Published studies on injection treatments for patellar tendinopathy
| Authors | Intervention treatment (per group) | Study type | Number of subjects (total/study group, sex) | Subject characteristics (age, symptoms duration) | Previous therapy | Concurrent treatment | Follow-up | Outcome measures | Results | Authors' conclusion | Delphi score (x/9)/NOS score (x/9) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Fredberg et al23 | 1: 2–3× USG 3.5 ml of 10 mg/ml lidocaine and 0.5 ml kenalog containing 20 mg triamcinolone to paratenon as near damaged area as possible, one injection longitudinally to both sides. 2: placebo: 3.5 ml of 1% lidocaine and 0.5 ml of 20% intralipid (crossover after 4 wk) | RCT | 24/12 (+12), 18♂/6♀ | 28.4 (18–47) yr, 21.5 mo, athletes | Failed conservative treatment (referred to surgery) | Graduated training including training and stretching thigh muscles | 1, 3, 4 wk, 6 mo | Pressure pain threshold, tendon diameter, walking pain, Blazina stages | All improved, especially in the short term. Pressure pain only significant improvement after 3 wk (p=0.02). Walking pain 2.9, 1.7 (1 wk), 1.3 (4 wk), 2.4 (6 mo) significantly different (p=0.02) with placebo (=4 wk). Blazina stages better after 3 mo than 6 mo | Can normalise US pathological lesions, has dramatic clinical effect but with aggressive rehabilitation, many relapse within 6 mo | 6/NA |
| Kongsgaard et al24 | 1: 2× USG 1 ml of 40 mg/ml methylprednisol in 0.5 ml of lidocaine injection to peritendinous tissue posterior to hypoechoic area. 2: eccentric training. 3: heavy slow resistance training | RCT | 37/(12/12/13) (11 bilateral), all ♂ | 32.4 (18–53) yr (total), 18.7 (3–36) mo, (1) CG: 34.3 (25–53) yr, 18.3 (4–36) mo, recreational athletes | 4-week ‘wash-out’ period (no treatment) | Refrain from training and sporting activities 1st wk | 12 wk (end intervention), 6 mo | VISA-P, VAS pain during activities, satisfaction, biopsies, US characteristics, mechanical properties | Baseline VISA-P 1: 64, 2: 53, 3: 56, 12 wk VISA-P 1: 82, 2: 75, 3: 78, ½ yr VISA-P 1: 64, 2: 76, 3: 86, 3 seems best, see article for other outcome measures. After 12 wk all significant. After ½ yr 2/3 unchanged, 1 decreased | 1: Good short-term, poor long-term clinical effects. 2 + 3: good short and long term (especially 3) | 5/NA |
| Capasso et al25 | 1: 62 500 units aprotinin and 2.5 ml of 1% lignocaine. 2: 40 mg methylprednisolone acetate and 2.5 ml of 1% lignocaine injection.3: 5 ml of 0.9% NaCl. Paratenon (in bursa or near tendinous insertion). 2–4 (every 2nd wk) | RCT | 116/(38/39) (5 bilateral) (95 attended final follow-up), 76♂, 40♀ | 24.4 (17–44) yr, ? duration, athletes | 25 steroid injection, 91 no previous treatment | Active rest (cycling, gentle jogging, swimming and stretching exercises) | 1, 12 mo | Poor, fair, good or excellent (symptoms + sport resumption) | 1: 72% good/excellent, 7% poor. 2: 59% good/excellent, 12% poor. 3: 28% good/excellent, 25% poor. Significant different groups: 1 better than 2 and 3 and 2 better than 3 | Aprotinin may have lasting beneficial effect. Further evidence needed | 5/NA |
| Hoksrud et al29 | 1: sclerosis max 6× USG max. 2 ml per knee, 10 mg/ml polidocanol injection to paratenon in neovascular area until all vessels closed. 2: placebo = lidocaine with epinephrine(4 mo crossover) max 3 sclerosing injections | RCT | 33/17 (10 bilateral), 3♀/2♀ | Sclerosis treatment: 25.4 (17–42) yr, 41 ± 37 (4–240) mo, CG: 24.3 (17–35) yr, 33 ± 43 (6–180) mo elite athletes | ? | 2nd wk light sport-specific training. After 2 wk all training allowed as pain permits | 4, 8, 12 mo | VISA-P, overall satisfaction (VAS) | Baseline VISA-P: 54, 8 mo follow-up: 75 12 mo follow-up: 77 (p<0.001) VAS ± 8 after 12 mo. Significantly improved sclerosis vs no significant difference CG (4 mo) | Significant improvement in knee function and reduced pain. Further evidence needed | 8/NA |
| Alfredson and Ohberg28 | Sclerosis 1–5× mean 3 USG 1–2 ml of 5 mg/ml polidocanol injection to paratenon in neovascular area of vessels entering tendon dorsally | NR prospective cohort study | 15/15, 12♂/3♀ | 29 (18–46) yr, 23 (6–84) mo, elite/recreational athletes | Cortisone injection 3, NSAIDs 13, rest 15 | 2 wk increasing training. Sports allowed again after 2 wk | 6 mo | Neovascular stage, VAS pain during activity | 12 of 15 satisfied. Baseline VAS: 81, 6 mo follow-up 19.4 | Potential curing tendon pain. Further evidence needed | 2/5 |
| Orchard et al31 | No USG 3 ml Trasylol with 30 000 KIU (4.2 mg) aprotinin combined with 2 ml lignocaine 2% (local anaesthetic) injection, peritendinous rather than intratendinous | Retrospective cohort study | 94/94 patientsn = 438 different tendinopathy (95 bilateral) | 29.8 yr, 14.9 mo, patients | ? | 11.7 mo (3–23) | Questionnaire, patients' impression of treatment, from completely cured to much worse | 7% completely cured, 34% much better, 31% slightly better, 28% similar, 3% slightly worse. Treatment cured? Sure better 31%, think better 34%, unsure 34% | Aprotinin is more appropriate 2nd-line injection option than steroids | 1/2 | |
| Volpi et al33 | 1× USG (3 ml) PRP (anticoagulant 1:10, 50–150 μl NaHCO3 solution (for pH)) intratendon injection 5–8× within affected tissue | NR prospective cohort study | 8/8 (3 bilateral), 7♂/1♀ | 26.6 (21–41) yr, >12 mo, 6 high-level, 2 amateur athletes | Recalcitrant to various treatments | Individual training programme, increasing from 5 wk eccentric and concentric strengthening. Start full sport >12 wk | 17 wk (1, 4, 8½ wk clinical evaluation) | VISA-P (MRI for visualisation) | Baseline VISA-P: 39.25. Follow-up: 75 | Suggest PRP may be valid therapeutic option (for recalcitrant patients). Further evidence needed | 2/3 |
| Kon et al34 | 3× non-USG (5 ml) PRP (±6.8 million platelets) intratendon injection 10% CaCl added for activation 4–6× | NR prospective cohort study | 20/20 (13 bilateral), ♂ | 25.5 (18–47) yr, 20.7 (3–60) mo, highly competitive non-professional athletes | Recalcitrant to various treatments | Stretching and light activities. Strengthening programme. Start sport gradually after 1 mo | EoT and 6 mo | Tegner, EQ-VAS and SF-36 (MRI or US) | Significant improvement on all scores | Safe method, encouraging results, aids regeneration. Further evidence needed | 2/4 |
| Filardo et al35 | 1: 3× non-USG (5 ml) PRP (±6.8 million platelets) intratendon injection 10% CaCl added for activation 4–6×. 2: no injection | Non-RCT | 31/15,♂ | TG: 28.8±8.5 yr, ±19.9 mo, CG: 25.5±9.2 yr, 8.4±4.1 mo, patients | TG: recalcitrant to various treatments, CG: no previous treatment | Stretching and light activities. Strengthening programme. Start sport gradually after 1 mo | EoT and 6 mo | Tegner, EQ-VAS, pain level, complications, functional recovery and patient satisfaction | Baseline EQ-VAS: 52.7 Follow-up (EoT): 68.0, follow-up (6 mo): 78.3. Baseline pain level: 6.6. Follow-up EoT: 4.3. Follow-up (6 mo): 3.1 Baseline Tegner: 3.7, 6 mo: 6.6. Only Tegner significantly different between TG and CG (p=0.048) | Encouraging, can be useful for treatment even when previous physical therapy had failed | 2/6 |
| James et al40 | 2× USG 3 ml autologous blood injection to intratendon proximal to area of interstitial tears + 1 min dry needling | NR prospective cohort study | 44/44 (3 bilateral), 40♂/7♀ | 34.5 (17–54) yr, 12.9 (1–48) mo, patients | ? | Standardised physical therapy programme | 14.8 mo (6–22) | VISA-P and sonographic assessment | Baseline VISA-P: 39.8. Follow-up: 74.3 (p<0.001) US: 22× reduced thickness and focal alteration. Still neovascularisation 23×, 9 same, 5 less, more florid 9 | Treatment shows promise for patients with patellar tendinosis. Further evidence needed | 2/4 |
| Crisp et al41 | (High volume) 1× USG 10 ml bupivacaine 0.5%, 25 mg hydrocortisone and 12–40 ml normal saline injection at interface between tendon and Hoffa's body adjacent to area of neovascularisation | NR retrospective cohort study | 9/9 | 29.2 (18–45) yr, >3 mo, professional and recreational athletes | Eccentric rehabilitation | Eccentric loading programme after 3–4 days rest | 2 wk, 9 mo | VISA-P four sections of questions including VAS | Baseline VISA-P: 46, 9 mo: 68 (p=0.028). Baseline VAS pain: 87, 2 wk 31 (p=0.018)Baseline VAS function: 94, 2 wk 36 (2 wk) (p=0.018) | Helpful to manage condition, further evidence needed | 2/4 |
CG, control group; EoT, end of therapy; mo, months; NA, not applicable; NR, non-randomised; RCT, randomised controlled trial; TG, training group; US, ultrasound; USG, ultrasound-guided; wk, weeks; yr, years.