Tendinopathy: Tackling Troubled Tendons

Home , Bursitis, Enthesopathy, Prepatellar bursitis, Tendinopathy

Deepak Patel, MD, FAAFP, FACSM

ACTIVITY DISCLAIMER

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

1 DISCLOSURE

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Deepak Patel, MD, FAAFP, FACSM

Director of Sports Medicine, Rush Copley Family Medicine Residency Program, Aurora, Illinois; Assistant Professor, Rush Medical College, Chicago, Illinois

A past FMX presenter, Dr. Patel practices family medicine and sports medicine in Aurora and Yorkville, Illinois, and is medical director for Rush Copley Sports Medicine. His specialty topics include musculoskeletal imaging, concussions, stress fractures, osteoarthritis, joint examinations, pediatric overuse injuries, knee pain, tendonitis/tendonopathy, fractures, and exercise recommendations, as well as evidence-based medicine. He is a fellow of the American College of Sports Medicine. Since Dr. Patel also practices family medicine, he is able to deliver effective presentations to help family physicians address sports medicine and musculoskeletal complaints. He serves as chair for the 2019 AAFP Musculoskeletal and Sports Care course. Dr. Patel has found that staying current with medical advances and evidence- based medicine is the most challenging aspect of family medicine.

2 Learning Objectives

1. Use evidence-based practices to diagnose patients presenting with joint pain for tendinopathy, and assess for red flags indicating infection or other serious condition.

2. Develop an evidence-based treatment strategy for patients with tendinopathy.

3. Counsel patients diagnosed with tendinopathy on prevention and immediate self-treatment strategies.

4. Coordinate referral to physical therapy for tendinopathy.

Associated Sessions • (PBL) Tendinopathy: Tackling Troubled Tendons

3 Audience Engagement System Step 1 Step 2 Step 3

Overview •Treatments: Tendinopathy‐ •Exercises achilles, lateral • Medications, epicondylitis, patellar • Physical Therapy & modalities, • Injections (steroid, prolotherapy, PRP)

• Subacromial Deep Bursitis • Greater Trochanteric De quervains tenosynovitis

4 Tendonitis/Tendinitis

Tendonitis?

• Tendonitis: acute inflammation (days to few wks) • Tendinosis: chronic degenerative/diseased • Tendinopathy: disorder

5 Tendonitis?? Tendonitis: acute inflammation (<3 wks)

Tendinopathy: disorder Tendinosis: chronic degenerative/diseased

Tendinopathy • History: • Repetitive, overuse activity • Suspected imbalance • Exam: • Tenderness over tendon • Pain w/ resistance on tendon • Thickening (Achilles)

6 AES Polling Question 1

Tendinopathy is best diagnosed by? A. Clinical (history and exam) B. Xray C. MRI with contrast D. MRI without contrast

Tendinopathy ‐ Imaging

• Xray ‐ limited value • MRI ‐ uncertain diagnosis • Ultrasound ‐ subluxation and Doppler changes

Khan, K.; Scott, A.; Overview of overuse (chronic) tendinopathy. Uptodate Literature review current through: May 2017. | This topic last updated: Apr 04, 2017. accessed 6/8/2017

7 Lateral Epicondylitis ‐ Imaging

• ACR: chronic elbow pain: xray best 1st test (SORT: C) • Chronic epicondylitis, xray neg: • MRI w/o contrast or ultrasound (SORT: C) • ACR ‐ clinical correlation required?

National Guideline Clearinghouse (NGC). Guideline summary: ACR Appropriateness Criteria® chronic elbow pain. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2015 Jan 01. [cited 2017 May 24]. Available: https://guideline.gov

AES Polling Question 2

The most effective exercise treatment for tendinopathy is? A. Rest with immobilization B. Stretching prior to exercise/activity C. Stretching after exercise/activity D. Eccentric exercise program E. Concentric exercise program

8 Tendinopathy Treatment

• Activity modification • Avoid prolonged immobilization • Physical therapy, eccentric exercises (SORT: B) • Achilles 60‐90% cure (SORT: A)

CHILDRESS, M., BEUTLER, A. Management of Chronic Tendon Injuries. Am FamPhysician. 2013 Apr 1;87 (7):486-490 Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15;92(8):694-9.

Eccentric exercise

9 Tendinopathy Treatment

• Avoid NSAIDs and steroids (SORT: B) • Corticosteroid injections: short‐term pain benefits for subacromial, trochanteric bursitis and lateral/medial epicondylitis (SORT: B)

Platelet‐Rich Plasma Injection (PRP)

• Cochrane 2014: insufficient evidence (SORT: A) • Meta‐Analysis 2016: Ultrasound guided PRP is effective in tendinopathy (SORT: A) • Meta‐Analysis 2018 of Achilles PRP vs saline US guided + eccentric: PRP injection didn’t help (SORT: A): • Pain scores, • Tendon thickness, or • Doppler activity

Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD010071. Jane Fitzpatrick, Max Bulsara, Ming H. Zheng.; The Effectiveness of Platelet-Rich Plasma in the Treatment of Tendinopathy: A Meta-analysis of Randomized Controlled Clinical Trials Am J Sports Med June 6, 2016 ; Vol 45, Issue 1, pp. 226 - 233 doi:10.1177/0363546516643716 Zhang, Y. et al. Is Platelet-rich Plasma Injection Effective for Chronic Achilles Tendinopathy? A Meta-analysis Clinical Orthopaedics & Related Research. 476(8):1633-1641, August 2018.

10 Prolotherapy & Stem Cells

• Achilles: dextrose prolotherapy + eccentric more effective than either alone (SORT: A) • Lateral epicondyle: monthly dextrose prolotherapy better than saline (SORT: B) • Stem cells for tendinopathy: no evidence for benefit (SORT: A)

Cj Covey, C., Sineath, M., Leggit, J., Prolotherapy: Can it help your patient? J Fam Pract. 2015 December; 64 (12): 763-768 Pas HIMFL, et al. No evidence for the use of stem cell therapy for tendon disorders: a systematic review Br J Sports Med 2017;0:1–9. doi:10.1136/bjsports-2016-096794

Lateral Epicondylitis ‐ Steroid Injection

• Without injection resolves in 6‐24 months • Corticosteroid 4‐6 wks benefit • At 1 yr, no difference • Recurrence rate: injection 35‐50% vs PT 8‐29% • Muscle energy = injection at 1 yr

Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15;92(8):694-9.

11 Lateral Epicondylitis ‐ Injection

• Corticosteroid injection: standard = peppered = via iontophoresis (SORT: B) • Corticosteroid injection NOT recommended (SORT: A) • Botulinum toxin A injection, prolotherapy, PRP, or autologous blood some pain benefit (SORT: B) • Hyaluronate injection, prolotherapy, autologous blood need further study (SORT: B)

Sims SEG, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (New York, NY). 2014;9(4):419-446. Dong W, Goost H, Lin X, et al Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta‐ analysis Br J Sports Med 2016;50:900‐908. Branson R., et al., Comparison of corticosteroid, autologous blood or sclerosant injections for chronic tennis elbow. J Sci Med Sport. 2017 Jun;20(6):528‐533. doi: 10.1016/j.jsams.2016.10.010. Epub 2016 Oct 29.

Lateral Epicondylitis

• Limited benefit in pain or function (SORT: A): • Bracing • Physical Therapy • Eccentric helps but not superior to other treatment (SORT: B) • ESWT

Sims SEG, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (New York, NY). 2014;9(4):419-446. doi:10.1007/s11552-014-9642-x. Heijnders ILC, Lin CC. The effect of eccentric exercise in improving function or reducing pain in lateral epicondylitis is unclear Br J Sports Med 2015;49:1087‐1088. Ortega‐Castillo, Miguel, and Ivan Medina‐Porqueres. "Effectiveness of the eccentric exercise therapy in physically active adults with symptomatic shoulder impingement or lateral epicondylar tendinopathy: A systematic review." Journal of Science and Medicine in Sport 19.6 (2016): 438‐453.

12 Lateral Epicondylitis ‐ Treatments

• Low Level Laser Treatment: no clear benefit (SORT: A) • NO benefit of Deep Friction massage for: (SORT: A) • Lateral epicondylitis • Knee tendinitis

Sims SEG, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (New York, NY). 2014;9(4):419-446. doi:10.1007/s11552-014-9642-x. Loew LM, Brosseau L, Tugwell P, Wells GA, Welch V, Shea B, Poitras S, De Angelis G, Rahman P. Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD003528. DOI: 10.1002/14651858.CD003528.pub2.

Patellar Tendinopathy Treatment

• Activity modification (limit running, jumping) • Physical therapy: focus on eccentric exercise

Schwartz A, Watson JN, Hutchinson MR. Patellar Tendinopathy. Sports Health. 2015;7(5):415-420. doi:10.1177/1941738114568775. Brennan, David, Thomas W. Allen, and Karen Sanders. "What is the efficacy of eccentric exercises for the treatment of patellar tendonitis?." Evidence-Based Practice Vol. 20 (1) Jan 2017. van Rijn, D. et. Al. Comparison of the Effect of 5 Different Treatment Options for Managing Patellar Tendinopathy, A Secondary Analysis Clinical Journal of Sport Medicine: May 2019 - Volume 29 - Issue 3 - p 181–187 doi: 10.1097/JSM.0000000000000520

13 Patellar Tendinopathy Treatment • NO steroid injection ‐ rupture risk (SORT: C) • Surgery if refractory • Shockwave + eccentric = eccentric exercise • Platelet‐rich plasma (Leukocyte rich vs poor) vs saline= no difference • Topical glyceryl trinitrate patch didn’t help

Schwartz A, Watson JN, Hutchinson MR. Patellar Tendinopathy. Sports Health. 2015;7(5):415-420. doi:10.1177/1941738114568775. Thijs,K. et al. Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double-Blinded Randomized Study Clin J Sport Med 2017;27:89–96) Steunebrink, M., R. L. Diercks, and J. Zwerver. "Comparison of the Effect of 5 Different Treatment Options for Managing Patellar Tendinopathy: A Secondary Analysis." Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine Oct 10 (2017). Scott, Alex, et al. “Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline.” The American Journal of Sports Medicine, vol. 47, no. 7, June 2019, pp. 1654–1661, doi:10.1177/0363546519837954.

Achilles tendinopathy

• NO steroid injection‐ rupture risk (SORT: C)1 • Eccentrics 60‐90% cure (SORT: A)1 • Custom orthotics not better than sham (SORT: B)2 • Night splint not helpful (SORT: C) 3 • ECSWT=HVIGI (10 ml lidocaine, 40 ml saline)4

1. LDRESS, M., BEUTLER, A. Management of Chronic Tendon Injuries. Am Fam Physician. 2013 Apr 1;87(7):486-490 2. Munteanu SE, Scott LA, Bonanno DR, et al Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial Br J Sports Med 2015;49:989-994. 3. Wilson F, Walshe M, O’Dwyer T, et al. Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta‐analysis Br J Sports Med 2018;52:1564‐1574. 4. Wheeler, Patrick, C., Tattersall, Chloe, Novel Interventions for Recalcitrant Achilles Tendinopathy: Benefits Seen Following High-Volume Image-Guided Injection or Extracorporeal Shockwave Therapy—A Prospective Cohort Study CJSM: May 16, 2018 - Volume Publish Ahead of Print doi: 10.1097/JSM.0000000000000580

14 Kinesio Tape

• No benefit vs conventional treatment (SORT: A)

Lim ECW, et al. Kinesio taping in musculoskeletal pain and disability that lasts for more than 4 weeks: is it time to peel off the tape and throw it out with the sweat? A systematic review with meta‐analysis focused on pain and also methods of tape application Br J Sports Med 2015;49:1558–1566. doi:10.1136/bjsports‐2014‐094151

Deep Bursitis Subacromial & Trochanteric

15 Subacromial Bursitis • Subacromial impingement syndrome: bursitis, cuff tendinitis, cuff syndrome • Injury and compression within subacromial space • Repetitive overhead use, activity • Painful arc 60‐120

CHILDRESS, M., BEUTLER, A. Management of Chronic Tendon Injuries. Am Fam Physician. 2013 Apr 1;87 (7):486-490 Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15;92(8):694-9.

Subacromial Impingement/Rotator Cuff

• Rotator cuff strengthening ‐ ? Eccentric (SORT: B) • Scapular stabilization exercise provides some benefit (SORT: B) • Scapular mobilization and tape need further study (SORT: B)

Dejaco, B., Habets, B., van Loon, C. et al. Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial. Knee Surg Sports Traumatol Arthrosc (2016). Jun 28. [Epub ahead of print] doi:10.1007/s00167‐016‐4223‐x Reijneveld EAE, Noten S, Michener LA, et al Clinical outcomes of a scapular‐focused treatment in patients with subacromial pain syndrome: a systematic review Br J Sports Med 2017;51:436‐441

16 Subacromial Impingement/Rotator Cuff

• Rehab = surgical treatment, superior vs placebo (SORT: A) • Rehab first‐line treatment (SORT: A) • Mobilization/manual therapy with exercise helps some in short term (SORT: A) • Manual therapy alone without obvious benefit & needs further evidence (SORT: A)

Haik MN, Alburquerque‐Sendín F, Moreira RFC, et al Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials Br J Sports Med 2016;50:1124‐1134. Page MJ, et. Al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016 Jun 10; (6):CD012224. Epub 2016 Jun 10. Page MJ, Green S, Mrocki MA, Surace SJ, Deitch J, McBain B, Lyttle N, Buchbinder R. Electrotherapy modalities for rotator cuff disease. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD012225.

Subacromial Impingement/Rotator Cuff

• Limited evidence for microwave diathermy and transcutaneous electrical nerve stimulation (TENS) (SORT: A) • Short‐term limited benefit of low‐level laser ultrasound (SORT: A) • No benefit of Pulsed Electromagnetic Field (PEMF) (SORT: A) • No evidence for taping (SORT: A) • Acupuncture needs more study (SORT: A)

Haik MN, Alburquerque-Sendín F, Moreira RFC, et al Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials Br J Sports Med 2016;50:1124-1134. Page MJ, et. Al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016 Jun 10; (6):CD012224. Epub 2016 Jun 10. Page MJ, Green S, Mrocki MA, Surace SJ, Deitch J, McBain B, Lyttle N, Buchbinder R. Electrotherapy modalities for rotator cuff disease. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD012225.

17 Subacromial Impingement/Rotator cuff • Corticosteroid: minimal benefit and = placebo, <4 wks • BJSM Sys. Rev.: Steroid vs anesthetic limited benefit <8wks • Injection + PT > PT at 6 wks, not after • Ketorolac > triamcinolone • Cochrane: Injection= ultrasound =acupuncture =NSAIDS • Ultrasound guided=landmark injection

Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15;92(8):694-9. Cook T, Minns Lowe C, Maybury M, et al Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review Br J Sports Med 2018;52:497-504. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003;(1):CD004016.

Rotator Cuff ‐ Injection

• Minimal limited pain benefit • May accelerate tendon degeneration • “Wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient’s drive toward physical intervention, or for remuneration, rather than their utility.”

Mohamadi, A., Chan, J.J., Claessen, F.M.A.P. et al. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis Clin Orthop Relat Res (2017) 475: 232. doi:10.1007/s11999-016-5002-1

18 Subacromial decompression • Defer surgery for after conservative treatment (SORT: A) • Similar results early on • Arthroscopy better than open • Possibly some long term clinical benefit • RCT x2 : no clinical benefit

W Dong, H Goost, XB Lin, et al. Treatments for shoulder impingement syndrome a PRISMA systematic review and network meta-analysis. Medicine (Baltimore) 2015;94:1–17. Farfaras, S. et al. Subacromial Decompression in Patients with Impingement Syndrome Results in Better Clinical Outcome Compared to Physiotherapy in the Long Term. A Prospective Randomised Study Orthopaedic Journal of Sports Medicine Vol 5, Issue 3_suppl3 First published date: March-31-2017 DOI 10.1177/2325967117S00117 Beard, David J, Ahrens, Philip et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial The Lancet 2018 , Vol 391(10118), 329 – 338 Paavola Mika, Malmivaara Antti, Taimela Simo, Kanto Kari, Inkinen Jari, Kalske Juha et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial BMJ 2018; 362 :k2860

Lateral Hip

19 AES Polling Question 3

A 45‐year‐old female complains of atraumatic lateral hip pain for 2 months. The most likely diagnosis is? A. Trochanteric bursitis B. Femoral acetabulum impingement C. Hip osteoarthritis D. Gluteal tendinopathy

Greater Trochanteric Pain Syndrome (GTPS)

• Trochanteric bursitis (acute, rare) • Gluteus medius tendinopathy • Gluteus minimus tendinopathy

20 GTPS History

• Lateral hip pain • Increased with sitting • Pain rolling or laying on affected side • May radiate to gluteal or lateral thigh region • Due to prolonged hip adduction positioning, pelvic tilt

Wilson J., Furukawa M., Evaluation of the patient with hip pain. Am Fam Physician. 2014 Jan 1;89(1):27-34. Grimaldi A., et. Al . Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Sports Med. 2015 Aug;45(8):1107-19. doi: 10.1007/s40279-015-0336-5

GTPS Treatment

• Eliminate/reduced iliotibial band/gluteal tension • Analgesics • Stretching, strengthening

Barratt, P. et. Al. Conservative treatments for greater trochanteric pain syndrome: a systematic review Br J Sports Med bjsports-2015-095858Published Online First: 10 November 2016 doi:10.1136/bjsports-2015-095858

21 GTPS Treatment

• Fluoroscopy‐guided injection = landmark (SORT: B) • Short‐term (<3 month) benefit • Radial Shock Wave Therapy (RSWT) ‐ little evidence (SORT: B) • Insoles ‐ little evidence (SORT: B)

Tendinopathy Prevention • Very limited data • Balance training limited evidence for patellar/Achilles tendinopathy • Shock absorbing insoles could for Achilles • HRT reduces structural Achilles tendon changes in active post‐ menopausal • Stretching exercises no evidence • Prophylactic eccentric training & stretching can increase the risk of injury in asymptomatic patellar tendon abnormalities • Strength training‐ acute and overuse prevention

Peters, J., et al., Preventive interventions for tendinopathy: A systematic review, J Sci and Medicine in Sport, Vol 19, (3), 2016, p205‐211, ISSN 1440‐ 2440, https://doi.org/10.1016/j.jsams.2015.03.008. Lauersen JB, Andersen TE, Andersen LB Strength training as superior, dose‐dependent and safe prevention of acute and overuse sports injuries: a systematic review, qualitative analysis and meta‐analysis Br J Sports Med 2018;52:1557‐1563.

22 De Quervain’s Tenosynovitis

De Quervain’s Tenosynovitis • Repetitive stress (radial deviation) • Tenosynovitis/tendinosis of extensor pollicis brevis & abductor pollicis longus tendons • Pain/swelling to proximal thumb/distal radius • Pain w/ radial/ulnar wrist deviation & active thumb ext. & abd.

23 De Quervain’s Tenosynovitis Treatment

• Rest (immobilization) • NSAIDs • Brace • O.T./home rehab • Steroid injection • Cochrane: injection better than bracing (SORT: A) • Alone better than injection + splint • Effective early treatment (SORT: B)

Peters‐Veluthamaningal C, van der Windt DAWM, Winters JC, Meyboom‐de Jong B. Corticosteroid injection for de Quervain's tenosynovitis. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005616. DOI: 10.1002/14651858.CD005616.pub2. Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15;92(8):694-9.

Practice Recommendations

• Avoid widespread use of NSAIDs for treatment of chronic tendinopathy (SORT: B) • Reserve corticosteroid injections for when needed for short‐term pain benefits for subacromial bursitis, greater trochanteric pain syndrome, lateral epicondylitis and subacromial impingement/rotator cuff tendinopathy (SORT: B) • Encourage eccentric exercises for treatment of chronic tendinopathy (SORT: B) • Perform corticosteroid injection early or carpal tunnel syndrome & De quervain’s (SORT:B)

CHILDRE SS, M., BEUTLER, A. Management of Chronic Tendon Injuries. Am Fam Physician. 2013 Apr 1;87(7):486-490 Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15;92(8):694-9. http://www.aafp.org/afp/2015/1015/p694.html

24 Questions

Thanks!

[email protected]

www.rushcopley.com/dpatel

25 Resources/links

• AAFP: Superficial bursitis: http://www.aafp.org/afp/2017/0215/p224‐s1.html • AAFP: Chronic tendon injury: http://www.aafp.org/afp/2015/1015/p694.html • AAFP: MSK injections: http://www.aafp.org/afp/2015/1015/p694.html

• NIH: bursitis/tendonitis: https://www.niams.nih.gov/health_info/Bursitis/

Bursitis Billing/Coding ICD10 M70.2‐ Olecranon bursitis M70.4‐ Prepatellar bursitis M70.5‐ Other bursitis of knee M70.6‐ Trochanteric bursitis M71.1‐‐ Other infective bursitis M71.5‐‐ Other bursitis, not elsewhere classified M71.9 Bursopathy, unspecified M75.5‐ Bursitis of shoulder

26 Tendinitis Billing/Coding ICD10 M75.5‐ Bursitis of shoulder M76.‐‐‐ Enthesopathies, lower limb, excluding foot M76.0‐ Gluteal tendinitis M76.5‐ Patellar tendinitis M76.6‐ Achilles tendinitis

M76.8‐‐ Other specified enthesopathies of lower limb, excluding foot M76.9 Unspecified enthesopathy, lower limb, excluding foot M77.‐‐ Other enthesopathies M77.0‐ Medial epicondylitis M77.1‐ Lateral epicondylitis

Billing/Coding CPT

20600 Arthorcentesis, aspiration and/or injection, small joint or bursa 20604 w/ ultrasound guidance, with permanent recording and reporting

Arthorcentesis, aspiration and/or injection, intermediate joint or 20605 bursa 20606 w/ ultrasound guidance, with permanent recording and reporting 20610 Arthorcentesis, aspiration and/or injection, major joint or bursa 20611 w/ ultrasound guidance, with permanent recording and reporting

27 References • Cj Covey, C., Sineath, M., Leggit, J., Prolotherapy: Can it help your patient? J Fam Pract. 2015 December; 64 (12): 763-768 • Khan, K.; Scott, A.; Overview of overuse (chronic) tendinopathy. Uptodate Literature review current through: May 2017. | This topic last updated: Apr 04, 2017. accessed 6/8/2017 • Thijs,K. et al. Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double‐ Blinded Randomized Study Clin J Sport Med 2017;27:89–96) • Mohamadi, A., Chan, J.J., Claessen, F.M.A.P. et al. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis Clin Orthop Relat Res (2017) 475: 232. doi:10.1007/s11999-016-5002-1 • Peters‐Veluthamaningal C, van der Windt DA, Winters JC, et al. Corticosteroid injection for de Quervain’s tenosynovitis. Cochrane Database Syst Rev. 2009;(3):CD005616. • Schwieterman B, Haas D, Columber K, Knupp D, Cook C. Diagnostic Accuracy Of Physical Examination Tests Of The Ankle/Foot Complex: A Systematic Review. International Journal Of Sports Physical Therapy. 2013;8(4):416-426. • Jane Fitzpatrick, Max Bulsara, Ming H. Zheng.; The Effectiveness of Platelet‐Rich Plasma in the Treatment of Tendinopathy: A Meta‐analysis of Randomized Controlled Clinical Trials Am J Sports Med June 6, 2016 ; doi:10.1177/0363546516643716 • Dejaco, B., Habets, B., van Loon, C. et al. Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial • Knee Surg Sports Traumatol Arthrosc (2016). Jun 28. [Epub ahead of print] doi:10.1007/s00167‐016‐4223‐x • Heijnders ILC, Lin CC. The effect of eccentric exercise in improving function or reducing pain in lateral epicondylitis is unclear Br J Sports Med 2015;49:1087‐1088.

References • Ortega-Castillo, Miguel, and Ivan Medina-Porqueres. "Effectiveness of the eccentric exercise therapy in physically active adults with symptomatic shoulder impingement or lateral epicondylar tendinopathy: A systematic review." Journal of Science and Medicine in Sport 19.6 (2016): 438-453 • Barratt, P. et. Al. Conservative treatments for greater trochanteric pain syndrome: a systematic review Br J Sports Med bjsports- 2015-095858Published Online First: 10 November 2016 doi:10.1136/bjsports-2015-095858 • Wilson J., Furukawa M., Evaluation of the patient with hip pain. Am Fam Physician. 2014 Jan 1;89(1):27-34. • Grimaldi A, et. Al. Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. Br J Sports Med. 2016 Sep 15. pii: bjsports-2016-096175. doi: 10.1136/bjsports-2016-096175. [Epub ahead of print] • Grimaldi A., et. Al . Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Sports Med. 2015 Aug;45(8):1107-19. doi: 10.1007/s40279-015-0336-5 • Farfaras, S. et al. Subacromial Decompression in Patients with Impingement Syndrome Results in Better Clinical Outcome Compared to Physiotherapy in the Long Term. A Prospective Randomised Study Orthopaedic Journal of Sports Medicine Vol 5, Issue 3_suppl3 First published date: March-31-2017 DOI 10.1177/2325967117S00117 • Paavola M, Malmivaara A, Taimela S on behalf of the FIMPACT Investigators, et al Finnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT): a protocol for a randomised trial comparing arthroscopic subacromial decompression and diagnostic arthroscopy (placebo control), with an exercise therapy control, in the treatment of shoulder impingement syndrome BMJ Open 2017;7:e014087. doi: 10.1136/bmjopen-2016-014087 • Haik MN, Alburquerque-Sendín F, Moreira RFC, et al Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials Br J Sports Med 2016;50:1124-1134.

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