeting the area with increased blood flow in the extensor origin have shown promising clinical results. Objective: To evaluate and compare effects of US and CD guided intratendinous injections with sclerosing polidocanol and a local anaesthetic (lidocaine + epinephrine), in patients with tennis elbow. Design: Prospective, randomised, controlled, double-blind, crossover study. Setting: Sports Medicine Unit, Umeå University. Patients: 32 patients (36 elbows), age range 27 to 66 years, with a long duration of elbow pain diagnosed as tennis elbow, were included in the study. All patients were followed up 3 and 12 months after treatment. Two patients were excluded due to other interventions during the study. Interventions: One US and CD guided injection with the sclerosing agent polidocanol (group 1) or the local anaesthetic lidocaine plus epinephrine (group 2). At the 3 month follow-up, additional injections with polidocanol were offered to both groups (crossover for group 2). Main outcome measures: Satisfaction with treatment (Yes/No), elbow pain during activity (visual analogue scale), and maximum voluntary grip strength. Results: There were no significant (p<0.05) differences in the outcome between group 1 and group 2. In both groups, there was a significantly lower VAS at the 3-month and 12-month follow-ups, and grip strength was significantly higher at the 12-month follow-up. Conclusions: US and CD guided intratendinous injections gave pain relief in patients with tennis elbow. Polidocanol and lidocaine plus epinephrine injections gave similar results.

Extensor origin vascularity related to pain in patients with Tennis elbow.

Tennis elbow, extensor carpi radialis brevis (ECRB) tendinosis, is a condition with unknown etiology and pathogenesis, known to be difficult to treat. The pain mechanisms have not been fully clarified, but involvement of a neurogenic inflammation mediated via the neuropeptide Substance-P (SP), has been suggested. In this investigation, grey-scale ultrasonography (US) and colour Doppler (CD) was used to examine the common extensor origin in 17 patients with the diagnose Tennis elbow in altogether 22 elbows, and in 11 controls with 22 pain-free elbows. In 21/22 elbows with chronic pain from the extensor origin, but only in 2/22 pain-free elbows, vascularity was demonstrated in the extensor origin. After US and CD-guided injection of a local anaesthetic, targeting the area with vessels, the patients were pain-free during extensor-loading activity. The area with vascularity found in the extensor origin seems to be related to pain. Most likely, the findings correspond with the vasculo-neural in growth that has been demonstrated in the chronic painful Achilles tendon, and possibly have implications for treatment.

A two-year sonographic follow-up after intratendinous injection therapy in patients with tennis elbow

Background Tennis elbow is a tendinopathy affecting the upper extremity. Recent studies have shown high sensitivity for ultrasound (US) examination and high specificity for colour Doppler (CD) examination. There are no mid- or long-term follow-up investigations of the tendon structure and blood flow using these techniques. Objective To use US and CD to study structure and blood flow in the extensor origin in patients with tennis elbow treated with intratendinous injections. Design Follow-up study Setting Sports Medicine Unit, Umeå University. Patients 25 patients (28 elbows), mean age 46 years (range 27–66), treated with intratendinous injections due to chronic pain from tennis elbow. Method US and CD examination of the extensor origin was carried out at inclusion and at follow-up two years after intratendinous injection treatment with polidocanol and/or a local anaesthetic. Main outcome measurements US (structure) and CD (blood flow) findings. Results All patients had structural tendon changes and high blood flow at inclusion when given the injection treatment. At the two-year follow-up, structural tendon changes were seen in 20/28 elbows and high blood flow was seen in 4/28 elbows. The majority of patients with a good clinical result after treatment had no visible blood flow (17/20), but the structural changes showed no relation to a good result (13/20 remaining changes). Conclusions Doppler findings, but not structure, might be related to the clinical result after intratendinous injection treatment of tennis elbow.

No normalisation of the tendon structure and thickness after intratendinous surgery for chronic painful midportion Achilles tendinosis

Objective: To characterise Achilles tendon structure and thickness a minimum of 8 years after intratendinous surgery. Material and Methods: Fourteen patients (16 tendons; nine men and five women, mean age 43 years, range 27–55) surgically treated (intratendinous surgery) for chronic painful midportion Achilles tendinosis, were followed with clinical examination and grey-scale ultrasonography for a minimum of 8 years (range 8–16, mean 13). Results: All patients were satisfied with the result of surgery and were active in Achilles tendon loading activities without restrictions. In all operated tendons, structural abnormalities remained and tendons remained thicker than normal tendons. Conclusions: Resection of tendinosis is associated with persistent structural abnormalities and thickening of the tendon 13 years after surgery, despite successful clinical outcomes.

Immunohistochemical evidence of local production of catecholamines in cells of the muscle origins at the lateral and medial humeral epicondyles: of importance for the development of tennis and golfer’s elbow?

Background: Tennis elbow (TE) is a painful condition affecting the common extensor origin at the lateral humeral epicondyle. Colour Doppler examination has shown increased blood flow at this site and the sensory, and sympathetic innervation patterns have been delineated. However, it is not known whether there is local production of catecholamines and/or acetylcholine in this tissue, which is the case in patellar and Achilles tendinopathies. Objective: To investigate the possible presence of local production of catecholamines and acetylcholine in non-neuronal cells (fibroblasts) in connective tissue at the muscle origin at the lateral humeral epicondyle in patients with TE. Design: Immunohistochemical studies were performed on biopsies taken from the extensor origin in patients with TE and in pain-free controls. For reference purpose, biopsies from the flexor origin in patients with golfer’s elbow (GE) were also studied. Patients: Seven patients with TE and four patients with GE. Six healthy asymptomatic individuals served as controls. Method: Immunohistochemistry, using antibodies detecting synthesising enzymes for catecholamines (tyrosine hydroxylase; TH) and acetylcholine (choline acetyltransferase; ChAT). Results: TH-like immunohistochemical reactions were seen in fibroblasts in four of the seven patients with TE and two of the four patients with GE. No such reactions were detected in controls (0/6). No ChAT reactions were seen in any of the investigated specimens. Conclusions: There is evidence of local, non-neuronal production of catecholamines, but not acetylcholine, in fibroblasts in the tissue at the muscle origin at the lateral and medial epicondyles in patients with TE and GE, respectively, which might have an influence on blood vessel regulation and pain mechanisms in these conditions.

Natural course in tennis elbow-lateral epicondylitis after all?

Tennis elbow is a common and difficult-to-treat condition largely because of lack of evidence. The natural history is unknown, but the condition is described as self-limiting. The objective of this case report is to describe the natural course of two control participants (pain free), who later developed tennis elbow, patient history, clinical findings, and ultrasound and colour Doppler examination before, during and after a period of tennis elbow.