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Treatment of chronic lateral epicondylosis: a randomized trial comparing the efficacy of ultrasound-guided tendon dry needling and open-release surgery

  • Musculoskeletal
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objective

Evaluate the efficacy of ultrasound-guided dry needling and open-release surgery in reducing pain and improving function in workers with lateral epicondylosis refractory to at least 6 months of nonsurgical management.

Methods

We randomly assigned participants in a 1:1 ratio to receive dry needling or surgery. The primary outcome was the Patient Rated Tennis Elbow Evaluation (PRTEE) score at 6 months. Secondary outcome measures examined the impact of these techniques on professional activity, grip strength, and Global Rating of Change and Satisfaction scales. Statistical analyses included mixed-effects models and Fisher’s exact tests.

Results

From October 2016 through June 2019, we enrolled 64 participants. Two participants were excluded, and data from 62 participants (48 ± 8 years, 33 men) with a mean duration of symptoms of 23 ± 21 months were analyzed. Baseline characteristics were similar in both groups. In the intention-to-treat analysis, no treatment-by-time interaction was observed (F(4,201) = 0.72; p = .58). The least-squares mean difference from baseline in PRTEE scores at 6 months was 33.4 (CI 25.2 – 41.5) in the surgery group and 26.9 (CI 19.4 – 34.4) in the dry needling group (p = .25). The proportion of successful treatment was 83% (CI 63 – 95%) and 81% (CI 63 – 93%) in the surgery and dry needling groups, respectively (p = 1.00). Changes in secondary outcomes were in the same direction as those of the primary outcome. No adverse event occurred.

Conclusions

Ultrasound-guided dry needling resulted in comparable improvement in outcome scores on scales of pain, physical function, and global assessment of change and satisfaction than open-release surgery.

Trial registration

ClinicalTrials.gov Identifier: NCT02710682

Key Points

• In patients with chronic lateral epicondylosis, ultrasound-guided tendon dry needling provides comparable therapeutic efficacy to open-release surgery.

• Ultrasound-guided tendon dry needling allows for an earlier return to work and may be less costly than open-release surgery.

• Care management guidelines should recommend treatment by ultrasound-guided tendon dry needling before open-release surgery.

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Abbreviations

CI:

95% confidence interval

GEE:

Generalized Equation Estimation model

IT:

Intention to treat

PP:

Per protocol

PRP:

Platelet-rich plasma

PRTEE:

Patient Rated Tennis Elbow Evaluation

QuickDASH:

Disabilities of the Arm, Shoulder, and Hand

RA-WIS:

Work Instability Scale for Rheumatoid Arthritis

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Acknowledgements

The authors would like to thank Siemens Healthcare Limited for the loan of the ACUSON S3000 ultrasound machine for the duration of this project.

We thank The University of Leeds for granting us permission to use the Leeds Rheumatoid Arthritis Work Instability Scale (RA-WIS) in this trial.

Funding

This study has received funding from the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (#2015-0034).

Nathalie J Bureau is supported by a research scholarship from the Fonds de Recherche du Québec – Santé (FRQ-S) and the Fondation de l’Association des Radiologistes du Québec (FRQS-ARQ 266408).

Author information

Authors and Affiliations

  1. Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), 1000 rue Saint-Denis, Montreal, Quebec, H2X 0C1, Canada

    Nathalie J Bureau & Véronique Freire

  2. Research Center, Centre hospitalier de l’Université de Montréal (CHUM), 900 rue Saint-Denis, Montreal, Quebec, H2X 0A9, Canada

    Nathalie J Bureau, Guy Cloutier & Manon Choinière

  3. Department of Orthopedics, Centre hospitalier de l’Université de Montréal (CHUM), 1000 rue Saint-Denis, Montreal, Quebec, H2X 0C1, Canada

    Patrice Tétreault & Philippe Grondin

  4. Research Center, Hôpital Maisonneuve-Rosemont (HMR), 5415 Blvd L’Assomption, Montreal, Quebec, H1T 2M4, Canada

    François Desmeules

  5. Department of Mathematics and Statistic, Université Laval, 1045 avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada

    Anne-Sophie Julien

  6. Department of Anesthesiology and Pain Medicine, Université de Montréal, C.P. 6128, succursale Centre-ville, Montreal, Quebec, H3C 3J7, Canada

    Manon Choinière

Authors
  1. Nathalie J Bureau
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  2. Patrice Tétreault
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  3. Philippe Grondin
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  4. Véronique Freire
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  5. François Desmeules
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  7. Anne-Sophie Julien
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Corresponding author

Correspondence to Nathalie J Bureau.

Ethics declarations

Guarantor

The scientific guarantor of this publication is Nathalie J Bureau.

Conflict of interest

The authors of this manuscript declare relationships with the following companies: Siemens Healthcare Limited.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• prospective

• randomized controlled trial

• performed at one institution

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Supplementary information

ESM 1

(DOCX 22 kb)

ESM 2

Pain-free grip strength ratio scores over the 12-month follow-up period. (Intention-to-treat analysis) Pain-free grip strength: ratio (symptomatic side / asymptomatic side x 100). The values in parentheses are 95% confidence intervals (also indicated by the bars). All available visits were considered in the linear mixed models. The between-group differences at each time point were not significant (p > 0.05). (JPEG 153 kb)

ESM 3

Shortened version of the Disabilities of the Arm, Shoulder, and Hand (11-item QuickDASH) total scores over the 12-month follow-up period. (Intention-to-treat analysis) QuickDASH total scores range from 0 to 100, with higher scores indicating higher level of disability. The values in parentheses are 95% confidence intervals (also indicated by the bars). All available visits were considered in the linear mixed models. The between-group differences at each time point were not significant (p > 0.05). (JPEG 172 kb)

ESM 4

Work Instability Scale for Rheumatoid Arthritis (RA-WIS) scores over the 12-month follow-up period. (Intention-to-treat analysis) RA-WIS scores range from 0 to 23, with the following work instability severity categories: low < 10; moderate 10 - 17; severe >17. The values in parentheses are 95% confidence intervals (also indicated by the bars). All available visits were considered in the linear mixed models. The between-group differences at each time point were not significant (p > 0.05). (JPEG 164 kb)

ESM 5

Medication Quantification Scale (MQS) scores over the 12-month follow-up period. (Intention-to-treat analysis) MQS scores range from 0 with no upper limit. A higher score indicates a greater medication regimen. No baseline values were recorded for the MQS score. The values in parentheses are 95% confidence intervals (also indicated by the bars). All available visits were considered in the linear mixed models. The between-group differences at each time point were not significant (p > 0.05). (JPEG 151 kb)

ESM 6

Ultrasound-guided tendon dry needling of the right elbow in a 45-year-old man with chronic lateral epicondylosis. The video clip demonstrates ultrasound-guided dry needling of the conjoint extensor tendon. A 22G needle is passed multiple times along the long axis of the tendon to obtain softening of the area of tendinosis. The needle is redirected to cover the affected tendon area and abrade the underlying cortex without exiting the tendon. (MP4 2680 kb)

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Bureau, N.J., Tétreault, P., Grondin, P. et al. Treatment of chronic lateral epicondylosis: a randomized trial comparing the efficacy of ultrasound-guided tendon dry needling and open-release surgery. Eur Radiol 32, 7612–7622 (2022). https://doi.org/10.1007/s00330-022-08794-4

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