Treating Lateral Epicondylopathy With Dry Needling and Exercise: A Case Series.

CONTEXT: Lateral epicondylopathy (LE) is a common overuse injury affecting elbow, wrist, and hand function. It is characterized by weakness and pain in the muscles and tendons of the forearm responsible for the extension of your wrist and fingers. Trigger point dry needling is a technique reported to be beneficial in managing pain and dysfunction after LE diagnosis. LE is also commonly treated with conservative treatment, such as joint and soft tissue mobilization, self-care home programs, and anti-inflammatory use. We explored a different dry needling approach consisting of in situ dry needling with electric stimulation combined with targeted therapeutic exercise to treat LE in 3 cases. CASE PRESENTATION: Three patients were referred for dry needling once a week for 6 weeks and home-based exercise therapy for LE. They were clinically evaluated using grip strength, a visual analog scale to assess pain, and Patient-Rated Tennis Elbow Evaluation Test scores. These were measured at 4 time points (weeks 0, 2, 4, and 6). MANAGEMENT AND OUTCOMES: The dry needling intervention incorporated 8 locations in the upper-extremity with 2 electric stimulation channels. The patients had reduced pain as measured by a visual analog scale, increased function as measured by the Patient-Rated Tennis Elbow Evaluation Test, and increased grip strength over 6 weeks. CONCLUSIONS: This case series illustrates the use of dry needling and a home exercise program to provide a favorable outcome in a patient with LE. Patients had an 80% to 100% reduction in pain and similar improvements in function that were significantly beyond the minimum clinically important difference. This dry needling approach is a safe and effective treatment of LE in the short term.

Comparison of the efficiency of peloidotherapy and extracorporeal shock wave therapies in patients diagnosed with lateral epicondylitis: a prospective, randomized, controlled study.

Various treatment methods are used in the management of lateral epicondylitis (LE); however, there is no universally accepted standard treatment approach. The aim of this study is to compare the effects of peloidotherapy and extracorporeal shock wave therapy (ESWT) on pain, functional status, and quality of life in the treatment of LE. The study was designed as a hospital-based, prospective randomized controlled trial. Ninety patients, with a mean age of 47.30±7.95 (range, 18 to 65 years), diagnosed with chronic (3 months) unilateral LE were included in the study. The patients were randomly divided into two groups. The peloidotherapy group received 15 sessions of peloid therapy for 3 weeks, 5 days a week, while the ESWT group received three sessions of ESWT (1.8 bar, 10.0 Hz, 2000 impulses) for 3 weeks, once a week. The patients were evaluated before treatment, at the end of the treatment, and one month after the treatment. The groups were compared in terms of pain, quality of life, functional status, and handgrip strength. At the end of the treatment and one-month follow-up, statistically significant improvements were observed in all parameters. This study is the first randomized trial comparing peloidotherapy to ESWT as an adjunct to exercise therapy in LE. Both ESWT and peloidotherapy, when added to exercise therapy, showed positive short-term effects on pain, quality of life, functional status, and handgrip strength in primary conservative treatment of chronic LE (p<0.001), and no superiority was found between them in terms of efficacy. Peloidotherapy or ESWT may be preferred in the treatment of lateral epicondylitis, depending on the patient's condition. Peloidotherapy appears to be more advantageous due to its lower side effects and painless nature. ClinicalTrials.gov ID: NCT04748406.

Bracing or kinesio taping in the management of lateral elbow tendinopathy: A prospective, randomized single-blinded trial.

OBJECTIVE: The aim of the study was to compare the effects of forearm counter force brace (FCB) and kinesio taping (KT) on pain severity, grip strength and functionality of patients with lateral elbow tendinopathy (LET). METHODS: The study was planned as a prospective, randomized and assessor-blinded study with 1-month follow-up period. Seventy-two patients, diagnosed as LET were randomly assigned to FCB (n = 41) or KT (n = 31) groups. In the FCB group, the patients were informed and instructed to wear the brace for three weeks continuously. In the KT group, tape was applied once a week for four weeks with muscle inhibition and fascia correction techniques. The outcome measures were pain pressure threshold (PPT), maximal pain-free hand grip strength measurement and patient-rated tennis elbow evaluation questionnaire (PRTEE). The assessments were performed at the baseline, immediately after treatment and one month later after treatment. RESULTS: PPT and grip strength were significantly increased over time in both groups. Pain, function and total scores of PRTEE were significantly decreased in both FCB and KT groups. The effect size of the improvement in PRTEE function score was within acceptable clinical significance in the KT group. However, there was no significant difference between groups. CONCLUSIONS: Pain severity, grip strength and functionality of patients with LET improved over time in both FCB and KT groups. However, neither was superior in the management of LET.

Comparing the effectiveness of prolotherapy and percutaneous dry needling in the treatment of lateral epicondylitis: a retrospective cohort study.

OBJECTIVE: Lateral epicondylitis (LE) can result in a functional loss in patients because of pain and has recently become more prevalent. This study compared the effects of minimally invasive prolotherapy (PRO) and percutaneous dry needling (PDN) on LE treatment. PATIENTS AND METHODS: Patients were divided into three groups; Group 1 included patients undergoing PDN, Group 2 included those undergoing PRO, and Group 3 included those undergoing PDN+PRO. All these treatments were administered three times and at a 3-week interval in each patient. Data on the visual analog scale (VAS) and patient-rated tennis elbow evaluation (PRTEE) scale scores of the patients were collected at weeks 0, 3, and 6 and month 6 and retrospectively analyzed. RESULTS: The VAS and PRTEE scores decreased in all groups. The decrease in Group 3 was higher than that in the other groups (p<0.001). Upon evaluating within-group differences in VAS and PRTEE scores, the scores at week 3, week 6, and month 6 gradually decreased compared with the baseline in all groups (p<0.001). CONCLUSIONS: PDN and PRO are minimally invasive and can successfully treat LE. A combination of PDN+PRO provides better results than PDN or PRO alone. As the materials we used in these treatments are relatively inexpensive and readily available, we believe our study will help reduce the national healthcare costs allocated for the treatment of LE.

Ultrasound-guided injection of platelet-rich plasma for tendinopathies: a systematic review and meta-analysis.

BACKGROUND: In this systematic review and meta-analysis, we evaluated ultrasound (US)-guided injections of platelet-rich plasma (PRP) as conservative treatment of tendinopathies. MATERIALS AND METHODS: We searched MEDLINE, EMBASE, SCOPUS, OVID, and the Cochrane Library to identify randomized controlled trials (RCT) on the use of US-guided PRP for tendinopathies. RESULTS: We found 33 RCT (2,025 subjects) that met our inclusion criteria: 8 in lateral epicondylitis, 5 in plantar fasciitis, 5 in Achilles tendinopathy, 7 in rotator cuff tendinopathy, 3 in patellar tendinopathy and 5 in carpal tunnel syndrome. PRP, given as a single injection (20 trials) or multiple injections (13 trials), was compared to US-guided injection of steroids, saline, autologous whole blood, local anesthetic, dry needling, prolotherapy, bone marrow mesenchymal stem cells, or with non-injective interventions. The outcomes more commonly reported included pain and functional measures, subgrouped as in the short-term (<3 months from the intervention), medium-term (3 to 6 months) or long-term (≥12 months). No clear between-group differences in these outcomes were observed in patients with lateral epicondylitis, plantar fasciitis, or Achilles, rotator cuff or patellar tendinopathy. In patients with carpal tunnel syndrome, visual analog scale scores for pain at 3 and 6 months and Boston Carpal Tunnel Questionnaire severity scores at 1, 3 and 6 months were significantly lower in PRP recipients than in controls. The certainty of evidence of all these comparisons was graded as low or very low due to risk of bias, imprecision and/or inconsistency. Pain at the injection site was more common among PRP recipients than among controls receiving other US-guided injections. DISCUSSION: In patients with tendinopathies, a trend towards pain reduction and functional improvement from baseline was observed after US-guided PRP injection, but in the majority of the comparisons, the effect size was comparable to that observed in control groups.

Comparative Effectiveness of Physical Therapy and Electrophysiotherapy for the Treatment of Lateral Epicondylitis: A Network Meta-Analysis.

BACKGROUND: Lateral epicondylitis is a common enthesopathy, possibly caused by overuse and repetitive activity. Although nonoperative management is the primary approach for treating lateral epicondylitis, clinical guidelines and the literature fail to identify the most effective nonoperative treatment. Therefore, the authors conducted a network meta-analysis to compare the effectiveness of physical therapy and electrophysiotherapy treatments for the treatment of lateral epicondylitis. METHODS: The authors searched MEDLINE, EMBASE, Web of Science, and Scopus for peer-reviewed randomized controlled trials evaluating the effectiveness of physical therapy and electrophysiotherapy treatments. Data related to article characteristics and outcomes (grip strength and pain visual analog scale score) were collected. RESULTS: Twenty-three clinical trials including 1363 participants (mean age ± SD, 47.4 ± 7.5 years; 53.1 percent women) were included in this study. Pain visual analog scale demonstrated significant reductions in scores after treatment with magnetic field [mean difference (95 percent CI), -1.88 (-2.66 to -1.11)], exercise [-0.90 (-1.69 to -0.1)], and acoustic waves [-0.83 (-1.37 to -0.29)] compared with placebo. For grip strength, no treatment modality was found to be significantly effective. A sensitivity analysis that excluded studies with high publication bias and high degrees of heterogeneity produced similar results to the main analysis with the exception of statistically improved grip strength after light therapy [mean difference (95 percent CI), 5.38 (1.71 to 9.04)] and acoustic wave therapy [7.79 (2.44 to 13.15)]. CONCLUSIONS: Electrophysiotherapy treatments should be prioritized over physical therapy. Magnetic field therapy was associated with pain reduction, whereas acoustic wave and light therapy were associated with increased grip strength. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The comparison of the effectiveness of Kinesio Taping and dry needling in the treatment of lateral epicondylitis: a clinical and ultrasonographic study.

BACKGROUND: The aim of this study was to investigate the short- and long-term effects of Kinesio Taping (KT) and dry needling (DN) applications on pain, functionality, and muscle strength in patients with lateral epicondylitis by use of questionnaires and ultrasonography. METHODS: Seventy-eight patients were randomized into 3 groups. Each group followed a program that consisted of 9 treatment sessions in total, with 3 sessions per week for 3 weeks. Group 1 received KT and performed exercise, group 2 received DN and performed exercise, and group 3 performed exercise alone. Pain, functional status, grip strength, and the thickness and echogenicity of the common extensor tendon were evaluated before treatment, after treatment (at the end of the third week), and after 6 months. RESULTS: In intragroup evaluations, KT and DN were found to be effective in the short and long term in terms of pain, functional status, muscle strength, and tendon thickness (P < .01). In intergroup evaluations, improvement in the KT and DN groups was superior to that in the control group for all parameters (P < .05). On comparison of the KT and DN groups, improvements in the clinical parameters and tendon thickness, heterogeneity, and elastography were significantly better in the DN group in the short and long term (P < .05). CONCLUSIONS: The ultrasonographic outcomes in our study objectively demonstrated that although DN in general is superior in the treatment of lateral epicondylitis, KT treatment is also effective.

Extracorporeal Shock Wave Therapy Shows Superiority Over Injections for Pain Relief and Grip Strength Recovery in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis.

PURPOSE: To examine the efficacy of extracorporeal shock wave therapy (ESWT) and injection therapies by synthesizing direct and indirect evidence for all pairs of competing therapies for lateral epicondylitis. METHODS: PubMed, EMBASE, and Web of Science databases were searched for all appropriate randomized controlled trials (RCTs), assessing the effect of ESWT or injection therapies. The primary outcome was short-term (≤3 months) and medium-term (>3 months but ≤12 months) pain, while the secondary outcomes were grip strength and patient-reported outcome measures. All outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs) and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to determine a hierarchy of treatments. Sensitivity analysis was performed to eliminate potential therapeutic effects of normal saline (NS) and exclude trials that included patients with acute lateral epicondylitis (LE). RESULTS: 40 RCTs were included to evaluate ESWT and five different injection therapies, including corticosteroids (CSs), autologous whole blood, platelet-rich plasma (PRP), botulinum toxin A (BoNT-A), and dextrose prolotherapy (DPT). DPT (-.78 [-1.34 to -.21]), ESWT (.57 [-.89 to -.25]), PRP (-.48 [-.85 to -.11]), and BoNT-A (-.43 [-.84 to -.02]) outperformed placebo for short-term pain relief; ESWT (-.44 [-.85 to -.04]) outperformed placebo for medium-term pain relief. DPT was ranked as the most optimal short-term and medium-term pain reliever (SUCRA, 87.3% and 98.6%, respectively). ESWT was ranked as the most optimal short-term and medium-term grip strength recovery (SUCRA; 79.4% and 86.4%, respectively). CONCLUSIONS: DPT and ESWT were the best two treatment options for pain control and ESWT was the best treatment option for grip strength recovery. CSs were not recommended for the treatment of LE. More evidence is required to confirm the superiority in pain control of DPT among all these treatment options on LE. LEVEL OF EVIDENCE: Level I, meta-analysis of Level I randomized controlled trials.

Comparison of the effectiveness of peloid therapy and kinesio taping in tennis elbow patients: a single-blind controlled study.

This study aimed to compare the peloid therapy and kinesio tape treatments in chronic lateral epicondylitis. While home exercise program and cold application were applied to the control group, peloid therapy (5 days a week for 3 weeks at 45 °C for 30 min each day, a total of 15 treatment days) was applied in addition to the first group, and kinesio taping (6 treatment days 2 times a week) was applied to the second group. Patients were evaluated with visual analog scale (VAS), grip strength with Jamar hydraulic dynamometer, Arm, Shoulder, and Hand Disabilities (DASH), quality of life in Short Form-36 (SF-36), and Patient-Rated Forearm Evaluation Questionnaire (PRFEQ) was recorded before treatment, after treatment (third week), and 1 month after the end of treatment. In this study, 156 patients with chronic lateral epicondylitis were included. In the follow-up of the patients, there was a statistically significant improvement in the hand grip strength, DASH, PRFEQ, VAS, and SF-36 scores in the 1st month follow-up after the treatment compared to the pre-treatment control in all groups (p < 0.001). At the end of the treatment, the hand grip strength (p = 0.002), DASH (p < 0.001), PRFEQ pain (p < 0.001) and function (p = 0.007), SF-36 physical health (p = 0.002) scores were statistically significant in the peloid therapy group compared to the control group. At the 1st month after the end of treatment, hand grip strength, VAS, DASH, PRFEQ pain, function, daily activities, and SF-36 physical health scores (all of p < 0.001) were statistically significant in the peloid treatment group compared to the control group. Peloid treatment was found to be more effective than kinesio taping in SF-36 physical health (p = 0.007) and PRFEQ pain (p = 0.003) scores in the 1st month follow-up after treatment. Peloid therapy in addition to exercise seems more effective in chronic lateral epicondylitis. Randomized controlled long-term studies are needed.ClinicalTrials ID: NCT04687943.

Extracorporeal Shockwave Therapy in the Management of Sports Medicine Injuries.

ABSTRACT: Treatment of musculoskeletal conditions in athletes with extracorporeal shockwave therapy (ESWT) is gaining popularity as greater evidence supports its use. ESWT protocols (describing energy flux density, number of impulses, type of shockwave (focused or radial), number/frequency/duration of treatment session, area of application, and postprocedural therapy protocols) can be adjusted in the clinical setting. Protocols vary across studies, and optimal protocols for most indications are yet to be determined. ESWT can safely be used to treat various musculoskeletal conditions in athletes, including rotator cuff tendinopathy, lateral elbow epicondlyopathy, greater trochanteric pain syndrome, hamstring tendinopathy, patellar tendinopathy, Achilles tendinopathy, other tendinopathies, plantar fasciopathy, bone stress injuries, and medial tibial stress syndrome. ESWT can be used to treat in-season athletes, as it often requires no/minimal time away from sport and may result in rapid benefits. ESWT should be used in conjunction with physical therapy to facilitate longer-term gains in function and to optimize healing.

Acupuncture therapy for tennis elbow: A protocol for systematic review and meta-analysis.

BACKGROUND: Acupuncture is widely used for analgesia in China and western countries. Lateral epicondylitis (LE) is a common disease, which influences the quality of life for many patients. The clinical practice indicates that acupuncture has a therapeutic effect on the LE; however, whether acupuncture is superior to sham acupuncture and some conventional therapy methods has been controversial. Hence, we will provide a protocol to explore the effectiveness and safety for acupuncture for LE. METHODS: We will search only the randomized controlled trials (RCTs) literatures of acupuncture for LE from the following seven databases, including PubMed, Cochrane Central Register of Controlled Trials (The Cochrane Library), Excerpta Medica Database (EMBASE), China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Data, and Chinese Scientific Journals Database (VIP). The Visual Analogue Scale (VAS) will be considered as the primary outcome and the secondary outcome will include effective rate and function recovery. Adverse events incidence caused by acupuncture will also be discussed, such as dizziness, nausea, vomiting, and weariness. The searching strategy, inclusion and exclusion criteria were made according to the principle of evidence-based medicine. The quality was evaluated by Cochrane Handbook for Systematic Reviews of Interventions (V5.1). All analyses will be conducted by Review Manager Software (V5.3). RESULT: The results of this review will be submitted to a recognized journal for publication. CONCLUSION: This proposed meta-analysis will assess the efficacy and safety of acupuncture therapy for LE.

The Effect of Scapular Muscle Strengthening on Functional Recovery in Patients With Lateral Elbow Tendinopathy: A Pilot Randomized Controlled Trial.

CONTEXT: There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET. OBJECTIVE: The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET. DESIGN: Prospective randomized clinical trial. SETTING: Multisite outpatient physical therapy. PATIENTS: Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS. INTERVENTIONS: Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises. MAIN OUTCOME MEASURE: The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure. RESULTS: The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05). CONCLUSION: The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

Study on the effect of extra capsular arthroscopy plus analgesic tincture in the treatment of external humeral epicondylitis.

External humeral epicondylitis (EHE) is an inflammation and pain of the lateral tendons of the elbow with poor clinical efficacy. In this study, we aim to observe the effect of extra capsular arthroscopy (ECA) plus Traditional Chinese medicine (TCM) analgesic tincture in the treatment of EHE. A retrospective analysis was performed on the follow-up data of 58 patients with intractable EHE treated by ECA plus TCM analgesic tincture over 2 years from January 2017 to October 2018. All patients were followed up during the operation, with a mean follow-up duration of 17.6 months. There were no complications such as infection, nerve injury, wound nonunion and joint stiffness. The postoperative and pronation angles were statistically different from preoperative. The visual analogue scale (VAS) score during rest and movement of the elbow joint after operation was significantly different from that before operation. Postoperative Mayo elbow joint function score was significantly different from preoperative. Postoperative elbow joint function and brachial and shoulder dysfunction scores were statistically significant compared with those before surgery. Postoperative elbow joint function and brachial and shoulder dysfunction scores were statistically significant compared with those before surgery. The satisfaction rate of patients was 100%, with 52 cases of completely satisfied, 6 cases of basically satisfied and no dissatisfied cases. The curative effect of external capsular arthroscopy plus analgesic tincture in the treatment of external humeral epicondylitis was promising, which was worthy of clinical promotion.

Efficacy of Nonoperative Treatments for Lateral Epicondylitis: A Systematic Review and Meta-Analysis.

BACKGROUND: Lateral epicondylitis is a common overuse injury affecting approximately 1 to 3 percent of the population. Although symptoms may disappear spontaneously within 1 year, the clinical guidelines for conservative treatment are not clear. The authors' objective was to examine the outcomes of nonsurgical treatments for lateral epicondylitis through a meta-analysis and provide a treatment recommendation using the available evidence. METHODS: The authors searched the PubMed, EMBASE, Scopus, and Web of Science databases to identify primary research articles studying conservative treatments (electrophysiotherapy, physical therapy, and injections) for lateral epicondylitis. The authors included randomized controlled trials published in peer-reviewed journals. Data related to outcomes (pain, grip strength, Patient-Rated Tennis Elbow Evaluation score, and Disabilities of the Arm, Shoulder and Hand score) and complications were extracted. RESULTS: Fifty-eight randomized controlled trials were included in the meta-analysis. Electrophysiotherapy was effective in improving pain [mean difference, -10.0 (95 percent CI, -13.8 to -6.1)], Patient-Rated Tennis Elbow Evaluation score [mean difference, -10.7 (95 percent CI, -16.3 to -5.0)], and Disabilities of the Arm, Shoulder and Hand score [mean difference, -11.9 (95 percent CI, -15.8 to -7.9)]; and physical therapy improved pain [mean difference, -6.0 (95 percent CI, -9.7 to -2.3)] and Patient-Rated Tennis Elbow Evaluation scores [mean difference, -7.5 (95 percent CI, -11.8 to -3.2)] compared to placebo. Injections did not improve any outcome measures. Patients who received electrophysiotherapy and injections reported higher adverse effects than physical therapy patients. CONCLUSIONS: Patients who received electrophysiotherapy and physical therapy reported statistically and clinically improved scores in pain and function compared to placebo. Injections may put patients at higher risk for adverse effects compared to other conservative treatments. When managing lateral epicondylitis conservatively, electrophysiotherapy and physical therapy should be prioritized before other interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Effects of manual acupuncture and electroacupuncture for lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to evaluate the effect of acupuncture/electroacupuncture, alone or combined with other interventions, on pain intensity, pain-related disability, and strength in lateral epicondylalgia (LE) of musculoskeletal origin. DATABASES AND DATA TREATMENT: Electronic databases were searched for randomized clinical trials, where at least one group received acupuncture or electroacupuncture for LE of musculoskeletal origin. To be eligible, trials had to include humans and collect outcomes on pain intensity or pain-related disability in LE. Data were extracted by two reviewers. The risk of bias (RoB) of the trials was assessed using the Cochrane RoB tool, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the level of evidence was summarized using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) using random effects were calculated. RESULTS: A total of 14 trials (10 acupuncture) were included. The meta-analysis found a moderate effect size of acupuncture (SMD = -0.66, 95% confidence interval (CI) = -1.22 to -0.10), but not electroacupuncture (SMD = -0.08, 95% CI = -0.99 to 0.83), in the reduction of elbow pain as compared to a comparative group. Acupuncture exhibited a significant moderate effect size (SMD = -0.51, 95% CI = -0.91 to -0.11) in the improvement of related-disability. Acupuncture (SMD = 0.36, 95% CI = 0.16 to 0.57), but not electroacupuncture (SMD = 0.34, 95% CI = -0.29 to 0.98), exhibited a significant but small effect size on strength. Most significant effects were in the short term. The RoB was low but the heterogeneity of trial results led to a downgrading of the GRADE evidence level. CONCLUSION: Low-level evidence suggests positive effects of acupuncture, but not electroacupuncture, for pain, related-disability, and strength, in LE of musculoskeletal origin, in the short term.

Tennis elbow, study protocol for a randomized clinical trial: needling with and without platelet-rich plasma after failure of up-to-date rehabilitation.

BACKGROUND: The conservative management of lateral epicondylitis is known to be a difficult-to-treat annoying condition. A treatment with platelet-rich plasma (PRP) is often performed, but its efficacy remains controversial. METHODS: This study is a single-center, randomized double-blind controlled trial, preceded by a case series. All the 232 planned patients of the case series will undergo an up-to-date comprehensive rehabilitation program, including focused extracorporeal shock waves therapy. This rehabilitation program is expected to have a maximum success rate 75%. It is therefore aimed to allocate a minimum of 58 patients with rehabilitation failure into the 1:1 randomized trial. Stratification is planned on age and lesion pattern. The masking will be quadruple (Participant, Care Provider, Investigator & Outcome Assessor). The patients will undergo an ultrasound (US)-guided needling combined with either PRP (intervention group) or saline (control group). The primary endpoint will be the pain improvement from baseline (month 0) at 3 months on a 0-10 visual analog scale (VAS) during a maximal strength isometric contraction of the extensor carpialis brevis muscle. The main secondary endpoints will include the rehabilitation success rate and improvements from baseline at 3, 6, and 12 months of the following outcomes: (i) Single Assessment Numeric Evaluation (SANE) score, (ii) Patient-Rated Tennis Elbow Evaluation (PRTEE) score, (iii) maximal grip strength on Jamar test, and (iv) the ultrasonographic evaluation of the US of the epicondylar tendons. DISCUSSION: The study results will provide insight into the effect of PRP as adjuvant therapy to tendon fenestration, and may contribute to identify the best preceding and concomitant rehabilitation protocol. TRIAL REGISTRATION: ClinicalTrials.gov NCT03987256. Registered on 20 August 2019.

Dextrose Prolotherapy Versus Normal Saline Injection for the Treatment of Lateral Epicondylopathy: A Randomized Controlled Trial.

Objective: To compare the effect of dextrose prolotherapy (DPT) with saline in the treatment of chronic lateral epicondylopathy (LE). Design: Triple-blinded randomized controlled trial. Setting: Physical medicine and rehabilitation outpatient clinic. Subjects: Sixty cases of chronic LE participants were included in the study. Methods: Participants were randomly divided into two groups as DPT and normal saline. Saline or hypertonic dextrose (15%) was injected at the baseline, and at the end of the 4th and 8th week. Assessments were performed at baseline, and at the end of the 4th, 8th, and 12th week. Outcome measures: Primary outcome measures were Visual Analog Scale (VAS) for pain, Patient Rated Tennis Elbow Evaluation (PRTEE-Total [PRTEE-T], PRTEE-Pain, PRTEE-Function); secondary outcome measures were Disabilities of the Arm, Shoulder, and Hand Score (DASH) and pain-free handgrip strength. Results: Intragroup analysis demonstrated that both groups significantly improved in VAS, PRTEE, DASH scores, and handgrip strength during the study period (p < 0.001, for all outcome measurements in both groups). Intergroup analysis showed that PRTEE-T score changes between baseline-4th and -12th week; VASrest change between baseline and 4th week in the DPT group were significantly higher than the saline group (p = 0.041, p = 0.038, p = 0.013 respectively). There was no significant difference between groups in VAS, DASH scores, and handgrip strength between any time points, in terms of improvement (p > 0.05). Conclusion: Our study results showed that DPT outperformed saline in PRTEE-T score. Although saline seems to be a comparable clinical effect with DPT, further studies comparing the effects of saline injection and DPT are necessary, in chronic LE.

Acupuncture for lateral epicondylitis: A prisma-compliant protocol for a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Acupuncture has been widely used for relieving pain associated with musculoskeletal disorders, such as lateral epicondylitis. Although the effect of acupuncture on pain has been demonstrated in previous reviews, it is still under debate. This study is aimed at evaluating the efficacy of acupuncture to treat lateral epicondylitis and establishing the evidence systematically. METHODS: Nine databases will be searched from their inception to May 2020 without language or publication status restrictions, including 3 English databases (MEDLINE, Embase, the Cochrane Central Register of Controlled Trials), 5 Korean databases (Korean Medical Database, KoreaMed, Korean Studies Information Service System, Research Information Service System, Oriental Medicine Advanced Searching Integrated System), and 1 Chinese database (China Knowledge Network Database). Only randomized controlled trials will be included. Pain intensity will be considered as the primary outcome. Secondary outcomes will include the grip strength, total effective rate, and adverse events. Two independent researchers will perform the study selection, data extraction, and quality assessment. The methodological quality of the identified studies will be assessed using the Cochrane Collaboration's risk-of-bias tool. In the meta-analysis, continuous data will be expressed as mean and 95% confidence interval, and dichotomous data will be expressed as risk ratio and 95% confidence interval. RESULTS: The results of this study will be submitted to a peer-reviewed journal for publication. CONCLUSION: The results of this study would provide the evidence of whether acupuncture is effective for lateral epicondylitis. REGISTRATION NUMBER: PROSPERO CRD42020186824.

Injection Therapy in Patients with Lateral Epicondylalgia: Hyaluronic Acid or Dextrose Prolotherapy? A Single-Blind, Randomized Clinical Trial.

Objective: To compare the effects of hyaluronic acid (HA) and dextrose prolotherapy (DPT) injections in patients with chronic lateral epicondylalgia (LE). Materials and Methods: Thirty-two patients with at least 6 months of signs and symptoms of LE were randomly allocated into two groups: an HA group (n = 16) and a DPT group (n = 16). HA injection was performed as a single dose of 30 mg/2 mL 1500 kDa high-molecular-weight preparation (baseline). DPT injection was administered with 15% dextrose solution in three doses (baseline, third week, and sixth week). Severity of pain using the visual analog scale score, grip strength with a hand dynamometer, and physical function as determined by the Quick-Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score were determined. Results: DPT was favored over HA for improvements from 0 to 12 weeks for pain with activity (4.81 ± 1.2 vs. 3.18 ± 2.3; p = 0.04), pain at night (5.1 ± 1.9 vs. 4.1 ± 2.2; p = 0.03), and pain at rest (3.8 ± 2.09 vs. 2.7 ± 1.7; p = 0.04). Q-DASH scores improved significantly more from 0 to 12 weeks in the DPT group (43.5 ± 17.6 vs. 28.4 ± 13.4; p = 0.04). No between-group improvement was observed for grip pain (7.3 ± 6.4 vs. 4.8 ± 3.2; p = 0.38). Conclusions: HA and DPT injections were both effective in reducing pain and increasing grip strength and function in patients with chronic LE. DPT injection was more effective in the short term than HA injection, in terms of pain relief and functional outcome. The study was registered at ClinicalTrials.gov under the identifier number NCT04395417.