Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study.

BACKGROUND: "Tennis elbow" is a difficult condition to treat. Ultrasonography (US) and colour Doppler (CD) guided injections with polidocanol targeting the area with increased blood flow in the extensor origin have shown promising clinical results. OBJECTIVE: To evaluate and compare effects of US and CD guided intratendinous injections with sclerosing polidocanol and a local anaesthetic (lidocaine + epinephrine), in patients with tennis elbow. DESIGN: Prospective, randomised, controlled, double-blind, crossover study. SETTING: Sports Medicine Unit, Umeå University. PATIENTS: 32 patients (36 elbows), age range 27 to 66 years, with a long duration of elbow pain diagnosed as tennis elbow, were included in the study. All patients were followed up 3 and 12 months after treatment. Two patients were excluded due to other interventions during the study. INTERVENTIONS: One US and CD guided injection with the sclerosing agent polidocanol (group 1) or the local anaesthetic lidocaine plus epinephrine (group 2). At the 3 month follow-up, additional injections with polidocanol were offered to both groups (crossover for group 2). MAIN OUTCOME MEASURES: Satisfaction with treatment (Yes/No), elbow pain during activity (visual analogue scale), and maximum voluntary grip strength. RESULTS: There were no significant (p<0.05) differences in the outcome between group 1 and group 2. In both groups, there was a significantly lower VAS at the 3-month and 12-month follow-ups, and grip strength was significantly higher at the 12-month follow-up. CONCLUSIONS: US and CD guided intratendinous injections gave pain relief in patients with tennis elbow. Polidocanol and lidocaine plus epinephrine injections gave similar results.

Sclerosing polidocanol injections of small vessels to treat the chronic painful tendon.

The chronic painful tendon (tendinopathy, tendinosis) is generally considered difficult to treat, not seldom causing long-term disability and sometimes ending the sports or work carreér. Most common sites for tendinopathy are the Achilles-, patellar-, extensor carpi radialis brevis (ERCB)-, and supraspinatus tendons. The origin of pain has for many years been unknown, but recently, by using ultrasound (US) + colour Doppler (CD), immunohistochemical analyses of tendon biopsies, and diagnostic injections of local anaestesia, we found a close relationship between areas with vasculo-neural ingrowth and tendon pain. Sensory nerves (Substance-P-SP and Calcitonin Gene Related Peptide-CGRP) were found inside and outside the vascular wall. In following clinical studies we have demonstrated good short-and mid-term clinical results using treatment with US+CD-guided sclerosing polidocanol injections, targeting the area with neovessels outside the tendon. Two-year follow ups have showed remaining good clinical results, and sonographically signs of remodelling with a significantly thinner tendon with a more normal structure. Whether the effects of polidocanol are mediated through destruction of neovessels, activity on nerves or a combination, is under evaluation.

Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment.

BACKGROUND: The mechanism that causes pain in chronic Achilles tendinosis is not known. However, high resolution colour Doppler ultrasound has shown that neovascularisation may be involved. OBJECTIVE: To investigate if sclerosing the neovessels would affect the level of tendon pain. METHODS: The effect of colour Doppler ultrasound guided injection of a sclerosing agent, polidocanol, against neovessels was studied in 10 patients (seven men and three women, mean age 55 years) with painful chronic mid-portion Achilles tendinosis. RESULTS: Eight patients were satisfied with the results of treatment. There was significantly reduced pain during activity (reported on a visual analogue scale (VAS)) and no remaining neovascularisation after an average of two injections. Two patients were not satisfied, and neovascularisation remained. At the six month follow up, the same eight patients remained satisfied and could perform Achilles tendon loading activities as desired. Their VAS score had decreased from 74 before treatment to 8 (p<0.01). CONCLUSIONS: Sclerosing neovessels appears to be an effective treatment for painful chronic Achilles tendinosis, suggesting that neovessels play a key part in causing chronic tendon pain.