Proloterapia del Gomito Dr. Stephen Cavallino Medicina Ortopedica Non Chirurgica Ferrara, Italy
Tennis Elbow Lateral Epicondylitis • • • •
Eccessivo abuso Meno comune <35 Livello alto workout 30 min or > per sessione • Allenamento inadeguata
Caso Clinico • 38YOWF Tennis player w/ 2 yr hx of tennis elbow • Tx w/ PT, CFB, ART, NSAIDS, Ionto, injected X 2, 6 mo apart w/ good ↓pain and fct after 1st, partial 2nd • Can you cure?
• DM Golfer w/ B/L lat epicondylosis X 2 Yrs • Cortisone w/ temp relief • 3 rounds of PT, ART, CFB- still in pain • Received new tx • Golfing w/o pain X 1Y
Strategie Terapeutiche Antiche â&#x20AC;˘ Almekinders and Temple after a thorough review of the literature concluded there is little evidence for NSAIDS and steroids in the treatment of tendinopathy. â&#x20AC;&#x201C; Etiology, diagnosis and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998;30(8):1183-1190.
Strategie Terapeutiche • • • • •
Considerare D.D. (Differential Diag) Radial Nerve Entrapment- meno comune Dolore Miofasciale e disfunzione del muscolo Problemi articolare RCL lesioni (leg.collaterale radiale) visti in 2530% con cronica laterale epicondilite • Persistente micro/ macro l’instabilità della testa del radio o le osse carpali prossimali
Perche la guarigione completa non avviene ?? • Non ci sono risposte semplice e non c’è una corretta attenzione su questi lesioni. • Instabilità articolare continuativo in seguito post lesione – legamenti… perche questi guariscono lentamente. • Inadequate nutrizion durante la guarigione • Assunzione dei FANS che ralenta la naturale guarigione. • Condizioni che ralenta la guarigione. (DM, cigarette smoking, Thyroid) • Genetiche alterazioni (?)
Nuove Strategie Terapeutiche • • • •
New Paradigm Change tissue back to normal Many new unproven treatments being used ECSW, RF ablation, percutaneous tenotomy, autologous growth factor injection, Prolotherapy, active release technique • The Nirschl mini open technique
Diagnostic Tests • MRI shows increase signal in area of collagen degeneration • U/S shows hypoechoic regions of tendinosis • Findings are confirmed at path w/ no inflammation
Imaging Modalities
Anatomia del Gomito
Anatomia del Gomito
Anatomia del Gomito
Anatomia del Gomito
Lateral Flat Surface (Omerale) ECRB(Extensor Carpi Radialis Brevis)
Anterior Flat Surface(Omerale) ECRL (Extensor Carpi Radialis Longus)
Infiltrazione Legamento Annulare
Legamento Collateral Laterale
Legamento Collateral Radiale
Elbow Surface Anatomy
Esame Obiettivo Epicondilo Laterale • Palpate enthesi del tendine estensore comune per dolore. • Palpate ECRL origine omerale anterior flat surface • Varus stress test w/ elbow in pronation and 20-30° flex- pain w/ or w/out instab (+) test • Tinels- Triangle of Frosche for parasthesias in radial n. distribution-
Infiltrazione Epicondilo Laterale • Determini le structure che neccesità inizioni basato sul E.O. • Disegnare il epicondilo laterale e il capitello radiale (leg annulare) • Anestesia superficale e profondo x ligamenti collaterali, annulare e tendini estensori.
• Infiltrare 1cc sul (ECRL) lateral flat surface and 1/2cc to all other sites • Infiltrazione intraarticolare – gomito semi flessa palpi una zona debole in prossimità epicondilo e capitello radiale. Ago lat – mediale (in deep dent) • Inject 2-3 cc of D25
Another view of ECRB Tech
ECRL Anterior Flat Surface
RCL Injection Technique
Infiltrazione Legamento Annulare
Punti di Repere Gomito Mediale • Origine del Tendine Flessore Comune and Pronatore Teres • Ulnar Collateral Leg • Ulnar Nerve • Note: Ulnar Nerve is protected by the medial condyle
E.O. del Ligamento Collaterale Ulnare • Palpate sopra UCL, e sentite un tessuto teso (tight band) • Perform Milking Maneuver as shown for pain and instability • MRI arthrogram or U/S negative for gr 3 tear w/ (+) Milking test- go for it • Caution: Ulnar N. if pt feels shock stop!
Tecnica Infiltrativo dell’Epicondilo Mediale • Palpare l’apice del condilo mediale tra le dita dove si infiltra il flat surface. • Ago 25 or 27 gauge • Inject ½ -1 cc su tendine • Con ago vai superiore ed inf del condyle • Attenzione: Inj solo su osso, Perche se infiltri nel vuoto, sei a rischio del nervo ulnare.
Medial Epicondyle
Tecnica Infiltrativa del Epicondilo Mediale
Legamento Collaterale Ulnare
Tecnica Infiltrattivo del Legamento Ulnare Collaterale (UCL) • Palpare il legamenti UCL e segnare il punto. • SEMPRE disegnare il Nervo Ulnare (solco ulnare) • Infiltrare l’origine del legamento toccando sempre osso con ½-1 cc di soluzione. • Inject deep UCL post to Ulnar N. w/caution (no)
Tx Tendinosi del Tricipite • Anatomia- Enthesi del tendine sta sul apice dell’ Olecreno • Trova l’apice e fare segno x infilt. • Anestesia locale • Infiltrare 1-2 cc lungo il bordo dell’ Olecreno • Alternate injection tech for elbow joint- posterior technique
Grazie Domande
? Dr. Stephen Cavallino
What is Prolotherapy? • George Hackett, M.D. first coined the term Prolo short for proliferation • Derived from Latin word proli - to regenerate or rebuild • Non-surgical treatment for ligamentous laxity • Ligament injection therapy that re-stimulates the healing process • Creating inflammation and Increase GF>hence collagen by the use of proliferants/ needling • Body lays down collagennew ligaments & tendons
Theory Behind Prolotherapy • Injection causes local tissue injury and causes release of inflammatory mediators • Granulocytes and Macrophages receive GF signal to begin the healing process • Fibroblasts synthesize collagen and deposit at injury site • Collagen matures, loses water content and contracts causing tightening of ligament • New Paradigm of changing tissue to normal
Signs of Ligamentous Laxity • • • • •
Pain- Point Specific vs Pain Referral Joint Hypermobility- Acquired vs Congenital Muscle Spasm in painful area (Chix vs egg) Myofascial Trigger Points- involved muscles Weakness/ atrophy of associated muscles despite good trial of PT • Recurrent Somatic Dysfunction
Sequencing Treatments • • • • • • •
Accurate Dx- Advanced Imaging? Caught early enough, still try usual care Try conservative course first Steroid Injections, 1 or 2 only if early? RIT Q 2-6 weeks. Hit all sites vs just painful When are we done? In-sport athlete?
Complications of Prolo • Immediate pain, inflammation, swelling and redness for a few days (can require steroids, NSAIDS) • Allergic rxn • Toxic dose of anesthetics • Spinal cord injury, spinal HA • Pneumothorax • Infection
• Nerve injury • Temporary or permanent paralysis • Nausea, diarrhea • Death • Frozen Shoulder • Tendon Rupture
• Not easy to learn
Lidocaine Toxicity • Symptoms – Excitation – Drunk feeling – Tingling around lips and tongue – Agitation and anxiety w/ progression to seizure, coma and respiratory arrest
Allergic Reaction to Injections • Symptoms of allergic Rxn – – – – – – –
Flushing Urticaria Itching Wheezing Chest Tightness Abdominal Pain Nausea/ Vomiting
• Suggested Emergency kit – – – – – – –
Disposable Plastic Airways IV needles and NSS O2 with masks and tubing Ambubag and mask Epinephrine 1/1000 Benadryl IV soln Hydrocortisone
References • Reeves et al. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alternative Therapies, March 2000, Vol.6, No.2 • Klein RG et al. A randomized double-blind trial of dextrose-glycerinephenol injections for chronic low back pain. J Spinal Discord. 1993;6:23-33. • Ongley MJ et al. A new approach to the treatment of chronic low back pain. Lancet. 1987;2:143-146. • Walter MV. Dr. Mark Vincent Walter’s Connective Tissue Report. • Ravin T et al. Manual of Musculoskeletal Medicine, p.67-75 • Almekinders LG et al. An in vitro investigation into the effects of repetitive motion and non steroidal anti-inflammatory medication on human tendon fibroblasts. Am J Sports Med 23:119-129, 1995
Reference cont. • • •
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Dahners LE et al. The effect of a non steroidal anti-inflammatory drug on the healing of ligaments. Am J Sports Med 16:641-646, 1988 Weiler JM. Medical modifiers of sports injury. Clinics in Sports Med 11:635-644, 1992 Hackett G et al. Ligament and Tendon Relaxation treated by Prolotherapy. 5th edition, 2002. pp287-296 Yelland MJ et al. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine, Jan 2004;29(1):9-16. Dechow E et al. A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain. Rheumatology 1999;38:1255-1259 Koop CE. Prolotherapy articles. American Association of Orthopedic Medicine. URL:http://www/kalindra.com/prolotherapy.htm. Nirschl, RP,Ashman, ES, Elbow Tendinopathy: tennis elbow. Clinics in Sports Medicine 2003; 22(4):813-836. Khan, KM, Cook, B, Overuse Tendinosis, Not Tendinitis, Part1 & 2: A new Paradigm for a Difficult Clinical Problem. Physician and Sports Medicine 2000;28(5):38-48, 28(6)31-46.