الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Lateral elbow pain (LEP) or lateral epicondylitis (LE) is a non-inflammatory degenerative disease of the common extensor origin due to an overload by repetitive microtrauma resulting in a process of immature reparative response and delayed tendon healing.
Lateral epicondylitis is characterized by non-inflammatory degeneration of Extensor Carpi Radialis Brevis (ECRB) or common extensor tendon or ”angiofibroblastic hyperplasia” together with cellular apoptosis, therefore the term ”tendinosis” has been recently adopted instead of the term ”tendinitis.
Diagnosis of LE is mainly clinical. Clinical picture include lateral elbow pain that is aggravated by activities including wrist extension and gripping. Examination reveals lateral epicondyle tenderness together with pain on resisted wrist extension. Provocative tests can be of value in diagnosing LE, The standard provocative tests for LE are: Cozen’s, Mill’s and Maudsley’s tests.
Ultrasound (US) examination is an easy available, low cost, and with no risk method to study tendons. The most common findings in a patient with lateral epicondylitis are hypoechoic areas and diffuse heterogeneity (disturbed fibrillar pattern), calcifications and bone surface irregularities.
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There are numerous treatments for lateral epicondylitis and no single intervention has been proven to be the most effective.
In other words, there are wide spectrum of treatment modalities such as rest, activity adaptation, stretching exercises, using of counterforce brace, NSAID, corticosteroid injections, PRP injection, botulinum toxin injections, therapeutic US, low Level LASER Therapy (LLLT), shock wave therapy and as a last option surgical intervention. However in some cases none of these treatment modalities is highly effective. Therapeutic US has been a common treatment modality for LE. However there is a debate on its effects.
There was an adapted technique of Perineural injection therapy or Neural Prolotherapy which was first introduced in literature by Lyftogt in his 2005 Achilles tendinosis pilot study. He described injecting tender points subcutaneously along the affected tendon as a management for painful Achilles tendonitis. This is known as perineural injection therapy (PNI). This was a deviation from the traditionally described prolotherapy in which a more concentrated proliferant is injected directly into the enthesis of an affected structure.
The conditions treated with perineural injection therapy (PIT) or Neural Prolotherapy that had encouraged results are: Achilis tendon pain, knee pain, shoulder pain,
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back pain, lateral elbow pain, facial pain, meralgia parathetica and carpal tunnel syndrome.
This study was carried out to determine the effectiveness of perineural injection of dextrose 5 % buffered with sodium bicarbonate subcutaneously in treating patients with lateral elbow pain originating from lateral epicondylitis (LE) associated with structural damage of the affected CEO tendon, thus it can be used in the treatment of LE.
This study was conducted on 30 patients diagnosed with lateral epicondylitis. Patients were 27 females and 3 males, their age ranged from 21 to 62 years.
Diagnosis was based on detailed history taking and full clinical examination with particular attention to provokative tests (Cozen’s, Mill’s and Maudsley’s tests), and ultrasonography assessment of the lateral epicondyle of the elbow.
Three clinical assessments scales were used: Tenderness grading scale, VAS, Patient-rated Tennis Elbow Evaluation Questionnaire (PRTEE) and a radiological assessment which is ultrasonographic assessement.
Patients were randomized into two groups, group I (PNI group ) included 15 patients who received PIT sessions, the injection was done once weekly for 8 sessions
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with dextrose 5% (500 ml) buffered with 2.4 ml sodium bicarbonate (8.4%concentration) each injection was done subcutaneously with insulin syringe around the path of superficial cutaneous nerves at lateral epicondyle (posterior ante-brachial cutaneous nerve; branch of radial nerve and lateral ante-brachial cutaneous nerve; branch of musclo-cutaneous nerve ) with ½ to 1 ml of the solution per injection point.
group II (TUS group) included 15 patients received therapeutic US (continuous US) over the CEO, 3 sessions/ week for 12 sessions. Patients were followed up after 12 weeks of the PNI & TUS using Tenderness grading scale, visual analogue scale, PRTEE score and ultrasonographic assessement.
Our results revealed that there was a highly statistically significant difference between both groups regarding the tenderness grading scale and PRTEE score reduction (improvement) in favour of PNI group.
Also, there was a highly statistically significant difference regarding VAS score reduction (improvement) in both groups but in comparable values.
Moreover, in ultrasound evaluation, the US findings were statistically comparable in both groups after treatment. However, in PNI group, the presence of CET hypoechoic area was very highly significantly decreased (improvement) after treatment, disturbed fibrillar pattern
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was also significantly decreased after treatment, and Positive Power Doppler signal was also significantly decreased after treatment. In TUS group, the presence of CET hypoechoic area was significantly decreased after treatment. In addition, the tendon thickness was significantly diminished after treatment compared to the pre-treatment value. The findings in either groups reflect an improvement in structural damage which explains the clinical improvement both subjective and objective.
We found no significant statistical correlation between tenderness grading scale after treatment in PNI group and the hypoechoic area (as an ultrasonographic finding) after PNI treatment (P value = 0.285).
In addition, there was no significant statistical correlation between PRTEE score and hypoechoic area in the CET origin in PNI group after treatment.
On the reverse, in TUS group we found a highly significant statistical correlation between tenderness grading scale after US treatment and hypoechoic area after treatment.
Also, we found a very highly significant statistical correlation between PRTEE score and hypoechoic area after us treatment in TUS group.
So, our patients responded to treatment by PIT after failing other modalities.
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Conclusion
The present study is a trial to compare the clinical efficacy of perineural injection therapy (PNI) (neural prolotherapy) versus therapeutic ultrasound (TUS) in the treatment of Lateral epicondylitis. It compared the effectiveness of perineural injection therapy with conventional therapeutic ultrasound for LEP (LE) and found that at 12th week follow-up, both groups showed a significant improvement in clinical parameters (pain, tenderness and function) but more in PNI group than TUS group especially in decreasing the local tenderness and functional improvement. Moreover, the clinical improvement was obvious than radiological (ultrasonographic) improvement (in both groups).
The current study supports the use of perineural injection as an alternative therapy for LEP or lateral epicondylitis in preference to therapeutic ultrasound therapy. Perineural injection, as it is performed once weekly but TUS trice weekly.
Perineural injection treatment with buffered dextrose is safe, well tolerated with minimal or no side effects with low cost as well as the availability of the technique and its ability to achieve a significant reduction in pain