Counterpoint Exercise vs Intervention for Recalcitrant Tendinopathy
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Transcript Counterpoint Exercise vs Intervention for Recalcitrant Tendinopathy
Point: Counterpoint
Exercise vs Intervention for
Recalcitrant Tendinopathy
Ken Mautner, MD
Emory Sports Medicine Center
The Continuum of Tendinopathy
Harmon K G , and Rao A L Hematology 2013;2013:620-626
©2013 by American Society of Hematology
20-25% do not get better with consesrvative tx- PT, etc
What to do with them ??
Patella tendon even worse?
Insertional achilles/ HS tendon ?
Before we get started…….
Rehabilitation is the cornerstone of any successful treatment for
tendinopathy
Eccentric exercise programs have a proven track record to be
successful in treatment of tendinosis, especially Achilles tendon
There are other modalities that are not going to be discussed here
that also have some efficacy in the treatment of tendinosis
STM (CFM, Graston, ASTYM)
NO patches
ECSWT
In most cases, interventions should be reserved for tendons that
have failed appropriate conservative/ less invasive treatments
However ….
20-25% of recalcitrant tendinopathy does not get better
with optimal rehabilitation
Rigorous program to be compliant
Outside of Achilles tendon, results may be even worse
Certain body regions seem to do even worse with
traditional care:
Insertional Achilles tendinosis
Proximal Patella tendinosis
Proximal HS tendinosis
BJSM,
Feb 2014
“There is strong evidence that PRP
injections are not efficacious in the
management of chronic lateral
elbow tendinopathy”
Arthroscopy,
Nov, 2013
”The current evidence suggests that PRP
may be of benefit over standard treatment
as a second line intervention…the current
evidence is promising but limited”
“The art of medicine “God heals, and the
involves amusing the doctor takes the
patient while nature
fees”
takes it course”
Dexamethasone
pH
??
Plt
Concentr.
??
Dextrose
RBC’s
Plt lysate
Autologous
Blood
Ropivicaine
Corticosteroids Injections
for Tendinopathy ?
Lancet, 2010
Corticosteroid Injections
Lancet, 2010
JAMA, 2013
JAMA, 2013
Among patients with chronic unilateral lateral
epicondylalgia, the use of corticosteroid injection vs
placebo injection resulted in worse clinical
outcomes after 1 year.
Physiotherapy did not result in any significant
differences .
Interventional guided
treatment for calcific
tendinopathy of the
shoulder?
Rotator Cuff Calcific Tendinopathy
Intratendinous calcification
Hydroxyapetite crystal
Supraspinatus (>50%) > Infraspinatus > Subscapularis
Uncertain Etiology
Degenerative
Reactive
Females > males
Age 30-50 most common
Seen on 7.5-20% of radiographs
Speed et al, 1999 NEJM
Calcific Tendinopathy (RTC)
Process may
be blocked
Studies
Several non-controlled studies from 1995-2005 showing
good – excellent results with US guided aspiration and
lavage
60-74% success rate from published studies
American Journal Of Roentgenology, 2007
67 consecutive pts treated and evaluated up till 1 year
after treatment
91% of shoulders had substantial or complete
improvement
64% with perfect motion
89% complete or near complete resolution of
calcifications
44% transient recurrence in symptoms (around 6 wks
after procedure)
Radiology, 2009
Rotator Cuff Calcific Tendonitis: short term and 10 year
outcome after 2 needle US guided percutaneous
treatment- non randomized controlled trial
219 treated
68 refused treatment – control group
1 treatment performed with 16g needle and 2 needles
Shoulder Function Scores (Constant)
Serafini G et al. Radiology 2009;252:157-164
Scores 1 mo- 73.2
Scores 1 yr - 91.7
VAS scores
Serafini G et al. Radiology 2009;252:157-164
VAS 1 mo- 4.8
VAS 1 yr- 2.7
Joint Bone Spine, 2009
102 pts
53 did not improve with steroid injection
Arthroscopic removal (20) vs PNT/aspiration (16) vs Control
(17)
At 4 month f/u
> 70% improvement
PNT 62% vs Scope 65%
> 90% improvement
PNT-48% vs Scope 8%
2 year f/u
Arthroscopy = PNT group >> Control
PNT/aspiration equal or better than Scope
Is Rehabilitation Effective
for Tendinopathy?
BJSM, Ocotober, 2012
Systematic review of the relationship between
observable structural changes and clinical outcomes
following response to therapeutic exercise
20 studies with 625 patients included
CONCLUSIONS:
“The available literature does not support
observable structural changes as an explanation
for the response to therapeutic exercise when
treated by eccentric exercise training”
NEED ANOTHER STUDY HERE
Conclusion:
“Limited evidence exists to suggest that EE has a positive
effect on clinical outcomes such as pain, function, and
patient satisfaction/ return to work when compared to
various control interventions such as concentric exercises,
stretching, splinting, friction, and ultrasound.”
“ This review demonstrates a dearth of high quality
research in support of the clinical effectiveness of EE over
other treatments in the management of tendinopathies.
Further adequate powered studies…. Are required”
Does needling a tendon
lead to healing?
Basic science of needling
Eliasson et al, 2013, FASEB
Needling an unloaded rat Achilles tendon induced same
gene expression as early mechanical loading
Mechanical loading may heal, at least in part, by micro trauma
Dallaudiere et al, 2013, Eur Radiology,
RCT on rat model of PRP vs Serum
Had clinically significant improvement in PRP group vs
serum group on joint motion, ultrasound appearance,
and histology
Tendon healing demonstrated as opposed to just clinical pain
relief
COULD USE MORE DATA HERE
Early literature on ultrasound guided
needle tenotomy for lateral epicondylosis
McShane et al, Journal of
Ultrasound Med. 2006
Ultrasound guided PNT with
McShane et al, Journal of
Ultrasound Med 2008
Ultrasound guided PNT without
steroid for chronic lat.
epicondylitis
steroid for chronic lat.
Epicondylitis
Failed conservative tx
Failed conservative tx
58 pts-- avg f/u 28 mo.
80 % Good or Excellent
57 pts --avg f/u 22 mo.
92% Good or Excellent Outcome
Outcome
90% would refer friend or close
85% would refer friend or
family for procedure
relative for procedure
PRP for chronic
lateral epicondylosis
AJSM, 2006
140 pts evaluated for lateral epicondylosis
20 had refractory pain an avg. of 15 months later
15 in treatment group, 5 in bupivicaine control group
Intervention
– Injection w/ autologous PRP once into common extensor tendon
followed by gradual increase in rehab program through 4 weeks
after which full activity allowed
Outcome
– A 46%, 60% and 81% improvement in VAS pain scores at 1, 2 and 6
months respectively in tx group
– 3/5 in bupivicaine group withdrew/ sought other tx
– At final F/U (12-38 months) 93% pain free (<10/100 VAS)
– No complications, no one got worse
British Medical
Bulletin, 2014
13 RCT included in the study
886 patients
53.8% with identical PRP protocol
Areas of controversy
Different comparators
Outcome scores
FU periods
Diverse injection protocols
Conclusion:
Pooling pain outcomes over time suggest that L+PRP ameliorates pain
in the intermediate and long term compared with control
interventions
Low power, precision
Further studies needed
Why are we still debating
if orthobiologics works?
Need to define what we are injecting ?
Platelet concentration
MSC concentration
Leukocyte count
RBC +/ RBC –
Autologous/ allogenic
Need to define the procedure
US guidance
Needle tenotomy performed ?
How many needle passes ?
Rehabilitation methods
Need to be studied/ validated
Immobilization
Timing of eccentrics
May need to separate out different body parts
JAMA, January 13, 2010
First double blind, placebo controlled, RCT on PRP
54 randomized patients age 18 to 70 with chronic (at least 2 mo)
achilles tendon pain 2 to 7 cm above calcaneus
Either 6cc PRP or Saline was injected with US guidance into
achilles
AJSM,
2011
tendon
Rehab for both groups involved rest and then after 2 weeks, started
on 12 week daily (180 repetitions) eccentric exercise program
No sports for at least 4 weeks and then only if pain <=3/10
f/u questionnaire at weeks 6,12,24 (6 mo)
AJSM, 2011
DISCUSSION
Both groups were treated with eccentrics AFTER
treatment; NONE treated before treatment
Big confounder in study
Eccentrics done early (started at 2 wks)
Both groups improved
Needle? Saline? Placebo? Eccentric Exercises?
BJSM, 2011
RCT-- ABI(n= 70) vs PRP (n=80)
2 injections done 1 month apart
All patients had FAILED an eccentric loading program
and stretching program
At 6 mo
66% success rate in PRP group
10% converted to surgery
72%success rate in ABI group
20% converted to surgery
AJSM, Feb, 2010
Double blind RCT with 1 year follow up of 100 pts
No ultrasound guidance was used
Success defined as >25% reduction in VAS or DASH score
RESULTS
At 1 yr, 49% of CSI group and 73% in PRP group were
successful (p<.001)
AJSM, March 2011
46 patients
RCT- PRP vs CSI to lateral epicondyle
AJSM, 2013
METHODS
N = 60
PRP vs Saline vs glucocorticoid (+ Lidocaine)
Primary end point - change in pain using
Patient-Rated Tennis Elbow Evaluation
(PRTEE) at 3 months
Secondary Outcomes - were ultrasonographic
changes in tendon thickness and color Doppler
activity
Main Outcome:
Neither injection of PRP nor
glucocorticoid was superior
to saline with regard to pain
reduction in LE at 3 months
Comparison of studies
K
r
o
g
h
PRP
CSI
CSI
Ferrero
PRP
Results of PRP can not be adequately
measured with only 3 months follow-up
Is it the Needle?
AJSM, 2013
Clinical Rehabilitation, 2012
2 PNT vs 2 PRP injections under US guidance for RTC tendinosis or
small, partial tear
Measured results using Shoulder Pain and Disability Index
Baseline
2wks after 1st injection
Right before second injection
2 wks after second injection
3 months
6 months
PMR journal, 2013
Pts age 16-70 (avg 48 yrs)
Greater than 6 months of pain (avg 36 months)
Diagnosed by clinical exam plus MRI or diagnostic US
ALL had Failed conventional treatments (not controlled)
Medications
Bracing
Stretching
•
•
•
Strengthening
CFM
Modalities
PRP done under US guidance
Patients either sent to PT or instructed to do HEP after treatment
Distribution of Tendons
Lateral Epicondyle
30
Hamstring
17
Patella Tendon
27
Gluteus Medius
16
Achilles
Medial Epicondyle
27
Rotator Cuff
11
21
Plantar Fascia
9
13 other tendons
<5
each
Overall Improvement
82% reported moderate to complete improvement
– 50%- 100% relief of symptoms
70 % reported mostly to complete improvement
-- 75-100% relief of symptoms
NO difference in outcomes in those who did PT vs No Therapy after
treatment.
BJSM, 2009
RCT with 43 patients randomized to 1 of 3 groups
12 week Eccentric training protocol (15)
Prolotherapy with hypertonic glucose/ lidocaine
(14)
Combination of both EE + Prolo (14)
Outcomes looked at
Pain
Function
Stiffness/ limiation of activities
Cost
Long term efficacy similar in all 3 groups, but ELE
combined with prolo gave more rapid improvement in
symptoms.
Cost effectiveness analysis shows that ELEs was the
lowest cost treatment, but when combined with
prolotherapy, the cost per additional responder was
exceptionally good value for money
Take Home points
There are a certain percentage of tendons that will not improve
with rehabilitation alone
Corticosteroids offer only short term improvement in tendinosis
and may provide long term detriment
Level 1 studies demonstrating lavage/ aspiration of calcific
tendinosis of shoulder is a successful intervention
Basic science suggests that needling a tendon can lead to a
healing response
Emerging data that US guided needle tenotomy +/- PRP is
successful for recalcitrant tendinopathies
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