Point: CounterpointExercise vs Intervention for

Recalcitrant TendinopathyKen Mautner, MD

Emory Sports Medicine Center

Harmon K G , and Rao A L Hematology 2013;2013:620-626

©2013 by American Society of Hematology

The Continuum of Tendinopathy

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

“There is strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy”

”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”

BJSM, Feb 2014

Arthroscopy, Nov, 2013

“God heals, and the doctor takes the fees”

“The art of medicine involves amusing the patient while nature takes it course”

Plt lysate

Cytokin

es

PltConcentr.

Lidocaine

Thrombi

n

WBC’

s

pH

Needl

e

RBC’s

Orthokin

e

??

?? Intervention for

Tendinopathy

ACP

CaCL

Marcaine

Dexamethasone

Ropivicaine

Autologous Blood

Dextrose

Rehabilitation

Corticosteroids Injectionsfor Tendinopathy ?

Lancet, 2010

Corticosteroid InjectionsLancet, 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- 73.2Scores 1 yr - 91.7

VAS scores

Serafini G et al. Radiology 2009;252:157-164VAS 1 mo- 4.8VAS 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 steroid for chronic lat. epicondylitis Failed conservative tx

58 pts-- avg f/u 28 mo. 80 % Good or Excellent

Outcome

85% would refer friend or family for procedure

McShane et al, Journal of Ultrasound Med 2008

Ultrasound guided PNT without steroid for chronic lat. Epicondylitis Failed conservative tx

57 pts --avg f/u 22 mo. 92% Good or Excellent

Outcome

90% would refer friend or close relative for procedure

PRP for chronic lateral epicondylosis

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

AJSM, 2006

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

British Medical Bulletin, 2014

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

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 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)

JAMA, January 13, 2010

AJSM, 2011

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?

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

BJSM, 2011

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, Feb, 2010

AJSM, March 2011

46 patients RCT- PRP vs CSI to lateral epicondyle

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

AJSM, 2013

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

Results of PRP can not be adequately measured with only 3 months follow-up

PRP

CSI

CSI

PRPKrogh

Ferrero

Is it the Needle?

AJSM, 2013

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

Clinical Rehabilitation, 2012

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

PRP done under US guidance

Patients either sent to PT or instructed to do HEP after treatment

PMR journal, 2013

• Strengthening• CFM• Modalities

Distribution of Tendons

Lateral Epicondyle 30

Patella Tendon 27

Achilles 27

Rotator Cuff 21

Hamstring17

Gluteus Medius16

Medial Epicondyle11

Plantar Fascia 9

13 other tendons<5 each

Overall Improvement

82% reported moderate to complete improvement

– 50%- 100% relief of symptoms70 % reported mostly to complete improvement

-- 75-100% relief of symptomsNO difference in outcomes in those who did PT vs No Therapy after treatment.

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

BJSM, 2009

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

Ken.mautner@emory.org