Background Lateral epicondylitis (LE) is a common musculoskeletal disorder for which an effective treatment strategy still remains absent. Objectives To examine whether one injection with Platelet-rich plasma (PRP) is more effective than saline and corticosteroid (CS) in reducing pain in adults with LE. Methods A block randomized, double-blind, placebo-controlled trial with primary outcome assessed at 3 months, and with a 12 months follow-up, conducted between January 2009, and June 2011. Patients who did not achieve a satisfying treatment response (assessment made by patient and doctor) at 3 month had the option to discontinue the study and receive other treatment. In total, 60 patients with chronic LE were randomized (1:1:1) to receive either a blinded injection of PRP, saline or CS. The primary outcome was change in pain compared to baseline using the Patient Rated Tennis Elbow Evaluation (PRTEE) questionnaire at 3 months. Secondary endpoints were all assessed at 1 month, plus ultrasonographic changes in tendon thickness and color doppler activity at 3 months. Results The 60 enrolled patients in the intention to treat population had an average PRTEE pain score at baseline of 26.8 (SD 7.6). All randomized patients completed the study. At endpoint 3 months from baseline pain reduction was observed in all three groups, with no statistical significant difference between the groups. CS vs. saline -3.76 (95% CI -9.94 to 2.42), PRP vs. saline -2.64 (95% CI -8.80 to 3.52) and CS vs. PRP -1.12 (95% CI -7.23 to 4.99). However, at one month CS reduced pain more efficiently than both saline and PRP. The mean difference at one month between CS and saline was -8.11 (95% CI -14.29 to -1.93), between CS and PRP -9.27 (95% CI -15.38 to -3.16). CS was more efficient than PRP and saline in reducing both color doppler activity and tendon thickness at three months. Only 16 of 60 patients completed the entire 12 months follow-up. The huge attrition rate was due to lack of treatment efficacy. Conclusions This RCT showed no superiority of either PRP or CS compared to saline in pain reduction in LE at primary endpoint. However, anticipating immediate relief, CS had a short term pain reducing effect at one month in contrast to the other therapies. At 6 and 12 months the attrition rates in all treatment arms were too high for any meaningful conclusions to be made. Disclosure of Interest None Declared

Neither injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at the primary end point at 3 months. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month in contrast to the other therapies. Injection of glucocorticoid in LE reduces both color Doppler activity and tendon thickness compared with PRP and saline.

Background Injection therapy with glucocorticoids has been used since the 1950s as a treatment strategy for lateral epicondylitis (tennis elbow). Lately several other injection therapies have become available. Objectives Using a systematic review and network meta-analysis, our objective was to assess the comparative effectiveness of different injection therapies used for pain reduction. Methods Structured literature searches in Medline, Embase, Cinahl, Web of Science, and the Cochrane Clinical Trials Database. Selected studies were randomized controlled trials comparing different injection therapies and/or placebo injections for lateral epicondylitis. Risk of bias was assessed in each of the included trials. The outcome measures were change in pain intensity at the end of the masked trial period (i.e., endpoint) and adverse events. Network (random effects) meta-analysis was applied to combine direct and indirect evidence within and across trial data. Following the arm-based network meta-analysis standardized mean differences (SMDs) were used as the effect size based on differences between means divided by the pooled standard deviation. Results Seventeen trials (1381 patients) allocating individuals to injection with glucocorticoid, botulinum toxin, platelet-rich plasma, autologous blood, hyaluronic acid, prolotherapy, polidocanol, glycosaminoglycan polysulfate, and/or placebo, fulfilled the inclusion criteria. Only 3 (18%) of the trials were judged to be at low risk of bias: one trial of glucocorticoid compared to platelet-rich plasma, and placebo-controlled trials of prolotherapy and polidocanol. Pooled results from all included studies showed that glucocorticoid injection (investigated in 12 treatment arms with 310 patients) was no more effective than placebo with respect to improvement in pain (SMD -0.04 [95% CI -0.45 to 0.35], P=0.81); Botulinum toxin injection (4 treatment arms with 130 patients) was statistically significant but clinically only marginally more effective than placebo (-0.50 [-0.91 to -0.08], P=0.023); whereas autologous blood injection investigated in three treatment arms with 96 patients (-1.43 [-2.15 to -0.71], P =0.001) and platelet-rich plasma with two treatment arms and 114 patients (-1.13 [-1.77 to -0.49], P =0.002) were both clearly more efficacious than placebo. Neither polidocanol (one treatment arm, 18 patients) nor glycosaminoglycan polysulfate (one treatment arm, 32 patients) were found to be superior to placebo, while prolotherapy (one treatment arm, 10 patients) and hyaluronic acid (one treatment arm, 165 patients) were both found to be much more efficacious than placebo (-2.71 [-4.60 to -0.82], P =0.009, and -5.58 [-6.35 to -4.82], P <0.0001 respectively). Conclusions Our study found that most trials that have assessed the value of injection therapy for lateral epicondylitis are at high risk of bias and that their results therefore need to be interpreted with caution. Further high quality trials are needed in this area. Disclosure of Interest None Declared

PRP injection did not result in an improved VISA-A score over a 3-month period in patients with chronic AT compared with placebo. The only secondary outcome demonstrating a statistically significant difference between the groups was change in tendon thickness; this difference indicates that a PRP injection could increase tendon thickness compared with saline injection. The conclusions are limited to the 3 months after treatment owing to the large dropout rate.

Background:Plantar fasciitis (PF) affects 7% to 10% of the population. The long-term prognosis is unknown.Purpose:Our study had 4 aims: (1) to assess the long-term prognosis of PF, (2) to evaluate whether baseline characteristics (sex, body mass index, age, smoking status, physical work, exercise-induced symptoms, bilateral heel pain, fascia thickness, and presence of a heel spur) could predict long-term outcomes, (3) to assess the long-term ultrasound (US) development in the fascia, and (4) to assess whether US-guided corticosteroid injections induce atrophy of the heel fat pad.Study Design:Cohort study; Level of evidence, 3.Methods:From 2001 to 2011 (baseline), 269 patients were diagnosed with PF based on symptoms and US. At follow-up (2016), all patients were invited to an interview regarding their medical history and for clinical and US re-examinations. Kaplan-Meier survival estimates were used to estimate the long-term prognosis, and a multiple Cox regression analysis was used for the prediction model.Results:In all, 174 patients (91 women, 83 men) participated in the study. All were interviewed, and 137 underwent a US examination. The mean follow-up was 9.7 years from the onset of symptoms and 8.9 years from baseline. At follow-up, 54% of patients were asymptomatic (mean duration of symptoms, 725 days), and 46% still had symptoms. The risk of having PF was 80.5% after 1 year, 50.0% after 5 years, 45.6% after 10 years, and 44.0% after 15 years from the onset of symptoms. The risk was significantly greater for women (P < .01) and patients with bilateral pain (P < .01). Fascia thickness decreased significantly in both the asymptomatic and symptomatic groups (P < .01) from 6.9 mm and 6.7 mm, respectively, to 4.3 mm in both groups. Fascia thickness (P = .49) and presence of a heel spur (P = .88) at baseline had no impact on prognosis. At follow-up, fascia thickness and echogenicity had normalized in only 24% of the asymptomatic group. The mean fat pad thickness was 9.0 mm in patients who had received a US-guided corticosteroid injection and 9.4 mm in those who had not been given an injection (P = .66).Conclusion:The risk of having PF in this study was 45.6% at a mean 10 years after the onset of symptoms. The asymptomatic patients had PF for a mean 725 days. The prognosis was significantly worse for women and patients with bilateral pain. Fascia thickness decreased over time regardless of symptoms and had no impact on prognosis, and neither did the presence of a heel spur. Only 24% of asymptomatic patients had a normal fascia on US at long-term follow-up. A US-guided corticosteroid injection did not cause atrophy of the heel fat pad. Our observational study did not allow us to determine the efficacy of different treatment strategies.

This systematic review and network meta-analysis of randomized controlled trials found a paucity of evidence from unbiased trials on which to base treatment recommendations regarding injection therapies for lateral epicondylitis.

Good to excellent reliability was obtained for all measurements. The ultrasonographic techniques evaluated in this trial can be recommended for use in both research and clinical practice.

Background:Ultrasonography (US) of the common extensor tendon (CET) of the elbow is often part of the assessment of patients with lateral epicondylitis. This US assessment is currently based on general tendinopathy references and not well-defined US entities.Purpose:To describe CET thickness, color Doppler activity, and bony spurs on US in asymptomatic volunteers and to investigate the influence of sex, age, height, body mass index (BMI), weight, and elbow dominance on the measurements.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Tendon thickness, color Doppler activity, and bony spurs of the CET were measured sonographically in 264 adults (50% women) aged 20 to 96 years. Two different tendon-thickness measuring techniques were applied, labeled the “plateau measure” and the “1-cm measure.” Color Doppler activity was based on a 0 to 4 rating scale (negative, grades 0 and 1; positive, grades 2-4). A bony spur was defined as a bony outgrowth (≥0.3 mm) arising at the insertional site of the CET.Results:With both tendon-thickness measuring techniques, the CET in the dominant elbow was thicker than that in the nondominant elbow, and male tendons were thicker than female tendons (all P ≤ .03). In regression analysis, tendon thickness correlated with weight, color Doppler activity, and arm dominance for both measuring techniques in multiple regression analysis. In addition, the plateau measure correlated with height and the presence of bony spurs. No correlations were observed regarding BMI, sex, or age. Positive color Doppler activity was found in 9% of examined elbows, with no difference between the sexes regarding dominant versus nondominant elbows (all P ≥.20). Bony spurs were found to increase with age, from 23% for people in their 20s to 74% in people older than 70 years. Bony spurs were more common in the dominant elbow (P ≤ .01). Women had a higher prevalence of bony spurs than men, but only in the dominant elbow (P = .03).Conclusion:This study presents the US characteristics and normal values of the CET. In 264 asymptomatic participants, the CET was found to be thicker in men and in the dominant elbow. No difference in tendon thickness could be demonstrated with regard to different age groups. Color Doppler activity was found to be positive in nearly 1 of 10 asymptomatic subjects. Bony spurs were a common finding; they increased in prevalence with every decade in age and were considered part of the aging process. Normal variations in CET morphologic characteristics should therefore be considered when implementing US in trials and clinical practice.