420-25% do not get better with consesrvative tx- PT, etc What to do with them ??Patella tendon even worse?Insertional achilles/ HS tendon ?
5Before we get started……. Rehabilitation is the cornerstone of any successful treatment for tendinopathyEccentric exercise programs have a proven track record to be successful in treatment of tendinosis, especially Achilles tendonThere are other modalities that are not going to be discussed here that also have some efficacy in the treatment of tendinosisSTM (CFM, Graston, ASTYM)NO patchesECSWTIn most cases, interventions should be reserved for tendons that have failed appropriate conservative/ less invasive treatments
6However ….20-25% of recalcitrant tendinopathy does not get better with optimal rehabilitationRigorous program to be compliantOutside of Achilles tendon, results may be even worseCertain body regions seem to do even worse with traditional care:Insertional Achilles tendinosisProximal Patella tendinosisProximal HS tendinosis
7“There is strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy”BJSM, Feb 2014Arthroscopy, 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”
9“God heals, and the doctor takes the fees” “The art of medicine involves amusing the patient while nature takes it course”“God heals, and the doctor takes the fees”Both cynical….
10Intervention for Tendinopathy DexamethasoneRehabilitationLidocaineThrombinpH??MarcaineCytokines??PltConcentr.Intervention for TendinopathyDextroseCaCLRBC’sWBC’sABX analogyNeedleACPPlt lysateOrthokineAutologous BloodRopivicaine
14JAMA, 2013Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively; P=.01) and greater 1-year recurrenceThe physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively; RR, 1.04 [99% CI, ]; P=.56) or recurrence (29% vs 38%)Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively; RR, 0.79 [99% CI, ]; P.001)No difference between the physiotherapy and no physiotherapy groups (71% vs69%, respectively; RR, 1.22 [99% CI, ]; P=.84).At 4 weeks:significant interaction between corticosteroid injection and physiotherapy (P=.01),patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%, respectively; P=.004).However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively; RR, 0.95 [99% CI, ]; P=.57).
15Physiotherapy did not result in any significant differences . JAMA, 2013Among 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 .Corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection (83% vs 96%, respectively; P=.01) and greater 1-year recurrenceThe physiotherapy and no physiotherapy groups did not differ on 1-year ratings of complete recovery or much improvement (91% vs 88%, respectively; RR, 1.04 [99% CI, ]; P=.56) or recurrence (29% vs 38%)Similar patterns were found at 26 weeks, with lower complete recovery or much improvement after corticosteroid injection vs placebo injection (55% vs 85%, respectively; RR, 0.79 [99% CI, ]; P.001)No difference between the physiotherapy and no physiotherapy groups (71% vs69%, respectively; RR, 1.22 [99% CI, ]; P=.84).At 4 weeks:significant interaction between corticosteroid injection and physiotherapy (P=.01),patients receiving the placebo injection plus physiotherapy had greater complete recovery or much improvement vs no physiotherapy (39% vs 10%, respectively; P=.004).However, there was no difference between patients receiving the corticosteroid injection plus physiotherapy vs corticosteroid alone (68% vs 71%, respectively; RR, 0.95 [99% CI, ]; P=.57).
16Interventional guided treatment for calcific tendinopathy of the shoulder?
17Rotator Cuff Calcific Tendinopathy Intratendinous calcificationHydroxyapetite crystalSupraspinatus (>50%) > Infraspinatus > SubscapularisUncertain EtiologyDegenerativeReactiveFemales > malesAge most commonSeen on % of radiographsSpeed et al, 1999 NEJM
18Calcific Tendinopathy (RTC) Process may be blocked
19StudiesSeveral non-controlled studies from showing good – excellent results with US guided aspiration and lavage60-74% success rate from published studies
20American Journal Of Roentgenology, 2007 67 consecutive pts treated and evaluated up till 1 year after treatment91% of shoulders had substantial or complete improvement64% with perfect motion89% complete or near complete resolution of calcifications44% transient recurrence in symptoms (around 6 wks after procedure)
21Radiology, 2009Rotator Cuff Calcific Tendonitis: short term and 10 year outcome after 2 needle US guided percutaneous treatment- non randomized controlled trial219 treated68 refused treatment – control group1 treatment performed with 16g needle and 2 needles
22Shoulder Function Scores (Constant) Graphs illustrate evolution of (a) Constant and (b) VAS scores in control subjects and patients with rotator cuff calcific tendonitis; 235 shoulders were treated, and 68 shoulders were not treated. Data are mean scores ± standard deviations. Significant differences (∗) between treated and nontreated patients are illustrated. (See also Table 3.)Scores 1 mo- 73.2Scores 1 yrSerafini G et al. Radiology 2009;252:
23VAS scores VAS 1 mo- 4.8 VAS 1 yr- 2.7 Graphs illustrate evolution of (a) Constant and (b) VAS scores in control subjects and patients with rotator cuff calcific tendonitis; 235 shoulders were treated, and 68 shoulders were not treated. Data are mean scores ± standard deviations. Significant differences (∗) between treated and nontreated patients are illustrated. (See also Table 3.)VAS 1 mo- 4.8VAS 1 yrSerafini G et al. Radiology 2009;252:
24Arthroscopic removal (20) vs PNT/aspiration (16) vs Control (17) Joint Bone Spine, 2009102 pts53 did not improve with steroid injectionArthroscopic removal (20) vs PNT/aspiration (16) vs Control (17)At 4 month f/u> 70% improvementPNT 62% vs Scope 65%> 90% improvementPNT-48% vs Scope 8%2 year f/uArthroscopy = PNT group >> ControlPNT/aspiration equal or better than Scope
25Is Rehabilitation Effective for Tendinopathy? Need another stu
2620 studies with 625 patients included CONCLUSIONS: BJSM, Ocotober, 2012Systematic review of the relationship between observable structural changes and clinical outcomes following response to therapeutic exercise20 studies with 625 patients includedCONCLUSIONS:“The available literature does not support observable structural changes as an explanation for the response to therapeutic exercise when treated by eccentric exercise training”Not arguing against effectiveness or eccentrics- but healing may not be the end result…..
28Conclusion:“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”
30Basic science of needling Eliasson et al, 2013, FASEBNeedling an unloaded rat Achilles tendon induced same gene expression as early mechanical loadingMechanical loading may heal, at least in part, by micro traumaDallaudiere et al, 2013, Eur Radiology,RCT on rat model of PRP vs SerumHad clinically significant improvement in PRP group vs serum group on joint motion, ultrasound appearance, and histologyTendon healing demonstrated as opposed to just clinical pain relief
32Early literature on ultrasound guided needle tenotomy for lateral epicondylosis McShane et al, Journal of Ultrasound Med. 2006Ultrasound guided PNT with steroid for chronic lat. epicondylitisFailed conservative tx58 pts-- avg f/u 28 mo.80 % Good or Excellent Outcome85% would refer friend or family for procedureMcShane et al, Journal of Ultrasound Med 2008Ultrasound guided PNT without steroid for chronic lat. EpicondylitisFailed conservative tx57 pts --avg f/u 22 mo.92% Good or Excellent Outcome90% would refer friend or close relative for procedure
33PRP for chronic lateral epicondylosis AJSM, 2006140 pts evaluated for lateral epicondylosis20 had refractory pain an avg. of 15 months later15 in treatment group, 5 in bupivicaine control groupInterventionInjection w/ autologous PRP once into common extensor tendon followed by gradual increase in rehab program through 4 weeks after which full activity allowedOutcomeA 46%, 60% and 81% improvement in VAS pain scores at 1, 2 and 6 months respectively in tx group3/5 in bupivicaine group withdrew/ sought other txAt final F/U (12-38 months) 93% pain free (<10/100 VAS)No complications, no one got worse
3413 RCT included in the study British Medical Bulletin, 201413 RCT included in the study886 patients53.8% with identical PRP protocolAreas of controversyDifferent comparatorsOutcome scoresFU periodsDiverse injection protocolsConclusion:Pooling pain outcomes over time suggest that L+PRP ameliorates pain in the intermediate and long term compared with control interventionsLow power, precisionFurther studies needed
37Why are we still debating if orthobiologics works? Need to define what we are injecting ?Platelet concentrationMSC concentrationLeukocyte countRBC +/ RBC –Autologous/ allogenicNeed to define the procedureUS guidanceNeedle tenotomy performed ?How many needle passes ?Rehabilitation methodsNeed to be studied/ validatedImmobilizationTiming of eccentricsMay need to separate out different body parts
38First double blind, placebo controlled, RCT on PRP JAMA, January 13, 2010First double blind, placebo controlled, RCT on PRP54 randomized patients age 18 to 70 with chronic (at least 2 mo) achilles tendon pain 2 to 7 cm above calcaneusEither 6cc PRP or Saline was injected with US guidance into achilles tendonRehab for both groups involved rest and then after 2 weeks, started on 12 week daily (180 repetitions) eccentric exercise programNo sports for at least 4 weeks and then only if pain <=3/10f/u questionnaire at weeks 6,12,24 (6 mo)AJSM, 2011
39AJSM, 2011Type I and II Represent normal/ organized tissue- 1 increased most, 2 a little, 3 and 4 decreased.Types 3 and 4 disorganized tissue
40Eccentrics done early (started at 2 wks) Both groups improved DISCUSSIONBoth groups were treated with eccentrics AFTER treatment; NONE treated before treatmentBig confounder in studyEccentrics done early (started at 2 wks)Both groups improvedNeedle? Saline? Placebo? Eccentric Exercises?
41RCT-- ABI(n= 70) vs PRP (n=80) 2 injections done 1 month apart BJSM, 2011RCT-- ABI(n= 70) vs PRP (n=80)2 injections done 1 month apartAll patients had FAILED an eccentric loading program and stretching programAt 6 mo66% success rate in PRP group10% converted to surgery72%success rate in ABI group20% converted to surgery
42Double blind RCT with 1 year follow up of 100 pts AJSM, Feb, 2010Double blind RCT with 1 year follow up of 100 ptsNo ultrasound guidance was usedSuccess defined as >25% reduction in VAS or DASH scoreRESULTSAt 1 yr, 49% of CSI group and 73% in PRP group weresuccessful (p<.001)
4446 patientsRCT- PRP vs CSI to lateral epicondyle
45AJSM, 2013METHODSN = 60PRP vs Saline vs glucocorticoid (+ Lidocaine)Primary end point - change in pain using Patient-Rated Tennis Elbow Evaluation (PRTEE) at 3 monthsSecondary Outcomes - were ultrasonographic changes in tendon thickness and color Doppler activityUTCOMES1. PRTEE Pain scoreReduction at 3 months in all 3 groups with no statistically significant difference between the groups;At 1 month glucocorticoid reduced pain more effectively than did both saline and PRP2. PRTEE Disability scoreAt 1 month glucocorticoid was superior to saline and PRPAt 3 months no difference3. US eval (tendon thickness and color doppler)Glucocorticoid was more effective than PRP and saline in reducing color Doppler activity and tendon thickness4. Pain associated with INJXNPRP = 9 > Saline = 7 > CSI = 6Main Outcome:Neither injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at 3 months
46Comparison of studiesKroghPRPCSICSIPRPThe regeneration of tissue is a process that last more than 3 monthsResults of PRP can not be adequately measured with only 3 months follow-up
47Comparison of studiesKroghPRPCSICSIFerreroPRPThe regeneration of tissue is a process that last more than 3 monthsResults of PRP can not be adequately measured with only 3 months follow-up
51Measured results using Shoulder Pain and Disability Index Clinical Rehabilitation, 20122 PNT vs 2 PRP injections under US guidance for RTC tendinosis or small, partial tearMeasured results using Shoulder Pain and Disability IndexBaseline2wks after 1st injectionRight before second injection2 wks after second injection3 months6 months
52Greater than 6 months of pain (avg 36 months) PMR journal, 2013Pts age (avg 48 yrs)Greater than 6 months of pain (avg 36 months)Diagnosed by clinical exam plus MRI or diagnostic USALL had Failed conventional treatments (not controlled)MedicationsBracingStretchingPRP done under US guidancePatients either sent to PT or instructed to do HEP after treatmentStrengtheningCFMModalities
53Distribution of Tendons Lateral EpicondylePatella TendonAchillesRotator CuffHamstring 17Gluteus Medius 16Medial Epicondyle 11Plantar Fascia 913 other tendons <5 each
54Overall Improvement 82% reported moderate to complete improvement 65% mod-complete in non tendon group82% reported moderate to complete improvement– 50%- 100% relief of symptoms70 % reported mostly to complete improvement% relief of symptomsNO difference in outcomes in those who did PT vs No Therapy after treatment.
55RCT with 43 patients randomized to 1 of 3 groups BJSM, 2009RCT with 43 patients randomized to 1 of 3 groups12 week Eccentric training protocol (15)Prolotherapy with hypertonic glucose/ lidocaine (14)Combination of both EE + Prolo (14)Outcomes looked atPainFunctionStiffness/ limiation of activitiesCost
57Long 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
58Take Home pointsThere are a certain percentage of tendons that will not improve with rehabilitation aloneCorticosteroids offer only short term improvement in tendinosis and may provide long term detrimentLevel 1 studies demonstrating lavage/ aspiration of calcific tendinosis of shoulder is a successful interventionBasic science suggests that needling a tendon can lead to a healing responseEmerging data that US guided needle tenotomy +/- PRP is successful for recalcitrant tendinopathies