Letters to the Editor
Prolotherapy for Treatment of Lateral Epicondylosis
Am Fam Physician. 2009 Sep 1;80(5):441-444.
Original Article: Treatment of Lateral Epicondylitis
Issue Date: September 15, 2007
Available at: http://www.aafp.org/afp/20070915/843.html
to the editor: The article on lateral epicondylitis provides a useful update of several therapies. In my opinion, however, the term “epicondylitis” is outdated, and although several treatments are well-described in the article, a promising therapy was omitted.
Data suggest that the term “lateral epicondylitis” may be a misnomer because the suffix “-itis” means inflammation. Surgical pathology studies of patients with painful overuse tendon conditions have shown that inflammatory cells are largely absent. Instead, pathologic tissue shows collagen disorganization and separation, mucoid ground substance, focal necrosis, and neovascularization. Inflammation may be present in the earliest stages of tendon disease, but it is unlikely to persist after a few days of elbow pain. These findings have prompted experts to use the term “tendinosis” (chronic tendon condition) or “tendinopathy” (tendon disease).1
Adopting a term that better reflects the underlying pathology is important. First, “elbow tendinopathy” and “epicondylosis” do not suggest inflammation and therefore do not suggest the use of anti-inflammatory medication, as does the term “epicondylitis.” Inappropriate pharmacotherapy for chronic tendon conditions, with resulting cost and comorbidity, is common. As the authors report, nonsteroidal anti-inflammatory drugs and injected corticosteroids have some effect on acute pain but not on chronic pain. Additionally, a recent study on lateral epicondylosis reported that outcomes with corticosteroid injections were significantly worse than those with physical therapy or nonspecific conservative treatment at one year.2 Second, these terms would be more realistic for patients and would allow physicians to more accurately frame expectations for improvement. And third, it is evidence-based practice.1
I also would like to draw attention to two promising, related therapies for lateral epicondylosis: injections with the sclerosant polidocanol, and injections with dextrose and the sclerosant morrhuate sodium, also known as prolotherapy.3 Both treatments target areas of neovascularity, a prominent pathologic feature of tendinopathy. A Swedish sports medicine group has published eight original papers documenting positive outcomes of ultrasound-guided sclerotherapy using polidocanol for tendinopathies, including lateral epicondylosis.4,5 My group recently reported clinically meaningful improvements in pain and functional outcomes in patients with severe lateral epicondylosis treated with prolotherapy.6 At four-month follow-up, patients who received prolotherapy, compared with the control group who received saline injections, reported near-total pain resolution and a 3.6-point absolute effect size on an 11-point Likert elbow pain scale (P <.001). The number needed to treat to achieve a clinically relevant two-point improvement was 1.4. Participants in the prolotherapy group also reported improved isometric resistance strength (P <.01) compared with control patients. The mechanism for these findings is unclear and requires further investigation. Two prolotherapy clinical trials are being conducted by the National Institutes of Health. This therapy is not widely available for clinical use.
1. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth. BMJ. 2002;324(7338):626–627.
2. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.
3. Rabago D, Best TM, Beamsley M, Patterson J. A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sports Med. 2005;15(5):376–380.
4. Hoksrud A, Ohberg L, Alfredson H, Bahr R. Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomized controlled trail. Am J Sports Med. 2006;34(11):1738–1746.
5. Zeisig E, Ohberg L, Alfredson H. Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study. Knee Surg Sports Traumatol Arthrosc. 2006;14(11):1218–1224.
6. Scarpone M, Rabago DP, Zgierska A, Arbogast G, Snell E. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sports Med. 2008;18(3):248–254.
editor's note: This letter was sent to the authors of “Treatment of Lateral Epicondylitis,” who declined to reply.
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