Background: Platelet-rich plasma (PRP) has been shown to be a general stimulation for repair and 1-year results showed promising success percentages. Purpose: This trial was undertaken to determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a 2-year follow-up. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: The trial was conducted in 2 Dutch teaching hospitals. One hundred patients with chronic lateral epicondylitis were randomly assigned to a leukocyte-enriched PRP group (n = 51) or the corticosteroid group (n = 49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included visual analog scale (VAS) pain scores and Disabilities of the Arm, Shoulder and Hand (DASH) outcome scores. Results: The PRP group was more often successfully treated than the corticosteroid group (P\.0001). Success was defined as a reduction of 25% on VAS or DASH scores without a reintervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2-year follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned to baseline levels, while those of the PRP group significantly improved (as-treated principle). There were no complications related to the use of PRP. Conclusion: Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.

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Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-year Follow-up

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

/pdf/extracorporeal-shockwave-therapy-in-musculoskeletal-4atujxco70.pdf

Extracorporeal shockwave therapy in musculoskeletal disorders

Synopsis The hallmark features of patellar tendinopathy are (1) pain localized to the inferior pole of the patella and (2) load-related pain that increases with the demand on the knee extensors, notably in activities that store and release energy in the patellar tendon. While imaging may assist in differential diagnosis, the diagnosis of patellar tendinopathy remains clinical, as asymptomatic tendon pathology may exist in people who have pain from other anterior knee sources. A thorough examination is required to diagnose patellar tendinopathy and contributing factors. Management of patellar tendinopathy should focus on progressively developing load tolerance of the tendon, the musculoskeletal unit, and the kinetic chain, as well as addressing key biomechanical and other risk factors. Rehabilitation can be slow and sometimes frustrating. This review aims to assist clinicians with key concepts related to examination, diagnosis, and management of patellar tendinopathy. Difficult clinical presentations (eg, highly irritable tendon, systemic comorbidities) as well as common pitfalls, such as unrealistic rehabilitation time frames and overreliance on passive treatments, are also discussed. J Orthop Sports Phys Ther 2015;45(11):887-898. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5987.

https://www.jospt.org/doi/pdf/10.2519/jospt.2015.5987

Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations

Background
Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

/pdf/efficacy-and-safety-of-extracorporeal-shock-wave-therapy-for-ec2zmw9z9q.pdf

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

Patellar tendinopathy is a common, painful, overuse disorder. Although many different treatment methods have been described, there is no consensus regarding the optimal treatment for this condition. The purpose of this study was to systematically review, summarize, and compare treatments for patellar tendinopathy from published randomized controlled trials. Database searches were performed for randomized prospective controlled trials comparing treatment methods for patellar tendinopathy. The thirteen articles considered relevant were scrutinized according to quality assessment guidelines and levels of evidence. Strong evidence was found for the use of eccentric training to treat patellar tendinopathy. Moderate evidence was found for conservative treatment (heavy slow resistance training) as an alternative to eccentric training. Moderate evidence suggests that low-intensity pulsed ultrasound treatment did not influence treatment outcomes. Limited evidence was found for surgery, sclerosing injections, and shockwave therapy. Physical training, and particularly eccentric training, appears to be the treatment of choice for patients suffering from patellar tendinopathy. However, type of exercise, frequency, load, and dosage must also be analyzed. Other treatment methods, such as surgical treatment, sclerosing injections, and shockwave therapy, must be investigated further before recommendations can be made regarding their use. Ultrasound can likely be excluded as a treatment for patellar tendinopathy. There is a persistent lack of well-designed studies with sufficiently long-term follow-up and number of patients to draw strong conclusions regarding therapy. II.

Treatment of patellar tendinopathy—a systematic review of randomized controlled trials

BackgroundChronic patellar tendinopathy is an overuse syndrome with pathologic changes similar to tendinopathies of the shoulder, elbow, and heel. Extracorporeal shockwave was shown effective in many tendinopathies.HypothesisExtracorporeal shockwave therapy may be more effective than conservative treatment for chronic patellar tendinopathy.Study DesignRandomized controlled clinical trial; Level of evidence, 2.MethodsThis study consisted of 27 patients (30 knees) in the study group and 23 patients (24 knees) in the control group. In the study group, patients were treated with 1500 impulses of extracorporeal shockwave at 14 KV (equivalent to 0.18 mJ/mm 2 energy flux density) to the affected knee at a single session. Patients in the control group were treated with conservative treatments including nonsteroidal anti-inflammatory drugs, physiotherapy, exercise program, and the use of a knee strap. The evaluation parameters included pain score, Victorian Institute of Sports Assessment score, and ultrasonographi...

http://journals.sagepub.com/doi/pdf/10.1177/0363546506298109

Shan-Lin Hsu

Papers

Extracorporeal Shockwave for Chronic Patellar Tendinopathy

Surgical Results in Rotator Cuff Tears with Shoulder Stiffness