Recurrent epicondylitis

[PMR 4 MSK]

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I have a 40-ish woman with recurrent bilateral medial and lateral epicdondylitis. She's been through PT and meds, does home stretching and strengthening, but it responds best to steroid injection. However, it keeps coming back after a few months. I've done 4 rounds of injections over the past 14 months.

She works data entry for an insurance company, and this is work comp. Px clearly c/w medial and lateral epicondylitis on both sides. I'm not into prolo, and the evidence for botox helping is weak. Fellowship trained UE ortho surgeon does not recommend surgery for her.

She can't change jobs right now for economic reasons. I've told her as long as she does the work she does,it'll keep coming back, and eventually the shots will stop working. Any thoughts on long-term treatment?

 

[axm397]

ergonomic evaluation?

autologous blood injection? http://www.ispub.com/journal/the_in...the_treatment_of_refractory_tennis_elbow.html

shockwave therapy?

 

[PMR 4 MSK]

Employer won't provide or allow ergonomic eval (small company).

I've never used autologous blood. I read the article. Not sure I could convince the pt or the adjuster to do it.

I'll check and see if anyone does shockwave therapy around here for it.

 

[Ludicolo]

Nitro patch?

Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2003;31:915-20.

 

[nvrsumr]

JBJS 2007

Treatment of Chronic Radial Epicondylitis
with Botulinum Toxin A
A Double-Blind, Placebo-Controlled, Randomized Multicenter Study


By Richard Placzek, MD, Wolf Drescher, MD, PhD, Georg Deuretzbacher, PhD, Axel Hempfing, MD, and A. Ludwig Meiss, MD
Investigation performed at Orthopädische Universitätsklinik Hamburg-Eppendorf, Hamburg, Germany

Background: Radial epicondylitis (tennis elbow) is the most frequent type of myotendinosis. Patients can experience
substantial loss of function, especially when this condition becomes chronic. A successful therapy has not yet been
established. A preliminary study of injections of botulinum toxin A in patients with chronic epicondylitis has shown
promising results.

Methods: In the present prospective, controlled, double-blinded clinical trial, 130 patients were examined at sixteen
study centers. A single injection of botulinum toxin A into the painful origin of the forearm extensor muscles was performed.
Follow-up examinations were performed at two, six, twelve, and eighteen weeks. Clinical findings were documented
with use of a new clinical pain score and with a visual analogue scale. A global assessment of the result of
treatment was also provided by the patient and the attending doctor. Strength of extension of the third finger and the wrist
was evaluated with use of the Brunner method, and grip strength (fist closure strength) was measured with a vigorimeter.

Results: The group treated with botulinum toxin A was found to have a significant improvement in the clinical findings,
compared with those in the placebo group, as early as the second week after injection (p = 0.003). Subjective
general assessment also showed improvement in that group, compared with the placebo group, at six weeks (p =
0.001) and at the time of the final examination (at eighteen weeks) (p = 0.001). There was a consistent increase in
fist closure strength in both the group treated with botulinum toxin A and the control group, but there was no significant
difference between groups. As was expected as a side effect, extension of the third finger was observed to be
significantly weakened at two weeks but this complication had completely resolved at eighteen weeks.

Conclusions: We concluded that local injection of botulinum toxin A is a beneficial treatment for radial epicondylitis
(tennis elbow). The treatment can be performed in an outpatient setting and does not impair the patient's ability to work.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.


I had a weird case of a below elbow amputee with chronic forearm pain. Got an MRI w/contrast looking for neuroma etc... and the wrist extensors lit up. LA and steroid injection provided excellent relief for a couple hours. Insurance denied botox, sent above article to physician reviewer and he denied approval because the study didnt show any evidence of improvement in grip stregnth..... the patient had no hand!! Gotta love it. Good luck getting it approved even with a recent RTC from a respected journal purporting level 1 ev.

 

[PMR 4 MSK]

I've discussed botox with her, done to 1 pt with minimal results. The extensor mass doesn't bother me, but I'm quite hesitant to do both extensor and flexor bilaterally.

 

[RUOkie]

Have you checked her Radial nerve (posterior interosseous syndrome), or even CTS?
Probably the most important thing though, is to eval her shoulder. If she has a functional limitation in external rotation, she will transmit forces down to the elbow. Often, treating the shoulder will fix the elbow. Also, you need to think about secondary gain.

 

[facetguy]

Consider some dedicated myofascial work, like Graston or Active Release or similar. Chronic myofascial shortening/dysfunction may be contributing to her underlying problem. Depending on the PT she's had to date, it's quite possible this wasn't adequately addressed.

 

[SSdoc33]

just met this british dude at a conference who, when i asked his specialty said "tendonopathy". ok, whatever, but apparently he has been doing some sort of hypertonic saline injection along the tendon sheath using ultrasound guidance. his rationale being that because there is tendonosis, rather than tendonitis, the injection strips the adherent connective tissue layer (epi-mysium?) from the tendon, allowing neovascularization, inflammatory cells, etc, to come in and fix things up. states he's had good results.

i understand that this post does you no practical good whatsoever, just food for thought

 

[facetguy]

Is that different than prolotherapy?

 

[SSdoc33]

yeah. i apologize that i dont know the exact name for it, but its not prolo

 

[RUOkie]

Injection of hypertonic saline into a tendon sheath IS prolotherapy. It is just safer than using phenol. Do a literature search prior to starting such treatment.

 

[SSdoc33]

Injection of hypertonic saline into a tendon sheath IS prolotherapy. It is just safer than using phenol. Do a literature search prior to starting such treatment.

prolotherapy may be a general term, but it was my understanding that it is typically done with dextrose, rather than phenol.

 

[PMR 4 MSK]

prolotherapy may be a general term, but it was my understanding that it is typically done with dextrose, rather than phenol.

Anything that theoretically causes "proliferation" of new/healthy tissue is proliferative therapy, or "prolotherapy" for short. Can be a substance like glucose or dextrose, phenol (although I consider that more toxic than healthy), plasma, even autologous blood. Some orthopods do a type of prolotherapy on the epicondyles for epicondylitis where they poke a needle or blade into the bone repeatedly to make it bleed.

By theory, use of oral glucosamine and chondoiten are prolotherapy, since they purport to cause growth of new cartilage.

 

[DistantMets]

I went to Thomas Jefferson's MSK US course in May and heard all three of the authors below speak. It may not even matter what, if anything, you inject (see below). Like MSK said percutaneous tenotomy is getting looked at more and more in tendonopathy. Our journal club also looked an article that did this in an RCT with and without platelet rich plasma and the PRP group did even better. It's interesting.

1: J Ultrasound Med. 2008 Aug;27(8):1137-44.

Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary?

McShane JM, Shah VN, Nazarian LN.

McShane Sports Medicine, 734 E Lancaster Ave, Villanova, PA 19085, USA.
[email protected]

OBJECTIVE: Chronic refractory common extensor tendinosis of the lateral elbow has been shown to respond to sonographically guided percutaneous needle tenotomy (PNT) followed by corticosteroid injection. In this analysis, we attempted to determine whether the corticosteroid is a necessary component of the procedure.
METHODS: We performed PNT on 57 consecutive patients (age range, 34-61 years) with persistent pain and disability resulting from common extensor tendinosis. Under a local anesthetic and sonographic guidance, a needle was advanced into the tendon, and the tip of the needle was used to fenestrate the tendinotic tissue, break up any calcifications, and abrade the adjacent bone. After the procedure, patients underwent a specified physical therapy protocol. During a subsequent telephone interview, patients answered questions about their symptoms, the level of functioning, and perceptions of the procedure outcome. RESULTS: Of the 52 patients who agreed to participate in the study, 30 (57.7%) reported excellent outcomes, 18 (34.6%) good, 1 (1.9%) fair, and 3 (5.8%) poor. The average follow-up time from the date of the procedure to the telephone interview was 22 months (range, 7-38 months). No adverse events were reported, and 90% stated that they would refer a friend or close relative for the procedure. CONCLUSIONS:
Sonographically guided PNT for refractory lateral elbow tendinosis is an
effective procedure, and subsequent corticosteroid injection is not necessary.

 

[DOctorJay]

DM do you have the reference for the article where the PRP subjects did better, would like to read that as well.

Just attended the AIUM MSK US course at Mayo which was fantastic. Lots of discussion re: PNT, PRP, steroid, prolo. No clear concensus as of yet but very interesting times for MSK medicine.

 

[DistantMets]

DM do you have the reference for the article where the PRP subjects did better, would like to read that as well.

Just attended the AIUM MSK US course at Mayo which was fantastic. Lots of discussion re: PNT, PRP, steroid, prolo. No clear concensus as of yet but very interesting times for MSK medicine.

Here you go. Small pilot study, but interesting results.

1: Am J Sports Med. 2006 Nov;34(11):1774-8. Epub 2006 May 30.

Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.

Mishra A, Pavelko T.

Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University
Medical Center, 1300 Crane Street, Menlo Park, CA 94025, USA.
[email protected]

BACKGROUND: Elbow epicondylar tendinosis is a common problem that usually
resolves with nonoperative treatments. When these measures fail, however,
patients are interested in an alternative to surgical intervention. HYPOTHESIS:
Treatment of chronic severe elbow tendinosis with buffered platelet-rich plasma will reduce pain and increase function in patients considering surgery for their problem. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: One hundred forty patients with elbow epicondylar pain were evaluated in this study. All these patients were initially given a standardized physical therapy protocol and a variety of other nonoperative treatments. Twenty of these patients had significant persistent pain for a mean of 15 months (mean, 82 of 100; range, 60-100 of 100 on a visual analog pain scale), despite these interventions. All patients were considering surgery. This cohort of patients who had failed nonoperative treatment was then given either a single percutaneous injection of platelet-rich plasma (active group, n = 15) or bupivacaine (control group, n = 5). RESULTS: Eight weeks after the treatment, the platelet-rich plasma patients noted 60% improvement in their visual analog pain scores versus 16% improvement
in control patients (P =.001). Sixty percent (3 of 5) of the control subjects
withdrew or sought other treatments after the 8-week period, preventing further direct analysis. Therefore, only the patients treated with platelet-rich plasma were available for continued evaluation. At 6 months, the patients treated with platelet-rich plasma noted 81% improvement in their visual analog pain scores (P =.0001). At final follow-up (mean, 25.6 months; range, 12-38 months), the platelet-rich plasma patients reported 93% reduction in pain compared with before the treatment (P <.0001). CONCLUSION: Treatment of patients with chronic elbow tendinosis with buffered platelet-rich plasma reduced pain significantly in this pilot investigation. Further evaluation of this novel treatment is warranted. Finally, platelet-rich plasma should be considered before surgical intervention.

 

[facetguy]

Maybe she can try this:

http://www.sciencedaily.com/releases/2009/07/090711085220.htm