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;" | AAA
| width="700" style="background: #FFEFE0;" |  
Nitro-glycerine patches (1.25mg/24 hrs) applied over tendon to enhance healing.
 
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| colspan="2" width="100" style="background: #efefef;" | '''Proposed Mechanism'''  
| colspan="2" width="100" style="background: #efefef;" | '''Proposed Mechanism'''  
| width="700" style="background: #FFEFE0;" | BBB
| width="700" style="background: #FFEFE0;" |  
Nitric oxide may stimulate repair by enhancing collagen synthesis in tenocytes.
 
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| 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;" |  
*CCC
*GTN + exercise improve outcomes compared to exercise alone.
*Increased compliance because of ease of application. Self-applied.
*Non-invasive.<br>


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| style="background: #efefef;" | '''Cons:'''  
| style="background: #efefef;" | '''Cons:'''  
| width="700" style="background: #FFEFE0;" |  
| width="700" style="background: #FFEFE0;" |  
*DDD
*Requires repeated applications over 12 weeks.
*Potential headache as a side-effect of nitro patch.<br>


|-
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| colspan="2" width="100" style="background: #efefef;" | '''Evidence'''  
| colspan="2" width="100" style="background: #efefef;" | '''Evidence'''  
| width="700" style="background: #FFEFE0;" | EEE
| width="700" style="background: #FFEFE0;" |  
A small amount of RCT level evidence suggests that GTN patches combined with exercise achieve clinically significant benefits compared to exercise alone.
 
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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;" | FFF
| width="700" style="background: #FFEFE0;" |  
Use of GTN may enhance exercise outcomes. If prescribed by a physician, it may be applied by a physiotherapist and used in conjunction with a multimodal exercise program.
 
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Revision as of 15:08, 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:
  • Inexpensive, easily accessible.
Cons:
  • Precautions and contra-indications that accompany specific medications.
  • Increased risk of gastrointestinal complications.
Evidence

Weak evidence for temporary pain relief in lateral elbow tendinopathy.
Insufficient evidence to make a recommendation.
Relative effectiveness of oral vs. topical application has not been examined.

Take Home Message
Implications for Physiotherapy

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.
Reduces tendon blood flow and tissue thickening.

Benefit: Pros/Cons
 Pros:
  • Easily accessible.
  • Careful administration outside the structure of the tendon is considered ‘safe’( i.e. in the paratendon sheath).
Cons:
  • 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.
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).
Repeated injections (3-6 times in 18 months) has poorer outcome than a single injection on pain reduction.
The benefit of early pain reduction to assist in return to activity may be counter-productive due to increased risk of recurrence.

Take Home Message
Implications for Physiotherapy

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

Nitro-glycerine patches (1.25mg/24 hrs) applied over tendon to enhance healing.

Proposed Mechanism

Nitric oxide may stimulate repair by enhancing collagen synthesis in tenocytes.

Benefit: Pros/Cons
 Pros:
  • GTN + exercise improve outcomes compared to exercise alone.
  • Increased compliance because of ease of application. Self-applied.
  • Non-invasive.
Cons:
  • Requires repeated applications over 12 weeks.
  • Potential headache as a side-effect of nitro patch.
Evidence

A small amount of RCT level evidence suggests that GTN patches combined with exercise achieve clinically significant benefits compared to exercise alone.

Take Home Message
Implications for Physiotherapy

Use of GTN may enhance exercise outcomes. If prescribed by a physician, it may be applied by a physiotherapist and used in conjunction with a multimodal exercise program.


Injection Therapies[edit | edit source]

Polidocanol[8][9][edit | edit source]

Method AAA
Proposed Mechanism BBB
Benefit: Pros/Cons
 Pros:
  • CCC
Cons:
  • DDD
Evidence EEE

Take Home Message
Implications for Physiotherapy

FFF


Prolotherapy[10][9][edit | edit source]

Method AAA
Proposed Mechanism BBB
Benefit: Pros/Cons
 Pros:
  • CCC
Cons:
  • DDD
Evidence EEE

Take Home Message
Implications for Physiotherapy

FFF


Platelet Rich Plasma (PRP)[9][11][12][5][edit | edit source]

Method AAA
Proposed Mechanism BBB
Benefit: Pros/Cons
 Pros:
  • CCC
Cons:
  • DDD
Evidence EEE

Take Home Message
Implications for Physiotherapy

FFF


Botox (Botulinum Toxin A)[13][14][edit | edit source]

Method AAA
Proposed Mechanism BBB
Benefit: Pros/Cons
 Pros:
  • CCC
Cons:
  • DDD
Evidence EEE

Take Home Message
Implications for Physiotherapy

FFF


Surgical Approaches[edit | edit source]

Denervation[15][edit | edit source]

Method AAA
Proposed Mechanism BBB
Benefit: Pros/Cons
 Pros:
  • CCC
Cons:
  • DDD
Evidence EEE

Take Home Message
Implications for Physiotherapy

FFF


Surgical Debridement[16][edit | edit source]

Method AAA
Proposed Mechanism BBB
Benefit: Pros/Cons
 Pros:
  • CCC
Cons:
  • DDD
Evidence EEE

Take Home Message
Implications for Physiotherapy

FFF


References[edit | edit source]

  1. ↑ Green et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2002; (2):CD003686.
  2. ↑ 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.
  3. ↑ Snyder K, Evans T. Effectiveness of corticosteroids in treatment of lateral epicondylosis. Jour Sports Rehab. 21(1): 83-88. Feb 2012.
  4. ↑ 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. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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. ↑ 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.
  10. ↑ Scarpone et al. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008;18: 248-254.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ Berry et al. Epicondylectomy versus denervation for lateral humeral epicondylitis. Hand (N Y). 2011 Jun;6(2): 174-8.
  16. ↑ 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.


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