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Point: Counterpoint Exercise vs Intervention for Recalcitrant Tendinopathy Ken Mautner, MD Emory Sports Medicine Center.

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Presentation on theme: "Point: Counterpoint Exercise vs Intervention for Recalcitrant Tendinopathy Ken Mautner, MD Emory Sports Medicine Center."— Presentation transcript:

1 Point: Counterpoint Exercise vs Intervention for Recalcitrant Tendinopathy Ken Mautner, MD Emory Sports Medicine Center

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3 Harmon K G, and Rao A L Hematology 2013;2013: ©2013 by American Society of Hematology The Continuum of Tendinopathy

4  20-25% do not get better with consesrvative tx- PT, etc  What to do with them ??  Patella tendon even worse?  Insertional achilles/ HS tendon ?

5 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

6 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

7 “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

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9 “God heals, and the doctor takes the fees” “The art of medicine involves amusing the patient while nature takes it course”

10 Plt lysate Cytokines Plt Concentr. Lidocain e Thrombin WBC’s pH Needle RBC’s Orthokine ?? I n t e r v e n t i o n f o r T e n d i n o p a t h y ACP CaCL Marcaine Dexamethasone Ropivicaine Autologous Blood Dextrose Rehabilitation

11 Corticosteroids Injections for Tendinopathy ?

12 Lancet, 2010

13 Corticosteroid Injections Lancet, 2010

14 JAMA, 2013

15  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.

16 Interventional guided treatment for calcific tendinopathy of the shoulder?

17 Rotator Cuff Calcific Tendinopathy  Intratendinous calcification  Hydroxyapetite crystal  Supraspinatus (>50%) > Infraspinatus > Subscapularis  Uncertain Etiology  Degenerative  Reactive  Females > males  Age most common  Seen on % of radiographs  Speed et al, 1999 NEJM

18 Calcific Tendinopathy (RTC) Process may be blocked

19 Studies  Several non-controlled studies from showing good – excellent results with US guided aspiration and lavage  60-74% success rate from published studies

20  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)

21  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

22 Shoulder Function Scores (Constant) Serafini G et al. Radiology 2009;252: Scores 1 mo Scores 1 yr

23 VAS scores Serafini G et al. Radiology 2009;252: VAS 1 mo- 4.8 VAS 1 yr- 2.7

24 Joint Bone Spine, 2009 1102 pts 553 did not improve with steroid injection AArthroscopic removal (20) vs PNT/aspiration (16) vs Control (17) AAt 4 month f/u >> 70% improvement PPNT 62% vs Scope 65% >> 90% improvement PPNT-48% vs Scope 8% 22 year f/u AArthroscopy = PNT group >> Control PPNT/aspiration equal or better than Scope

25 Is Rehabilitation Effective for Tendinopathy?

26 BBJSM, Ocotober, 2012 SSystematic review of the relationship between observable structural changes and clinical outcomes following response to therapeutic exercise 220 studies with 625 patients included C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”

27 NEED ANOTHER STUDY HERE

28 C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”

29 Does needling a tendon lead to healing?

30 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

31 COULD USE MORE DATA HERE

32 Early literature on ultrasound guided needle tenotomy for lateral epicondylosis  McShane et al, Journal of Ultrasound Med  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

33 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

34  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

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37 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

38  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

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40  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?

41  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

42  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

43 AJSM, March 2011

44  46 patients  RCT- PRP vs CSI to lateral epicondyle

45 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

46 Comparison of studies Results of PRP can not be adequately measured with only 3 months follow-up PRP CSI PRP KroghKrogh

47 Comparison of studies Results of PRP can not be adequately measured with only 3 months follow-up PRP CSI PRP KroghKrogh Ferrero

48 Is it the Needle? AJSM, 2013

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51  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 1 st injection  Right before second injection  2 wks after second injection  3 months  6 months Clinical Rehabilitation, 2012

52  Pts age (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

53 Distribution of Tendons  Lateral Epicondyle 30  Patella Tendon 27  Achilles 27  Rotator Cuff 21  Hamstring17  Gluteus Medius16  Medial Epicondyle 11  Plantar Fascia9  13 other tendons<5 each

54 Overall Improvement 82% reported moderate to complete improvement – 50%- 100% relief of symptoms 70 % reported mostly to complete improvement % relief of symptoms NO difference in outcomes in those who did PT vs No Therapy after treatment.

55  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

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57  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

58 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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60 Outline  Need for treatments beyond PT/ rehab  No cortisone  History of tenotomy/ prolotherapy  Basic science of how it works  Level 1 data- dbrct showing positive benefits and those that do not!!!!


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