Sport Medicine Journal Club
training programs, hyaluronic acid injection, and single (uninjured) leg cycling may be beneficial. Preoperative and postoperative informational videos may be valuable for psychological wellbeing. Insufficient evidence was found to recommend bracing.
Commentary The rehabilitation of athletes after ACL reconstruction continues to evolve, with the goals of returning athletes to the activity of their choice as soon as possible and hoping to slow the almost inevitable development of degenerative changes in the knee. The serendipitous discovery of the benefits of “accelerated” rehabilitation1 and the advances in arthroscopic surgery (eg, visualization, equipment, and fixation) are 2 of the most important developments in decreasing associated surgical morbidity and shortening the patients’ recovery time. Much research has focused on improving short- and long-term functional outcomes while decreasing the time required to reach “game ready” status. Research topics include moving away from restrictive bracing, beginning rehabilitation ever earlier and more intensely, moving towards more cost-effective rehabilitation by decreasing the amount of supervision, using training techniques to improve neuromuscular feedback, and making use of biological adjuncts to assist/accelerate healing. The study by Kruse et al is an updated systematic review that adds to 2 previous reports performed primarily by members of the Multicenter Orthopaedic Outcomes Network (MOON).2,3 These 2 previous reviews, published in 2008, covered the use of continuous passive motion, early weight bearing, postoperative bracing, home-based rehabilitation, open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and other miscellaneous topics. These reviews included level I or II evidence reported up to 2005. Kruse et al have reviewed the additional literature published from 2006 to 2010, using a method similar to that of the previous reviews, with all 3 authors performing and reconciling the searches. Twenty-nine studies met inclusion
502
| www.cjsportmed.com
Clin J Sport Med Volume 23, Number 6, November 2013
criteria and were assessed for methodologic quality using the CONSORT checklist. The current study upholds many of the conclusions of the original reviews in that 1) post-operative bracing is neither necessary nor beneficial, 2) accelerated rehabilitation with early strengthening is beneficial, and 3) home-based or limited supervision of rehabilitation can be successful in motivated patients. Neuromuscular, proprioception, vibration, and perturbation training studies were more prevalent in the current review. They showed some early benefits to balance but no clear improvements in long-term outcomes or functional return to sport. Despite limiting the systematic review to level I and II studies, the included studies were still relatively poor quality. Limited description of randomization and general lack of sample size or power analysis bring into question the many “no difference” results. Some studies found differences at specific time points, but most failed to include long-term follow-up (.2 years is usually expected for the evaluation of surgical outcomes), comments on complications, or evaluations of the patients’ ability to return to activity or sport (usually the most important outcome to the patient). When significant differences were shown, they usually did not meet clinically relevant thresholds. Finally, there was a limited use of validated knee-specific patient-reported outcomes such as the International Knee Documentation Committee (IKDC) score, the ACL Quality of Life (ACL QOL) questionnaire, or the Knee Osteoarthritis Outcome Score (KOOS). The study by Kruse et al updates the evidence available for advancing the successful rehabilitation of patients after ACL reconstruction. It also, however, identifies, that despite efforts to improve the methodologic quality of orthopedic research, much work is still required to provide statistically sound and unbiased information to help guide our clinical practices. John A. Grant, PhD, MD Department of Surgery Dalhousie University Saint John, New Brunswick, Canada
REFERENCES 1. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18: 292–299. 2. Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation. Part I: continuous passive motion, early weight bearing, postoperative bracing, and homebased rehabilitation. J Knee Surg. 2008;21: 217–224. 3. Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation. Part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008;21:225–234.
How Effective Are Injection Treatments for Lateral Epicondylitis? Krogh TP, Fredberg U, StengaardPedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline. Am J Sports Med. 2013;41:625–635. Objective: To compare the effectiveness, after 3 months, of a single injection of platelet-rich plasma (PRP), glucocorticoid (GC), or saline in reducing pain in lateral epicondylitis. Design: Randomized, controlled, 3group trial (RCT). Patients and outcome assessors were blinded to intervention group. Sample size was calculated to show a clinically important difference in patient-reported pain intensity at 12 months with 17 patients per group. Setting: Tertiary study at the Rheumatology Unit at the Diagnostic Centre of the Region Hospital Silkeborg, Denmark. Participants: Patients were referred to the Rheumatology Unit by general practitioners or other rheumatology or orthopedic departments. Inclusion criteria (verified by 1 physician) were lateral epicondylitis symptoms for $3 months (pain on the lateral side of the elbow and at the lateral epicondyle on Source of funding for the original study: In part, Biomet Biologics Inc, Warsaw, Indiana. Correspondence about the original article: Torkell Ellingsen, MD, PhD, Diagnostic Centre, Region Hospital Silkeborg, Falkevej 1, 8600 Silkeborg, Denmark ([email protected]).
Ó 2013 Lippincott Williams & Wilkins
Clin J Sport Med Volume 23, Number 6, November 2013
palpation and during resisted dorsiflexion of the wrist), an ultrasound (US) color Doppler flow of $ grade 2 (range, 0-4). Exclusion criteria were age ,18 years, treatment with GC injection within 3 months, inflammatory diseases, and conditions causing chronic pain. The 60 included patients had a mean age of 45 years, 52% were women, 58% had $1 previous injection, and 58% used analgesics. Intervention: The patients were randomized to a single US-guided injection of PRP, GC, or saline, administered by the 1 physician who had made the diagnosis. All patients were blindfolded during blood collection and injection. They all received an injection of 10 to 15 mL of lidocaine into the peritendon before the procedure. The PRP injection was of approximately 3.5 mL of autologous platelets (collected and centrifuged for 15 minutes from 27 mL of whole blood) buffered with 8.4% sodium bicarbonate, and immediately peppered into the common tendon origin. The GC injection (1 mL triamcinolon, 40 mg/mL + 2 mL lidocaine, 10 mg/mL) was delivered through 1 site. The saline injection (3 mL saline, 0.9%) was peppered in the same manner as the PRP injection. After treatment, the patients were asked to use the arm minimally for 3 days and then gradually to return to normal use. Main Outcome Measures: The pain intensity scale of the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire was the main outcome measure (least to most pain = 0-50 points). The secondary end points included changes in functional disability using the functional section of the PRTEE, (least to most disability = 0-100 points), US changes in color Doppler signal and tendon thickness, and adverse events, which included pain after the injection. After 3 months, if the patient was unsatisfied with the result of treatment, he or she could be released from the study to seek other management. Main Results: Ten, 11, and 13 patients (58% of the total) dropped out of the PRP, GC, and saline groups, respectively, at the 3-month follow-up, thus Ó 2013 Lippincott Williams & Wilkins
evaluations were only made at 1 and 3 months. At 1 month, the mean reduction in pain for the PRP group versus the saline group was 1.2 (95% confidence interval [CI], –5.0 to 7.3); for the GC group versus the saline group was –8.1 (95% CI, –14.3 to –1.9); and for the GC group versus the PRP group, – 9.3 (95% CI, –15.4 to –3.2). At 3 months, the mean reduction in pain for no group was significantly greater than for others (PRP vs the saline group, –2.7; 95% CI, –8.8 to 3.5; GC vs the saline group, –3.8; 95% CI, –9.9 to 2.4; GC vs the PRP group, –1.1; 95% CI, –7.2 to 5.0). The PRTEE disability scores at 1 month also favored the GC group versus saline, but no differences were found between any groups at 3 months. The improvement in Doppler grades at 3 months favored the GC group versus the saline group and the PRP group (P,0.0001 for both comparisons). Mean reduction in tendon thickness was greater for the GC group versus the saline group (P,0.0001) and the PRP group (P=0.002). PRP injections were found to be more painful than GC and saline injections. No adverse events leading to hospitalization, and no reports of infections resulting from the injections, occurred. Conclusions: The dropout rate of 58% at 3 months showed that none of PRP, glucocorticoid, or saline injections adequately reduced the pain and disability of lateral epicondylitis.
Commentary The study by Krogh et al compared 3 injection treatments for lateral epicondylitis. The original design of the study was to perform a single treatment and then to assess the patients’ results over a 12-month period. Patient selection and randomization were adequate, and resulted in very similar patients in each group. The outcome measures were appropriate, and adverse events were recorded. Both PRP and glucocorticoid injections were safe to use in the short term. The patients and the outcome assessor were blinded to group assignment, but the physician administering the treatments was not. Blinding may have had some unforeseen effects. All patients were
Sport Medicine Journal Club
injected through the skin to the peritendon of the common extensor with 10 to 15 mL of lidocaine. This was performed in an attempt to provide preprocedure anesthesia without introducing any anesthetic into the target tissue using US guidance. The authors report evidence that, in vitro, lidocaine had an inhibitory effect on tenocyte survival in the presence of local anesthetics and PRP.1 Applying this quantity of full strength lidocaine on the target tissue is not standard practice and may have had an unexpected negative effect in all 3 patient groups. The study protocol permitted patients to leave the study after 3 or 6 months if they or the physician was dissatisfied with their clinical improvement. They could then pursue other treatments. No attempt was made to follow the large proportion of patients who left after 3 months. Krogh et al noted that a saline injection arm may not have been a suitable placebo in this trial. Scarpone et al, however, in a RCT comparing a saline injection control to a prolotherapy injection treatment for chronic lateral epicondylitis showed that the prolotherapy treatment improved clinical outcome measures significantly.2 Krogh et al may have overlooked a significant treatment effect of the needling of the common extensor in the saline placebo group that was almost identical to the experiences after the procedure of the PRP treatment arm. The findings of the study suggest that the effectiveness of PRP and glucocorticord injections for lateral epicondylitis requires further evaluation in well-designed placebo-controlled trials. Brian J. Shiple, DO Department of Family and Community Medicine Temple University School of Medicine Philadelphia, Pennsylvania
REFERENCES 1. Carofino B, Chowaniec DM, McCarthy MB, et al. Corticosteroids and local anesthetics decrease positive effects of platelet-rich plasma: an in vitro study on human tendon cells. Athroscopy. 2012;28:711–719. 2. Scarpone M, Rabago DP, et al; ZgierskSport Medicine Journal Club A. The efficacy of prolotherapy for lateral epicondylitis: a pilot study. Clin J Sport Med. 2008;18: 248–254.
www.cjsportmed.com |
503
training programs, hyaluronic acid injection, and single (uninjured) leg cycling may be beneficial. Preoperative and postoperative informational videos may be valuable for psychological wellbeing. Insufficient evidence was found to recommend bracing.
Commentary The rehabilitation of athletes after ACL reconstruction continues to evolve, with the goals of returning athletes to the activity of their choice as soon as possible and hoping to slow the almost inevitable development of degenerative changes in the knee. The serendipitous discovery of the benefits of “accelerated” rehabilitation1 and the advances in arthroscopic surgery (eg, visualization, equipment, and fixation) are 2 of the most important developments in decreasing associated surgical morbidity and shortening the patients’ recovery time. Much research has focused on improving short- and long-term functional outcomes while decreasing the time required to reach “game ready” status. Research topics include moving away from restrictive bracing, beginning rehabilitation ever earlier and more intensely, moving towards more cost-effective rehabilitation by decreasing the amount of supervision, using training techniques to improve neuromuscular feedback, and making use of biological adjuncts to assist/accelerate healing. The study by Kruse et al is an updated systematic review that adds to 2 previous reports performed primarily by members of the Multicenter Orthopaedic Outcomes Network (MOON).2,3 These 2 previous reviews, published in 2008, covered the use of continuous passive motion, early weight bearing, postoperative bracing, home-based rehabilitation, open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and other miscellaneous topics. These reviews included level I or II evidence reported up to 2005. Kruse et al have reviewed the additional literature published from 2006 to 2010, using a method similar to that of the previous reviews, with all 3 authors performing and reconciling the searches. Twenty-nine studies met inclusion
502
| www.cjsportmed.com
Clin J Sport Med Volume 23, Number 6, November 2013
criteria and were assessed for methodologic quality using the CONSORT checklist. The current study upholds many of the conclusions of the original reviews in that 1) post-operative bracing is neither necessary nor beneficial, 2) accelerated rehabilitation with early strengthening is beneficial, and 3) home-based or limited supervision of rehabilitation can be successful in motivated patients. Neuromuscular, proprioception, vibration, and perturbation training studies were more prevalent in the current review. They showed some early benefits to balance but no clear improvements in long-term outcomes or functional return to sport. Despite limiting the systematic review to level I and II studies, the included studies were still relatively poor quality. Limited description of randomization and general lack of sample size or power analysis bring into question the many “no difference” results. Some studies found differences at specific time points, but most failed to include long-term follow-up (.2 years is usually expected for the evaluation of surgical outcomes), comments on complications, or evaluations of the patients’ ability to return to activity or sport (usually the most important outcome to the patient). When significant differences were shown, they usually did not meet clinically relevant thresholds. Finally, there was a limited use of validated knee-specific patient-reported outcomes such as the International Knee Documentation Committee (IKDC) score, the ACL Quality of Life (ACL QOL) questionnaire, or the Knee Osteoarthritis Outcome Score (KOOS). The study by Kruse et al updates the evidence available for advancing the successful rehabilitation of patients after ACL reconstruction. It also, however, identifies, that despite efforts to improve the methodologic quality of orthopedic research, much work is still required to provide statistically sound and unbiased information to help guide our clinical practices. John A. Grant, PhD, MD Department of Surgery Dalhousie University Saint John, New Brunswick, Canada
REFERENCES 1. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18: 292–299. 2. Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation. Part I: continuous passive motion, early weight bearing, postoperative bracing, and homebased rehabilitation. J Knee Surg. 2008;21: 217–224. 3. Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation. Part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008;21:225–234.
How Effective Are Injection Treatments for Lateral Epicondylitis? Krogh TP, Fredberg U, StengaardPedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline. Am J Sports Med. 2013;41:625–635. Objective: To compare the effectiveness, after 3 months, of a single injection of platelet-rich plasma (PRP), glucocorticoid (GC), or saline in reducing pain in lateral epicondylitis. Design: Randomized, controlled, 3group trial (RCT). Patients and outcome assessors were blinded to intervention group. Sample size was calculated to show a clinically important difference in patient-reported pain intensity at 12 months with 17 patients per group. Setting: Tertiary study at the Rheumatology Unit at the Diagnostic Centre of the Region Hospital Silkeborg, Denmark. Participants: Patients were referred to the Rheumatology Unit by general practitioners or other rheumatology or orthopedic departments. Inclusion criteria (verified by 1 physician) were lateral epicondylitis symptoms for $3 months (pain on the lateral side of the elbow and at the lateral epicondyle on Source of funding for the original study: In part, Biomet Biologics Inc, Warsaw, Indiana. Correspondence about the original article: Torkell Ellingsen, MD, PhD, Diagnostic Centre, Region Hospital Silkeborg, Falkevej 1, 8600 Silkeborg, Denmark ([email protected]).
Ó 2013 Lippincott Williams & Wilkins
Clin J Sport Med Volume 23, Number 6, November 2013
palpation and during resisted dorsiflexion of the wrist), an ultrasound (US) color Doppler flow of $ grade 2 (range, 0-4). Exclusion criteria were age ,18 years, treatment with GC injection within 3 months, inflammatory diseases, and conditions causing chronic pain. The 60 included patients had a mean age of 45 years, 52% were women, 58% had $1 previous injection, and 58% used analgesics. Intervention: The patients were randomized to a single US-guided injection of PRP, GC, or saline, administered by the 1 physician who had made the diagnosis. All patients were blindfolded during blood collection and injection. They all received an injection of 10 to 15 mL of lidocaine into the peritendon before the procedure. The PRP injection was of approximately 3.5 mL of autologous platelets (collected and centrifuged for 15 minutes from 27 mL of whole blood) buffered with 8.4% sodium bicarbonate, and immediately peppered into the common tendon origin. The GC injection (1 mL triamcinolon, 40 mg/mL + 2 mL lidocaine, 10 mg/mL) was delivered through 1 site. The saline injection (3 mL saline, 0.9%) was peppered in the same manner as the PRP injection. After treatment, the patients were asked to use the arm minimally for 3 days and then gradually to return to normal use. Main Outcome Measures: The pain intensity scale of the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire was the main outcome measure (least to most pain = 0-50 points). The secondary end points included changes in functional disability using the functional section of the PRTEE, (least to most disability = 0-100 points), US changes in color Doppler signal and tendon thickness, and adverse events, which included pain after the injection. After 3 months, if the patient was unsatisfied with the result of treatment, he or she could be released from the study to seek other management. Main Results: Ten, 11, and 13 patients (58% of the total) dropped out of the PRP, GC, and saline groups, respectively, at the 3-month follow-up, thus Ó 2013 Lippincott Williams & Wilkins
evaluations were only made at 1 and 3 months. At 1 month, the mean reduction in pain for the PRP group versus the saline group was 1.2 (95% confidence interval [CI], –5.0 to 7.3); for the GC group versus the saline group was –8.1 (95% CI, –14.3 to –1.9); and for the GC group versus the PRP group, – 9.3 (95% CI, –15.4 to –3.2). At 3 months, the mean reduction in pain for no group was significantly greater than for others (PRP vs the saline group, –2.7; 95% CI, –8.8 to 3.5; GC vs the saline group, –3.8; 95% CI, –9.9 to 2.4; GC vs the PRP group, –1.1; 95% CI, –7.2 to 5.0). The PRTEE disability scores at 1 month also favored the GC group versus saline, but no differences were found between any groups at 3 months. The improvement in Doppler grades at 3 months favored the GC group versus the saline group and the PRP group (P,0.0001 for both comparisons). Mean reduction in tendon thickness was greater for the GC group versus the saline group (P,0.0001) and the PRP group (P=0.002). PRP injections were found to be more painful than GC and saline injections. No adverse events leading to hospitalization, and no reports of infections resulting from the injections, occurred. Conclusions: The dropout rate of 58% at 3 months showed that none of PRP, glucocorticoid, or saline injections adequately reduced the pain and disability of lateral epicondylitis.
Commentary The study by Krogh et al compared 3 injection treatments for lateral epicondylitis. The original design of the study was to perform a single treatment and then to assess the patients’ results over a 12-month period. Patient selection and randomization were adequate, and resulted in very similar patients in each group. The outcome measures were appropriate, and adverse events were recorded. Both PRP and glucocorticoid injections were safe to use in the short term. The patients and the outcome assessor were blinded to group assignment, but the physician administering the treatments was not. Blinding may have had some unforeseen effects. All patients were
Sport Medicine Journal Club
injected through the skin to the peritendon of the common extensor with 10 to 15 mL of lidocaine. This was performed in an attempt to provide preprocedure anesthesia without introducing any anesthetic into the target tissue using US guidance. The authors report evidence that, in vitro, lidocaine had an inhibitory effect on tenocyte survival in the presence of local anesthetics and PRP.1 Applying this quantity of full strength lidocaine on the target tissue is not standard practice and may have had an unexpected negative effect in all 3 patient groups. The study protocol permitted patients to leave the study after 3 or 6 months if they or the physician was dissatisfied with their clinical improvement. They could then pursue other treatments. No attempt was made to follow the large proportion of patients who left after 3 months. Krogh et al noted that a saline injection arm may not have been a suitable placebo in this trial. Scarpone et al, however, in a RCT comparing a saline injection control to a prolotherapy injection treatment for chronic lateral epicondylitis showed that the prolotherapy treatment improved clinical outcome measures significantly.2 Krogh et al may have overlooked a significant treatment effect of the needling of the common extensor in the saline placebo group that was almost identical to the experiences after the procedure of the PRP treatment arm. The findings of the study suggest that the effectiveness of PRP and glucocorticord injections for lateral epicondylitis requires further evaluation in well-designed placebo-controlled trials. Brian J. Shiple, DO Department of Family and Community Medicine Temple University School of Medicine Philadelphia, Pennsylvania
REFERENCES 1. Carofino B, Chowaniec DM, McCarthy MB, et al. Corticosteroids and local anesthetics decrease positive effects of platelet-rich plasma: an in vitro study on human tendon cells. Athroscopy. 2012;28:711–719. 2. Scarpone M, Rabago DP, et al; ZgierskSport Medicine Journal Club A. The efficacy of prolotherapy for lateral epicondylitis: a pilot study. Clin J Sport Med. 2008;18: 248–254.
www.cjsportmed.com |
503
