Ultrasound-Guided Needle Therapy Effective for Tennis Elbow
This is an excellent article and strongly supports what I talk about in my office. For everyone out there who thinks steroid injections are a useful procedure, think again. Articles in the past have supported the concept that it is not the steroid that heals (quite the contrary–it inhibits the formation of collagen crosslinks, resulting in weaker connective tissues!), but rather the damage created by the needle that produces injury and bleeding that promotes the healing. This is right in line with many manual therapies that I use in my office–ligaments and tendons are actually injured in the therapy process, resulting in an inflammatory response that heals the lesion.
RSNA 88th Scientific Assembly: Abstract 1449. Presented Dec. 5, 2002.
A new minimally invasive treatment that combines the skills of a radiologist and a sports medicine physician effectively reduced pain and restored function in 65% of patients with a range of injuries, from tennis elbow to jumper knee, according to Levon N. Nazarian, MD, professor of radiology at Jefferson Medical College, Thomas Jefferson University, in Philadelphia, Pennsylvania.For years, sports medicine specialists have been injecting injured elbows and knees with either anesthetics or corticosteroids to treat minor tears, said Dr. Nazarian, “but we are combining ultrasound with needle therapy so that the needle is carefully guided to the point of injury.” He presented the study here at the 88th Scientific Assembly and Annual Meeting of the Radiological Society of North America.While standard “needle therapy” either draws fluid out of a joint or injects something into the injured joint, the ultrasound-guided needle therapy allows the sports medicine specialist to use the needle as a very tiny surgical instrument “to either break up scars or poke holes in an injured ligament so that bleeding occurs. The blood cells carry precursors to collagen, which eventually develops into collagen to replace the damaged tissue,” Dr. Nazarian said.All patients are initially injected with an anesthetic into the injured area. “This serves as a useful test to determine if the pathology visualized on ultrasound is the actual cause of the patient’s pain. If the pain disappears after anesthesia we know we are on the right track,” said Dr. Nazarian. But once the anesthesia is injected, the patient may be treated with just “needle surgery” or may receive corticosteroid injections or additional anesthesia. “The advantage to this procedure is that it is so minimally invasive that restoration of function is very rapid, much more so than even arthroscopic surgery,” said Dr. Nazarian. This offers a surgical option for patients who have “tears or abnormalities that are so small that they cannot be fixed by surgeons and yet they are not responding to conservative treatment of rest, ice, and support.” So far, Dr. Nazarian has accumulated more than 300 patients in his series, but he presented data on 273 patients who ranged in age from 13 to 82 years (mean age, 39.8 years). About half of the patients were men and all of the patients had failed conservative management. Patients were treated from December 1999 through January 2002 and all received ultrasound-guided needle therapy using a phased array linear transducer (7.5 MHz to 13 MHz).Two hundred forty-six patients underwent ultrasound-guided corticosteroid injection combined with needle debridement. The range of pathology treated included tendonopathy, tendon tear, muscle tear, bursitis, tenosynovitis, ligamentous injury, and plantar fasciitis. The most common anatomic areas were the common extensor tendon at the lateral elbow and the patellar tendon. The remaining 27 patients were treated with needle debridement without corticosteroid injection.The average procedure time was one hour. Patients were instructed to perform only light stretching for the first two weeks, strengthening exercises from weeks 2 to 6, and then a gradual return to higher-level activities. Symptom relieft was reported by 65% of patients within 2 to 12 weeks, while 35% were unchanged. “But these patients still had all options open to them. Since we didn’t treat with traditional surgery, no bridges were burned,” Dr. Nazarian said. Moreover, even patients who did not improve didn’t have worsening of symptoms. There were no complications from bleeding, infections, or the procedure itself.According to Michael A. Sullivan, MD, associate chairman of the department of radiology at Ochsner Clinic Foundation in New Orleans, Louisiana, using ultrasound to guide needle therapy is a major advance. “For years people have been injecting joints blindly: if it hurts here, inject here. That can be successful, but it can also cause more harm than good. This is really a logical way to improve that approach.”