Image-guided versus palpation-guided injections for the
                    treatment of chronic lateral epicondylopathy: a randomized controlled clinical
                    trial

Michael-Alexander Malahias; Maria-Kyriaki Kaseta; Sotirios-Tsambikos Kazas; Panayiotis D Megaloikonomos; Andreas F Mavrogenis; George C Babis

doi:10.1055/a-0732-5556

Handchirurgie · Mikrochirurgie · Plastische Chirurgie, Table of Contents

Handchir Mikrochir Plast Chir 2018; 50(05): 348-352
DOI: 10.1055/a-0732-5556

Originalarbeit

Image-guided versus palpation-guided injections for the treatment of chronic lateral epicondylopathy: a randomized controlled clinical trial

Ultraschall- versus palpationsgesteuerte Injektionen zur Behandlung der chronischen lateralen Epikondylopathie: eine randomisierte kontrollierte klinische Studie

Michael-Alexander Malahias

¹Second Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

,

Maria-Kyriaki Kaseta

¹Second Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

,

Sotirios-Tsambikos Kazas

¹Second Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

,

Panayiotis D Megaloikonomos

²First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

,

Andreas F Mavrogenis

²First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

,

George C Babis

¹Second Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece

› Author Affiliations

Abstract

Background There have been several studies published comparing the ultrasound-guided with the “blind” infiltrations in the shoulder’s area. On the contrary, there is only very limited data regarding the necessity of ultrasound guidance in lateral epicondylitis.

Materials and Methods A prospective, randomized, blinded at initial and follow-up evaluation, comparative clinical trial was conducted, involving 44 patients with a history of chronic persistent epicondylopathy. The patients were randomly divided into 2 groups of 22 people each. Group A patients underwent three ultrasound-guided betamethazone injections, while group B included those who underwent three “blind” injections, centered at the palpable point of maximum pain. The evaluation was done before and after (4 and 12 weeks) the injections using the Visual Analogue Scale for pain (VAS, 0–10) and the Roles & Maudsley score.

Results There was not any significant statistical difference between the two groups as for mean VAS at 4 weeks (p = 0.150, t-test) and mean VAS at 12 weeks (p = 0.286, t-test). Furthermore, the final success rate, as measured by the Roles & Maudsley score, was slightly superior in group B (67 % of the patients with excellent or good results) when compared with group A (46 % of the patients), but without any statistical difference (p = 0.161, chi-square).

Conclusion Our trial proved that an ultrasound-guided injection is not superior than a palpation-guided injection of corticosteroids in the treatment of lateral epicondylopathy.

Zusammenfassung

Hintergrund In mehreren Studien wurden ultraschallgesteuerte mit „blinden“ Infiltrationen im Schulterbereich verglichen. Im Gegensatz dazu gibt es nur sehr begrenzte Daten bezüglich der ultraschallkontrollierten Infiltrationstherapie bei einer Epikondylitis humeri lateralis.

Patienten und Methoden: In die prospektive, randomisierte, verblindete Studie wurden 44 Patienten mit chronischer, therapieresistenter Epikondylitis humeri lateralis eingeschlossen. Die Patienten wurden nach dem Zufallsprinzip in 2 Gruppen von jeweils 22 Patienten eingeteilt. Patienten der Gruppe A erhielten drei ultraschallgesteuerte Betamethazon-Injektionen, Patienten der Gruppe B drei „blinde“ (= palpationsgesteuerte) Injektionen am Ort ihrer maximalen Schmerzen. Vor sowie 4 und 12 Wochen nach der letzten Injektion wurden die Schmerzen mittels der Visuellen Analogskala (VAS, 0–10) und der Roles & Maudsley-Score erfasst.

Ergebnisse Weder 4 noch 12 Wochen nach Injektionsbehandlung fand sich ein statistisch signifikanter Unterschied punkto Schmerzen (p = 0,150; p = 0,286). Bzgl. der endgültiger Erfolgsrate (Roles & Maudsley-Score) zeigte sich Gruppe B mit 67 % exzellenten oder guten Ergebnissen der Gruppe A mit 46% exzellenten oder guten Ergebnissen leicht überlegen, ohne dass dies statistisch signifikant war.

Schlussfolgerung Die Studie zeigt, dass eine ultraschallgesteuerte Injektionsbehandlung der Epikondylitis humeri lateralis der palpationsgesteuerten nicht überlegen ist.

Key words

ultrasound-guided - palpation-guided - epicondylopathy - epicondylitis - corticosteroid injections

Schlüsselwörter

ultraschallgesteuert - palpationsgesteuert - Epikondylopathie - Epikondylitis - Kortikosteroidinjektionen

Full Text

References

References
1 Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg Am 2007; 32: 1271-1279
2 Bisset L, Paungmali A, Vicenzino B. et al. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 2005; 39: 411-422
3 Lin CL, Lee JS, Su WR. et al. Clinical and Ultrasonographic Results of Ultrasonographically Guided Percutaneous Radiofrequency Lesioning in the Treatment of Recalcitrant Lateral Epicondylitis. Am J Sports Med 2011; 39: 2429-2435
4 Paoloni JA, Appleyard RC, Nelson J. et al. 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: 915-920
5 Wise C. Arthrocentesis and injection of joints and soft tissues. In: Harris ED, Budd RC, Genovese MC. et al. Kelley’s Textbook of Rheumatology. 7th ed. New York, NY: Saunders; 2004
6 Smidt N, Assendelft WJ, van der Windt DA. et al. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002; 96: 23-40
7 Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006; 34: 1774-1778
8 Shiple BJ. How effective are injection treatments for lateral epicondylitis?. Clin J Sport Med 2013; 23: 502-503
9 Berkoff DJ, Miller LE, Block JE. Clinical utility of ultrasound guidance for intra-articular knee injections: a review. Clin Interv Aging 2012; 7: 89-95
10 Gilliland CA, Salazar LD, Borchers JR. Ultrasound versus anatomic guidance for intra-articular and periarticular injection: a systematic review. Phys Sportsmed 2011; 39: 121-131
11 Adler RS, Buly R, Ambrose R. et al. Diagnostic and Therapeutic Use of Sonography-Guided Iliopsoas Peritendinous Injections. Am J Roentgenol 2005; 185: 940-943
12 Bloom JE, Rischin A, Johnston RV. et al. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev 2012; 15: CD009147
13 Soh E, Li W, Ong KO. et al. Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic review. BMC Musculoskelet Disord 2011; 12: 137
14 Wu T, Song HX, Dong Y. et al. Ultrasound-guided versus blind subacromial-subdeltoid bursa injection in adults with shoulder pain: A systematic review and meta-analysis. Semin Arthritis Rheum 2015; 45: 374-378
15 Gulabi D, Uysal MA, Akça A. et al. USG-guided injection of corticosteroid for lateral epicondylitis does not improve clinical outcomes: a prospective randomised study. Arch Orthop Trauma Surg 2017; 137: 601-606
16 Geoffroy P, Yaffe MJ, Rohan I. Diagnosing and treating lateral epicondylitis. Can Fam Physician 1994; 40: 73-78
17 Weinreb JH, Sheth C, Apostolakos J. et al. Tendon structure, disease, and imaging. Muscles Ligaments Tendons J 2014; 4: 66-73
18 Gautam VK, Verma S, Batra S. et al. Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis: clinical and ultrasonographic evaluation. J Orthop Surg (Hong Kong) 2015; 23: 1-5
19 Montalvan B, Le Goux P, Klouche S. et al. Inefficacy of ultrasound-guided local injections of autologous conditioned plasma for recent epicondylitis: results of a double-blind placebo-controlled randomized clinical trial with one-year follow-up. Rheumatology (Oxford) 2016; 55: 279-285
20 Sussman WI, Williams CJ, Mautner K. Ultrasound-Guided Elbow Procedures. Phys Med Rehabil Clin N Am 2016; 27: 573-587
21 Saartok T, Eriksson E. Randomized trial of oral naproxen or local injection of betamethasone in lateral epicondylitis of the humerus. Orthopedics 1986; 9: 191-194
22 Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the elbow region. Am Fam Physician 2002; 66: 2097-2100
23 Lee JH, Lee SH. Lateral antebrachial cutaneous neuropathy after steroid injection at lateral epicondyle. J Back Musculoskelet Rehabil 2015; 28: 419-422
24 Nam SH, Kim J, Lee JH. et al. Palpation versus ultrasound-guided corticosteroid injections and short-term effect in the distal radioulnar joint disorder: a randomized, prospective single-blinded study. Clin Rheumatol 2014; 33: 1807-1814