Lateral Epicondyle Tendinopathy Toolkit: Appendix G - Medical and Surgical Interventions: Difference between revisions
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| colspan="2" width="100" style="background: #efefef;" | '''Method''' | | colspan="2" width="100" style="background: #efefef;" | '''Method''' | ||
| width="700" style="background: #FFEFE0;" | | | width="700" style="background: #FFEFE0;" | | ||
Peritendinous injections | |||
|- | |- | ||
| colspan="2" width="100" style="background: #efefef;" | '''Proposed Mechanism''' | | colspan="2" width="100" style="background: #efefef;" | '''Proposed Mechanism''' | ||
| width="700" style="background: #FFEFE0;" | | | width="700" style="background: #FFEFE0;" | | ||
Applied locally to interrupt the inflammatory process.<br>Reduces tendon blood flow and tissue thickening. | |||
|- | |- | ||
| rowspan="2" width="100" style="background: #efefef;" | '''Benefit: Pros/Cons'''<br> | | rowspan="2" width="100" style="background: #efefef;" | '''Benefit: Pros/Cons'''<br> | ||
| style="background: #efefef;" | '''Pros:''' | | style="background: #efefef;" | '''Pros:''' | ||
| width="700" style="background: #FFEFE0;" | | | width="700" style="background: #FFEFE0;" | | ||
* | *Easily accessible. | ||
*Careful administration outside the structure of the tendon is considered ‘safe’( i.e. in the paratendon sheath). | |||
|- | |- | ||
| style="background: #efefef;" | '''Cons:''' | | style="background: #efefef;" | '''Cons:''' | ||
| width="700" style="background: #FFEFE0;" | | | width="700" style="background: #FFEFE0;" | | ||
* | *Worse long-term outcomes. | ||
*Risk of infection (1%) ‘Universal precautions’ required. | |||
*Destructive; impairs tissue repair mechanism. | |||
*Intra-tendon injection may weaken tissue structure, with risk of tendon rupture. | |||
*Skin depigmentation. | |||
*Sub-cutaneous atrophy. | |||
*Post injection pain.<br> | |||
|- | |- | ||
| colspan="2" width="100" style="background: #efefef;" | '''Evidence''' | | colspan="2" width="100" style="background: #efefef;" | '''Evidence''' | ||
| width="700" style="background: #FFEFE0;" | | | width="700" style="background: #FFEFE0;" | | ||
There is high quality evidence that local corticosteroid injections are effective for short term pain relief, but are inferior to multimodal physiotherapy in the long term (6 and 12 months).<br>Repeated injections (3-6 times in 18 months) has poorer outcome than a single injection on pain reduction.<br>The benefit of early pain reduction to assist in return to activity may be counter-productive due to increased risk of recurrence. | |||
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| colspan="2" width="100" style="background: #efefef;" | | | colspan="2" width="100" style="background: #efefef;" | | ||
'''Take Home Message'''<br>'''Implications for Physiotherapy''' | '''Take Home Message'''<br>'''Implications for Physiotherapy''' | ||
| width="700" style="background: #FFEFE0;" | | | width="700" style="background: #FFEFE0;" | | ||
Corticosteroid injections provide short-term relief but are associated with worse long-term outcomes with a high rate of recurrence. | |||
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Revision as of 15:04, 16 August 2013
Pharmacological Approaches[edit | edit source]
NSAIDs[1][edit | edit source]
Method |
Oral or topical application | |
Proposed Mechanism |
Interrupts the main pathway of inflammation by inhibiting the action of cyclooxygenases. | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence |
Weak evidence for temporary pain relief in lateral elbow tendinopathy. | |
Take Home Message |
General knowledge of commonly used NSAIDS is important for treatment planning. NSAIDs are not curative for this condition and there is no evidence of sustained benefit in the long term. |
Corticosteroid (Injection)[2][3][4][5][edit | edit source]
Method |
Peritendinous injections | |
Proposed Mechanism |
Applied locally to interrupt the inflammatory process. | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence |
There is high quality evidence that local corticosteroid injections are effective for short term pain relief, but are inferior to multimodal physiotherapy in the long term (6 and 12 months). | |
Take Home Message |
Corticosteroid injections provide short-term relief but are associated with worse long-term outcomes with a high rate of recurrence. |
Glycerol Trinitrate (GTN)[6][7][edit | edit source]
Method | AAA | |
Proposed Mechanism | BBB | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | EEE | |
Take Home Message |
FFF |
Injection Therapies[edit | edit source]
Polidocanol[8][9][edit | edit source]
Method | AAA | |
Proposed Mechanism | BBB | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | EEE | |
Take Home Message |
FFF |
Prolotherapy[10][9][edit | edit source]
Method | AAA | |
Proposed Mechanism | BBB | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | EEE | |
Take Home Message |
FFF |
Platelet Rich Plasma (PRP)[9][11][12][5][edit | edit source]
Method | AAA | |
Proposed Mechanism | BBB | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | EEE | |
Take Home Message |
FFF |
Botox (Botulinum Toxin A)[13][14][edit | edit source]
Method | AAA | |
Proposed Mechanism | BBB | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | EEE | |
Take Home Message |
FFF |
Surgical Approaches[edit | edit source]
Denervation[15][edit | edit source]
Method | AAA | |
Proposed Mechanism | BBB | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | EEE | |
Take Home Message |
FFF |
Surgical Debridement[16][edit | edit source]
Method | AAA | |
Proposed Mechanism | BBB | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | EEE | |
Take Home Message |
FFF |
References[edit | edit source]
- ↑ Green et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2002; (2):CD003686.
- ↑ Coombes B et al. Efficiency and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of RCTs. LANCET. 376(9754): 1751-67. Nov 2010.
- ↑ Snyder K, Evans T. Effectiveness of corticosteroids in treatment of lateral epicondylosis. Jour Sports Rehab. 21(1): 83-88. Feb 2012.
- ↑ Coombes B et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013 Feb 6;309(5):461-9.
- ↑ 5.0 5.1 Krogh et al. Treatment of Lateral Epicondylitis With Platelet-Rich Plasma, Glucocorticoid, or Saline: A Randomized, Double-Blind, Placebo-Controlled Trial. AJSM e-pub. March 4, 2013.
- ↑ Paoloni et al. Randomised, double-blind, placebo-controlled clinical trial of a new topical glyceryl trinitrate patch for chronic lateral epicondylosis. Br J Sports Med. 2009;43:299-302.
- ↑ Paoloni et al. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized double-blinded placebo controlled trail. Am J Sports Med. 2003; 31: 915-20.
- ↑ Zeisig et al. Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study. Br J Sports Med. 2008;42:267-271.
- ↑ 9.0 9.1 9.2 Krogh et al. Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Am J Sports Med. e-pub. Sep 12, 2012.
- ↑ Scarpone et al. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008;18: 248-254.
- ↑ Creaney L et al. Growth factor–based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med. 2011;45: 966-971.
- ↑ Peerbooms JC et al. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38: 255-262.
- ↑ Lin YC et al. Comparison between botulinum toxin and corticosteroid injection in the treatment of acute and subacute tennis elbow a prospective, randomized, double-blind, active drug controlled pilot study. Am J Phys Med Rehabil. 2010; 89: 653-659.
- ↑ Placzek R et al. Treatment of chronic radial epicondylitis with botulinum toxin A: a double-blind, placebo-controlled, randomized multicenter study. J Bone Joint Surg Am. 2007; 89: 255-260.
- ↑ Berry et al. Epicondylectomy versus denervation for lateral humeral epicondylitis. Hand (N Y). 2011 Jun;6(2): 174-8.
- ↑ Dunn et al. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. 2008 Feb;36(2): 261-6.