Leanne Margaret Bisset

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.

A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

A systematic review of the literature on the effectiveness of physical interventions for lateral epicondylalgia (tennis elbow) was carried out. Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow. There is a lack of evidence for the long term benefit of physical interventions in general. However, further research with long term follow up into manipulation and exercise as treatments is indicated.

A new integrative model of lateral epicondylalgia

Tennis elbow or lateral epicondylalgia is a diagnosis familiar to many within the general community and presents with an uncomplicated clinical picture in most cases. However, the underlying pathophysiology presents a more complex state and its management has not been conclusively determined. Research on this topic extends across anatomical, biomechanical and clinical literature; however, integration of findings is lacking. We propose that the current understanding of the underlying pathophysiology of lateral epicondylalgia can be conceptualised as encompassing three interrelated components: (i) the local tendon pathology, (ii) changes in the pain system, and (iii) motor system impairments. This paper presents a model that integrates these components on the basis of a literature review with the express aim of assisting in the targeting of specific treatments or combinations thereof to individual patients.

Foot Orthoses in Lower Limb Overuse Conditions: A Systematic Review and Meta-Analysis

There is evidence from the meta-analysis to support the use of foot orthoses in the prevention of the first incidence of lower-limb overuse conditions. The inclusion of orthoses in a treatment program for individuals who already have an overuse condition is difficult to support or refute because of the generally poor research base, which has been highlighted by this systematic review. There is evidence from pooled data that there is no difference between the use of custom and prefabricated foot orthoses, inferring that practitioners may use either in the prevention and treatment of lower-limb overuse injuries. Focal points for future research conducted in this area include longer intervention durations, greater consistency with reliable measures, and better consensus in definitions of foot orthoses.

Diagnostic accuracy of power-doppler ultrasound in patients with chronic tennis elbow

Objective: To determine the diagnostic accuracy of power Doppler and grey scale ultrasonography, assess the relationship between severity measures and neovascularity, and describe the intra-tendon distribution of neovascularity in chronic tennis elbow. Design: Between group cross sectional study. Setting: Sports medicine clinic and radiology centre. Participants: 32 affected elbows (median and range of duration: 10; 3–120 months) and 18 unaffected contralateral elbows in 25 patients (mean age 50 years) with lateral elbow pain, and 38 unaffected elbows in 19 asymptomatic participants (mean age 45 years) underwent a clinical examination (reference standard test) and grey scale and power Doppler ultrasonographic examination. Main outcome measures: Ultrasound examination with power Doppler identified neovascularity and grey scale ultrasound changes (lateral epicondyle bony spurring or irregularity, maximum anterior–posterior thickness, and echo characteristics) of the common extensor tendon. Results: Power Doppler had a strong positive likelihood ratio of 45.39, whereas a combined null finding in power Doppler and grey scale ultrasonography resulted in a robust negative likelihood ratio of 0.05. Grey scale changes were generally not as diagnostically accurate. Common extensor tendon neovascularity was equally distributed between the superficial and deep part of the tendon, and clinical severity measures did not correlate with neovascularity scores. Conclusions: Neovascularity identified with power Doppler ultrasonography when compared to grey scale changes (alone or in combination with Doppler) was diagnostically superior in identifying chronic tennis elbow. The lack of both neovascularity and grey scale changes on ultrasound examination also substantially increase the probability that the condition is not present and should prompt the clinician to consider other causes for lateral elbow pain.

Efficacy of nonsurgical interventions for anterior knee pain: Systematic review and meta-analysis of randomized trials

Anterior knee pain is a chronic condition that presents frequently to sports medicine clinics, and can have a long-term impact on participation in physical activity. Conceivably, effective early management may prevent chronicity and facilitate physical activity. Although a variety of nonsurgical interventions have been advocated, previous systematic reviews have consistently been unable to reach conclusions to support their use. Considering a decade has lapsed since publication of the most recent data in these reviews, it is timely to provide an updated synthesis of the literature to assist sports medicine practitioners in making informed, evidence-based decisions. A systematic review and meta-analysis was conducted to evaluate the evidence for nonsurgical interventions for anterior knee pain.A comprehensive search strategy was used to search MEDLINE, EMBASE, CINAHL® and Pre-CINAHL®, PEDro, PubMed, SportDiscus®, Web of Science®, BIOSIS Previews®, and the full Cochrane Library, while reference lists of included papers and previous systematic reviews were hand searched. Studies were eligible for inclusion if they were randomized clinical trials that used a measure of pain to evaluate at least one nonsurgical intervention over at least 2 weeks in participants with anterior knee pain. A modified version of the PEDro scale was used to rate methodological quality and risk of bias. Effect size calculation and meta-analyses were based on random effects models.Of 48 suitable studies, 27 studies with low-to-moderate risk of bias were included. There was minimal opportunity for meta-analysis because of heterogeneity of interventions, comparators and follow-up times. Metaanalysis of high-quality clinical trials supports the use of a 6-week multimodal physiotherapy programme (standardized mean difference [SMD] 1.08, 95% CI 0.73, 1.43), but does not support the addition of electromyography biofeedback to an exercise programme in the short-term (4 weeks: SMD −0.21, 95% CI −0.64, 0.21; 8–12 weeks: SMD −0.22, 95% CI −0.65, 0.20). Individual study data showed beneficial effects for foot orthoses with and without multimodal physiotherapy (vs flat inserts), exercise (vs control), closed chain exercises (vs open chain exercises), patella taping in conjunction with exercise (vs exercise alone) and acupuncture (vs control).Findings suggest that, in implementing evidence-based practice for the nonsurgical management of anterior knee pain, sports medicine practitioners should prescribe local, proximal and distal components of multimodal physiotherapy in the first instance for suitable patients, and then consider foot orthoses or acupuncture as required.

Thermal Hyperalgesia Distinguishes Those With Severe Pain and Disability in Unilateral Lateral Epicondylalgia

Objectives: To evaluate if sensory, motor, and psychological factors are different in severe lateral epicondylalgia compared with less severe cases and control. Methods: A total of 164 patients with unilateral lateral epicondylalgia and 62 healthy control participants of comparable age and sex underwent the following testing: quantitative sensory testing (pressure, thermal pain thresholds), pain-free grip, quality of life (EuroQol), and psychological (Hospital Anxiety and Depression Scale, Tampa Scale for Kinesiophobia) testing. Cluster analysis classified patients into mild, moderate, or severe subgroups using the Patient Rated Tennis Elbow Evaluation. Data were then evaluated to determine differences between control and lateral epicondylalgia subgroups. Results: Bilateral cold hyperalgesia (affected elbow, standardized mean difference (SMD) −1.14, P=0.000; unaffected elbow SMD −0.94, P=0.000) and unilateral heat hyperalgesia (SMD −1.06, P=0.001) were evident in severe lateral epicondylalgia in comparison to healthy controls. All patient groups regardless of severity demonstrated bilateral and widespread mechanical hyperalgesia relative to controls (P<0.003); however, only those with moderate and severe symptoms showed large differences (Absolute SMD>0.8) at all sites. Quality of life was significantly poorer in patients with severe symptoms, whereas anxiety, depression, and kinesiophobia did not differ between subgroups. Discussion: Lateral epicondylalgia patients presenting with severe pain and disability could be distinguished by hypersensitivity to thermal stimuli, notably bilateral cold hyperalgesia. Findings may implicate a combination of central, peripheral, and sympathetic nervous system processes and may help explain the poorer outcomes found in this subpopulation.

Joint manipulation in the management of lateral epicondylalgia: a clinical commentary.

Abstract Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.

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

BackgroundCorticosteroid injection and physiotherapy are two commonly prescribed interventions for management of lateral epicondylalgia. Corticosteroid injections are the most clinically efficacious in the short term but are associated with high recurrence rates and delayed recovery, while physiotherapy is similar to injections at 6 weeks but with significantly lower recurrence rates. Whilst practitioners frequently recommend combining physiotherapy and injection to overcome harmful effects and improve outcomes, study of the benefits of this combination of treatments is lacking. Clinicians are also faced with the paradox that the powerful anti-inflammatory corticosteroid injections work well, albeit in the short term, for a non-inflammatory condition like lateral epicondylalgia. Surprisingly, these injections have not been rigorously tested against placebo injections. This study primarily addresses both of these issues.MethodsA randomised placebo-controlled clinical trial with a 2 × 2 factorial design will evaluate the clinical efficacy, cost-effectiveness and recurrence rates of adding physiotherapy to an injection. In addition, the clinical efficacy and adverse effects of corticosteroid injection beyond that of a placebo saline injection will be studied. 132 participants with a diagnosis of lateral epicondylalgia will be randomly assigned by concealed allocation to one of four treatment groups – corticosteroid injection, saline injection, corticosteroid injection with physiotherapy or saline injection with physiotherapy. Physiotherapy will comprise 8 sessions of elbow manipulation and exercise over an 8 week period. Blinded follow-up assessments will be conducted at baseline, 4, 8, 12, 26 and 52 weeks after randomisation. The primary outcome will be a participant rating of global improvement, from which measures of success and recurrence will be derived. Analyses will be conducted on an intention-to-treat basis using linear mixed and logistic regression models. Healthcare costs will be collected from a societal perspective, and along with willingness-to-pay and quality of life data will facilitate cost-effectiveness and cost-benefit analyses.ConclusionThis trial will utilise high quality trial methodologies in accordance with CONSORT guidelines. Findings from this study will assist in the development of evidence based practice recommendations and potentially the optimisation of resource allocation for rehabilitating lateral epicondylalgia.Trial registrationAustralian New Zealand Clinical Trials Register ACTRN12609000051246

Cold hyperalgesia associated with poorer prognosis in lateral epicondylalgia: a 1-year prognostic study of physical and psychological factors

Background:Predictors of outcome in lateral epicondylalgia, which is mainly characterized as a mechanical hyperalgesia, are largely limited to sociodemographic and symptomatic factors. Quantitative sensory testing is used to study altered pain processing in various chronic pain conditions and may be of prognostic relevance. Methods:The predictive capacity of early measures of physical and psychological impairment on pain and disability and mechanical hyperalgesia, were examined using data from 41 patients assigned to placebo in a prospective randomized controlled trial of unilateral lateral epicondylalgia. Quantitative sensory testing (pressure, cold pain thresholds), motor function (pain-free grip), and psychological factors (Tampa Scale of Kinesiophobia, Hospital Anxiety and Depression Scale) were measured at baseline. The outcome measures were the Patient-rated Tennis Elbow Evaluation (PRTEE) scale and pressure pain threshold (PPT) measured by digital algometry at the affected elbow. Backward stepwise linear regression was used to predict PRTEE and PPT scores at 2 and 12 months. Results:Cold pain threshold was the only consistent predictor for both PRTEE (P<0.034) and PPT (P<0.048). Initial PRTEE was the strongest single predictor of PRTEE at 2 months, whereas female sex was the strongest single predictor of PPT (P<0.002). At 1 year, final models explained 9% to 52% of the variability in pain and disability and mechanical hyperalgesia, respectively. Discussion:Early assessment of cold pain threshold could be a useful clinical tool to help identify patients at risk of poorer outcomes and might provide direction for future research into mechanism-based treatment approaches for these patients.