Download PDF
Z Orthop Unfall 2021; 159(05): 554-564
DOI: 10.1055/a-1202-6220
Review/Übersicht

Botulinum Toxin for Chronic Lateral Epicondylitis (LE)

Indications, Techniques and Literature Review Article in several languages: English | deutsch
Stephan Grüner
1   Practice of Dr. Grüner, Cologne
,
Axel Schulz
2   Orthopaedic Practice of Dr. Schulz, Lüdenscheid
,
Klaus Schlüter-Brust
3   Orthopaedic Department, St. Franziskus Hospital, Cologne
,
Marcela Lippert-Grüner
4   Department of Physical and Rehabilitative Medicine, Charles University Third Faculty of Medicine, Prague, Czech Republic
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Lateral epicondylitis is a common disease in orthopaedic practice. Although the majority of cases do not become chronic, patients who do not respond to the initial treatment may suffer from pain in the long term and effective treatment is challenging. The off-label use of botulinum toxin is one of the common potential indications for the substance in orthopaedics and traumatology. In a literature review of 2000 – 2019, eight EBM ≥ level 3 studies evaluating the use of botulinum toxin in lateral epicondylitis were found. Five of these studies evaluated botulinum toxin versus placebo in chronic cases; two other studies compared botulinum toxin with corticosteroids in acute cases and classic Hohmann surgery in chronic cases; the eighth study compared botulinum toxin in two different injection sites and corticosteroids by classic injection. Our findings suggest that the use of this substance may be a treatment option in refractory chronic cases before surgery is indicated. The working group on botulinum toxin in O & T of the International Musculoskeletal Pain Society (IMPS/IGOST) introduced an alternative injection schedule, which combines findings from the recent clinical literature with practical experience in order to reduce the risk of side effects while ensuring treatment effectiveness. Using 2 simple tests of function and, if necessary, sonographic verification, 2 separate injection sites in the extensor carpi radialis or the extensor digitorum can be identified by palpation. The tendon level on the lateral epicondyle acts as the third injection site. With optimal use of the ampoule content, the 3 injection sites can be infiltrated individually, depending on the muscle status. On the one hand, this enables treatment to take place after a dual therapy approach and, on the other hand, the risk of overdose in a muscle with subsequent unnecessary muscle weakening can be reduced.

Key words

lateral epicondylitis - botulinum toxin - literature review - injection scheme


Publication History

Article published online:
03 August 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References/Literatur

  • 1 Palacio EP, Schiavetti RR, Kanimatsu M. et al. Effects of platelet-rich plasma on lateral epicondylitis of the elbow: prospective randomized controlled trial. Rev Bras Orthop 2016; 51: 90-95
    PubMedGoogle Scholar
  • 2 Smidt N, van der Windt AV, Assendelft WJ. et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002; 359: 657-672
    CrossrefPubMedGoogle Scholar
  • 3 Schöffl V, Willauschus W, Sauer F. et al. Autologous conditioned plasma versus placebo injection therapy in lateral epicondylitis of the elbow: a double blind, randomized study. Sportverletz Sportschaden 2017; 31: 31-36
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie. S2k-Leitlinie Epicondylopathia radialis humeri, Stand 06/2019. Online (last access: 30.10.2019): https://www.awmf.org/uploads/tx_szleitlinien/033-019l_S2k_Epicondylopathia_radialis_humeri_2019-09.pdf
    PubMedGoogle Scholar
  • 5 Petrella RJ, Cogliano A, Decaria J. et al. Management of tennis elbow with sodium hyaluronate periarticular injections. Sports Med Arthrosc Rehabil Ther Technol 2010; 2: 4
    PubMedGoogle Scholar
  • 6 Schulz A, Grüner S, Lippert-Grüner M. Botulinumtoxin – mögliche Indikationen in O & U. OUP 2016; 5: 218-221
    PubMedGoogle Scholar
  • 7 Lippert-Grüner M, Schulz A, Grüner S. Konservative Behandlungsoptionen bei Spastik. Orthopädie & Rheuma 2018; 21: 21-25
    CrossrefPubMedGoogle Scholar
  • 8 Dressler D. Botulinum toxin drugs: brief history and outlook. J Neural Transm 2016; 123: 277-279
    CrossrefPubMedGoogle Scholar
  • 9 Grüner S, Schulz A, Lippert-Grüner M. Einsatz von Botulinumtoxin bei chronischer Plantarfasziitis. Orthopädie & Rheuma 2019; 22: 20-25
    CrossrefPubMedGoogle Scholar
  • 10 Keizer SB, Rutten HP, Pilot P. et al. Botulinum toxin Injection versus surgical treatment for tennis elbow. Clin Orthop Relat Res 2002; 401: 125-131
    CrossrefPubMedGoogle Scholar
  • 11 Hayton MJ, Santini AJA, Hughes PJ. et al. Botulinum toxin injection in the treatment of tennis elbow. J Bone Joint Surg Am 2005; 87: 503-507
    CrossrefPubMedGoogle Scholar
  • 12 Wong SM, Hui ACF, Tong PY. et al. Treatment of lateral epicondylitis with Botulinum toxin. Ann Intern Med 2005; 143: 793-797
    CrossrefPubMedGoogle Scholar
  • 13 Placzek R, Deuretzbacher G, Meiss AL. Therapie der chronischen Epicondylopathia humeri radialis mit Botulinumtoxin A – eine doppelblinde, placebokontrollierte und randomisierte Multicenterstudie. Orthopädische Praxis 2006; 42: 629-636
    PubMedGoogle Scholar
  • 14 Espandar R, Heidari P, Rasouli MR. et al. Use of anatomic measurement to guide injection of botulinum toxin for the management of chronic lateral epicondylitis: a randomized controlled trial. CMAJ 2010; 182: 768-773
    CrossrefPubMedGoogle Scholar
  • 15 Lin YC, Tu YK, Chen SC. et al. Comparison between Botulinum toxin and corticosteroid injection in the treatment of acute and subacute tennis elbow: a prospective, randomized, double-blind, active drug-controlled pilot study. Am J Phys Med Rehabil 2010; 89: 653-659
    CrossrefPubMedGoogle Scholar
  • 16 Guo YH, Kuan TS, Chen KL. et al. Comparison between steroid and 2 different sites of Botulinum toxin injection in the treatment of lateral epicondylalgia: a randomized, double-blind, active drug-controlled pilot study. Arch Phys Med Rehabil 2017; 98: 36-42
    CrossrefPubMedGoogle Scholar
  • 17 Creuzé A, Petit H, de Sèze M. Short-term effect of low-dose, electromyography-guided Botulinum toxin A injection in the treatment of chronic lateral epicondylar tendinopathy: a randomized, double-blinded study. J Bone Joint Surg Am 2018; 100: 818-826
    CrossrefPubMedGoogle Scholar
  • 18 Placzek R, Lindner MS, Deuretzbacher G. et al. Therapie der chronischen Epicondylopathia humeri radialis mit Botulinumtoxin A – eine Therapiestudie mit 2 Jahren Nachuntersuchungszeitraum. Z Orthop Ihre Grenzgeb 2004; 142: 701-705
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Tillmann BN. Atlas der Anatomie des Menschen. 3. Aufl.. Berlin, Heidelberg: Springer; 2016
    CrossrefGoogle Scholar
  • 20 Babcock MS, Foster L, Pasquina P. et al. Treatment of pain attributed to plantar fasciitis with Botulinum toxin A: a short term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rehabil 2005; 84: 649-654
    CrossrefPubMedGoogle Scholar
  • 21 Leung HB, Yen CH, Tse PYT. Reliability of Hong Kong Chinese version of the patient-rated forearm evaluation questionnaire for lateral epicondylitis. Hong Kong Med J 2004; 10: 172-177
    PubMedGoogle Scholar
  • 22 West CT, Ricketts D, Brassett C. An anatomical study of additional radial wrist extensors including a unique extensor carpi radialis accessorius. Folia Morphol (Warsz) 2017; 76: 742-747
    CrossrefPubMedGoogle Scholar
  • 23 Greenbaum B, Itamura J, Vangsness CT. et al. Extensor carpi radialis brevis: an anatomical analysis of its origin. J Bone Joint Surg Br 1999; 81: 926-929
    CrossrefPubMedGoogle Scholar
  • 24 Yoshida Y. Anatomical studies on the extensor carpi radialis longus and brevis muscles in Japanese. Okajimas Folia Anat Jpn 1994; 71: 127-136
    CrossrefPubMedGoogle Scholar
  • 25 Kerver ALA, Carati L, Eileers PHC. et al. An anatomical study of the ECRL and ECRB: feasibility of developing a preoperative test for evaluating the strength of the individual wrist extensors. J Plast Reconstr Aesthet Surg 2013; 66: 543-550
    CrossrefPubMedGoogle Scholar
  • 26 Kalichman L, Bannuru RR, Severin M. et al. Injection of botulinum toxin for treatment of lateral chronic lateral epicondylitis: systematic review and meta-analysis. Semin Arthritis Rheum 2011; 40: 532-538
    CrossrefPubMedGoogle Scholar
  • 27 Dong W, Goost H, Lin XB. et al. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med 2016; 50: 900-908
    CrossrefPubMedGoogle Scholar
  • 28 Lin YC, Wu WT, Hsu YC. et al. Comparative effectiveness of botulinum toxin versus non-surgical treatments for treating lateral epicondylitis: a systematic review and meta-analysis. Clin Rehabil 2018; 32: 131-145
    CrossrefPubMedGoogle Scholar
  • 29 Grüner S, Schulz A, Lippert-Grüner M. Treatment of chronic epicondylitis with botulinum toxin – literature review, modified injection scheme and case report. AJPMR 2020; 99 (Suppl. 13) a369
    PubMedGoogle Scholar
  • 30 Lehmus T, Jääskelainen S, Taskinen H-S. et al. Botulinum toxin A injections in lateral epicondylitis – a prospective 3-month follow-up of 30 patients. PRM+ 2018; 1: 49-51
    PubMedGoogle Scholar
  • 31 Ruiz AG, Díaz GV, Fernández BR. et al. Effects of ultrasound-guided administration of botulinum toxin (incobotulinumtoxin A) in patients with lateral epicondylitis. Toxins (Basel) 2019; 11: 46 doi:10.3390/toxins11010046
    CrossrefPubMedGoogle Scholar
  • 32 Cogné M, Creuzé A, Petit H. et al. Number of botulinum toxin injections needed to stop requests for treatment for chronic lateral epicondylar tendinopathy. Ann Phys Rehabil Med 2019; 62: 336-341 doi:10.1016/j.rehab.2018.12.003
    CrossrefPubMedGoogle Scholar