Point: Counterpoint
Exercise vs Intervention for
Recalcitrant Tendinopathy
Ken Mautner, MD
Emory Sports Medicine Center
The Continuum of Tendinopathy
Harmon K G , and Rao A L Hematology 2013;2013:620-626
©2013 by American Society of Hematology
 20-25% do not get better with consesrvative tx- PT, etc
 What to do with them ??
 Patella tendon even worse?
 Insertional achilles/ HS tendon ?
Before we get started…….
 Rehabilitation is the cornerstone of any successful treatment for
tendinopathy
 Eccentric exercise programs have a proven track record to be
successful in treatment of tendinosis, especially Achilles tendon
 There are other modalities that are not going to be discussed here
that also have some efficacy in the treatment of tendinosis
 STM (CFM, Graston, ASTYM)
 NO patches
 ECSWT
 In most cases, interventions should be reserved for tendons that
have failed appropriate conservative/ less invasive treatments
However ….
 20-25% of recalcitrant tendinopathy does not get better
with optimal rehabilitation
 Rigorous program to be compliant
 Outside of Achilles tendon, results may be even worse
 Certain body regions seem to do even worse with
traditional care:
 Insertional Achilles tendinosis
 Proximal Patella tendinosis
 Proximal HS tendinosis
BJSM,
Feb 2014
“There is strong evidence that PRP
injections are not efficacious in the
management of chronic lateral
elbow tendinopathy”
Arthroscopy,
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”
“The art of medicine “God heals, and the
involves amusing the doctor takes the
patient while nature
fees”
takes it course”
Dexamethasone
pH
??
Plt
Concentr.
??
Dextrose
RBC’s
Plt lysate
Autologous
Blood
Ropivicaine
Corticosteroids Injections
for Tendinopathy ?
Lancet, 2010
Corticosteroid Injections
Lancet, 2010
JAMA, 2013
JAMA, 2013
 Among 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 .
Interventional guided
treatment for calcific
tendinopathy of the
shoulder?
Rotator Cuff Calcific Tendinopathy
 Intratendinous calcification
 Hydroxyapetite crystal
 Supraspinatus (>50%) > Infraspinatus > Subscapularis
 Uncertain Etiology
 Degenerative
 Reactive
 Females > males
 Age 30-50 most common
 Seen on 7.5-20% of radiographs
 Speed et al, 1999 NEJM
Calcific Tendinopathy (RTC)
Process may
be blocked
Studies
 Several non-controlled studies from 1995-2005 showing
good – excellent results with US guided aspiration and
lavage
 60-74% success rate from published studies
 American Journal Of Roentgenology, 2007
 67 consecutive pts treated and evaluated up till 1 year
after treatment
 91% of shoulders had substantial or complete
improvement
 64% with perfect motion
 89% complete or near complete resolution of
calcifications
 44% transient recurrence in symptoms (around 6 wks
after procedure)
 Radiology, 2009
 Rotator Cuff Calcific Tendonitis: short term and 10 year
outcome after 2 needle US guided percutaneous
treatment- non randomized controlled trial
 219 treated
 68 refused treatment – control group
 1 treatment performed with 16g needle and 2 needles
Shoulder Function Scores (Constant)
Serafini G et al. Radiology 2009;252:157-164
Scores 1 mo- 73.2
Scores 1 yr - 91.7
VAS scores
Serafini G et al. Radiology 2009;252:157-164
VAS 1 mo- 4.8
VAS 1 yr- 2.7
Joint Bone Spine, 2009
 102 pts
 53 did not improve with steroid injection
 Arthroscopic removal (20) vs PNT/aspiration (16) vs Control
(17)
 At 4 month f/u
 > 70% improvement
 PNT 62% vs Scope 65%
 > 90% improvement
 PNT-48% vs Scope 8%
 2 year f/u
 Arthroscopy = PNT group >> Control
 PNT/aspiration equal or better than Scope
Is Rehabilitation Effective
for Tendinopathy?
 BJSM, Ocotober, 2012
 Systematic review of the relationship between
observable structural changes and clinical outcomes
following response to therapeutic exercise
 20 studies with 625 patients included
 CONCLUSIONS:
 “The available literature does not support
observable structural changes as an explanation
for the response to therapeutic exercise when
treated by eccentric exercise training”
NEED ANOTHER STUDY HERE
 Conclusion:
 “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”
Does needling a tendon
lead to healing?
Basic science of needling
 Eliasson et al, 2013, FASEB
 Needling an unloaded rat Achilles tendon induced same
gene expression as early mechanical loading
 Mechanical loading may heal, at least in part, by micro trauma
 Dallaudiere et al, 2013, Eur Radiology,
 RCT on rat model of PRP vs Serum
 Had clinically significant improvement in PRP group vs
serum group on joint motion, ultrasound appearance,
and histology
 Tendon healing demonstrated as opposed to just clinical pain
relief
COULD USE MORE DATA HERE
Early literature on ultrasound guided
needle tenotomy for lateral epicondylosis
 McShane et al, Journal of
Ultrasound Med. 2006
 Ultrasound guided PNT with
 McShane et al, Journal of
Ultrasound Med 2008
 Ultrasound guided PNT without
steroid for chronic lat.
epicondylitis
steroid for chronic lat.
Epicondylitis
 Failed conservative tx
 Failed conservative tx
 58 pts-- avg f/u 28 mo.
 80 % Good or Excellent
 57 pts --avg f/u 22 mo.
 92% Good or Excellent Outcome
Outcome
 90% would refer friend or close
 85% would refer friend or
family for procedure
relative for procedure
PRP for chronic
lateral epicondylosis
AJSM, 2006
 140 pts evaluated for lateral epicondylosis
 20 had refractory pain an avg. of 15 months later
 15 in treatment group, 5 in bupivicaine control group
 Intervention
– Injection w/ autologous PRP once into common extensor tendon
followed by gradual increase in rehab program through 4 weeks
after which full activity allowed
 Outcome
– A 46%, 60% and 81% improvement in VAS pain scores at 1, 2 and 6
months respectively in tx group
– 3/5 in bupivicaine group withdrew/ sought other tx
– At final F/U (12-38 months) 93% pain free (<10/100 VAS)
– No complications, no one got worse
British Medical
Bulletin, 2014
 13 RCT included in the study
 886 patients
 53.8% with identical PRP protocol
 Areas of controversy
 Different comparators
 Outcome scores
 FU periods
 Diverse injection protocols
 Conclusion:
 Pooling pain outcomes over time suggest that L+PRP ameliorates pain
in the intermediate and long term compared with control
interventions
 Low power, precision
 Further studies needed
Why are we still debating
if orthobiologics works?
 Need to define what we are injecting ?
 Platelet concentration
 MSC concentration
 Leukocyte count
 RBC +/ RBC –
 Autologous/ allogenic
 Need to define the procedure
 US guidance
 Needle tenotomy performed ?

How many needle passes ?
 Rehabilitation methods
 Need to be studied/ validated
 Immobilization
 Timing of eccentrics
 May need to separate out different body parts
JAMA, January 13, 2010
 First double blind, placebo controlled, RCT on PRP
 54 randomized patients age 18 to 70 with chronic (at least 2 mo)




achilles tendon pain 2 to 7 cm above calcaneus
Either 6cc PRP or Saline was injected with US guidance into
achilles
AJSM,
2011
tendon
Rehab for both groups involved rest and then after 2 weeks, started
on 12 week daily (180 repetitions) eccentric exercise program
No sports for at least 4 weeks and then only if pain <=3/10
f/u questionnaire at weeks 6,12,24 (6 mo)
AJSM, 2011
 DISCUSSION
 Both groups were treated with eccentrics AFTER
treatment; NONE treated before treatment
 Big confounder in study
 Eccentrics done early (started at 2 wks)
 Both groups improved
 Needle? Saline? Placebo? Eccentric Exercises?
BJSM, 2011
 RCT-- ABI(n= 70) vs PRP (n=80)
 2 injections done 1 month apart
 All patients had FAILED an eccentric loading program
and stretching program
 At 6 mo
 66% success rate in PRP group
 10% converted to surgery
 72%success rate in ABI group
 20% converted to surgery
AJSM, Feb, 2010
 Double blind RCT with 1 year follow up of 100 pts
 No ultrasound guidance was used
 Success defined as >25% reduction in VAS or DASH score
 RESULTS
 At 1 yr, 49% of CSI group and 73% in PRP group were
successful (p<.001)
AJSM, March 2011
 46 patients
 RCT- PRP vs CSI to lateral epicondyle
AJSM, 2013
METHODS




N = 60
PRP vs Saline vs glucocorticoid (+ Lidocaine)
Primary end point - change in pain using
Patient-Rated Tennis Elbow Evaluation
(PRTEE) at 3 months
Secondary Outcomes - were ultrasonographic
changes in tendon thickness and color Doppler
activity
Main Outcome:
Neither injection of PRP nor
glucocorticoid was superior
to saline with regard to pain
reduction in LE at 3 months
Comparison of studies
K
r
o
g
h
PRP
CSI
CSI
Ferrero
PRP
Results of PRP can not be adequately
measured with only 3 months follow-up
Is it the Needle?
AJSM, 2013
Clinical Rehabilitation, 2012
 2 PNT vs 2 PRP injections under US guidance for RTC tendinosis or
small, partial tear
 Measured results using Shoulder Pain and Disability Index

Baseline

2wks after 1st injection

Right before second injection

2 wks after second injection

3 months

6 months
PMR journal, 2013
 Pts age 16-70 (avg 48 yrs)
 Greater than 6 months of pain (avg 36 months)
 Diagnosed by clinical exam plus MRI or diagnostic US
 ALL had Failed conventional treatments (not controlled)



Medications
Bracing
Stretching
•
•
•
Strengthening
CFM
Modalities
 PRP done under US guidance
 Patients either sent to PT or instructed to do HEP after treatment
Distribution of Tendons
 Lateral Epicondyle
30
 Hamstring
17
 Patella Tendon
27
 Gluteus Medius
16
 Achilles
 Medial Epicondyle
27
 Rotator Cuff
11
21
 Plantar Fascia
9
 13 other tendons
<5
each
Overall Improvement
82% reported moderate to complete improvement
– 50%- 100% relief of symptoms
70 % reported mostly to complete improvement
-- 75-100% relief of symptoms
NO difference in outcomes in those who did PT vs No Therapy after
treatment.
BJSM, 2009
 RCT with 43 patients randomized to 1 of 3 groups
 12 week Eccentric training protocol (15)
 Prolotherapy with hypertonic glucose/ lidocaine
(14)
 Combination of both EE + Prolo (14)
 Outcomes looked at
 Pain
 Function
 Stiffness/ limiation of activities
 Cost
 Long 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
Take Home points
 There are a certain percentage of tendons that will not improve
with rehabilitation alone
 Corticosteroids offer only short term improvement in tendinosis
and may provide long term detriment
 Level 1 studies demonstrating lavage/ aspiration of calcific
tendinosis of shoulder is a successful intervention
 Basic science suggests that needling a tendon can lead to a
healing response
 Emerging data that US guided needle tenotomy +/- PRP is
successful for recalcitrant tendinopathies
Ken.mautner@emory.org