Injection of Botulinum Toxin for Treatment of Chronic Lateral Epicondylitis: Systematic Review and Meta-Analysis

doi:10.1016/j.semarthrit.2010.07.002

Seminars in Arthritis and Rheumatism

Volume 40, Issue 6, June 2011, Pages 532-538

https://doi.org/10.1016/j.semarthrit.2010.07.002 Get rights and content

Objectives

Lateral epicondylitis can be chronic and difficult to manage with conservative measures such as physical therapy and corticosteroid injection. We attempted to determine the efficacy of botulinum toxin for the treatment of chronic lateral epicondylitis.

Methods

We searched PubMed, MEDLINE, CINAHL, Google Scholar, EMBASE, PEDro, and ISI web of Science databases from inception until November 2009. Studies were included if they used any formulation of botulinum toxin A for treatment of chronic lateral epicondylitis and reported at least 1 pain outcome. One author extracted the relevant data using a standardized data extraction sheet and a second author checked the data. We performed a meta-analysis by computing effect sizes for each study separately for pain and grip strength at 3 months after injection. Impact of bias was assessed independently by 2 authors.

Results

The search found 10 studies relevant to the question. Four of these were randomized controlled trials that could be pooled in a meta-analysis. Results showed a moderate effect for pain favoring botulinum toxin (effect size −0.5, 95% CI −0.9, −0.1, I² = 56%) at 3 months and a no effect for grip strength. Qualitative analysis of the studies that could not be pooled also showed improvement in pain, but was limited by potential bias.

Conclusions

Present literature provides support for use of botulinum toxin A injections into the forearm extensor muscles (60 units) for treatment of chronic treatment-resistant lateral epicondylitis. It is minimally invasive and can be performed in an outpatient setting.

Section snippets

Search Strategy

PubMed, MEDLINE, CINAHL, Google Scholar, EMBASE, PEDro, and ISI web of Science databases were searched from inception until November 2009 for the key words “elbow,” “lateral,” “epicondylitis,” “tennis elbow,” “epicondylalgia,” “treatment,” “injections,” “Botox,” “Dysport,” and “botulinum.” The titles and abstracts of all articles were reviewed. The search was initially run by 1 reviewer (L.K.) and then it was repeated by 2 reviewers (R.B. and W.H.). The last full search was run on November 3,

Trials

Our search yielded 874 articles. An additional newly published study was identified by hand search after the initial submission of this article. After review of the title and abstracts, 19 references considered as potentially relevant were reviewed in full. After full review, 9 articles were excluded since they were not relevant to the study question. Several articles did not include sufficient data for pooling. One author provided additional data not available in the article, but used surgery

Discussion

This systematic review and meta-analysis identified 10 studies evaluating botulinum for treatment of chronic lateral epicondylitis. The highest level evidence (the RCTs) shows a moderate benefit for botulinum toxin A injection for pain at 3 months in patients with chronic lateral epicondylitis that was resistant to other conventional therapies. Generally effect sizes of 0.2 are considered small; 0.5 are considered medium, and ≥0.8 are considered large (30). Given the lack of very effective

Conclusions

Present literature provides support for use of botulinum toxin A injections into the forearm extensor muscles (60 units Disport or equivalent) for the treatment of chronic treatment-resistant lateral epicondylitis.

Acknowledgments

We are grateful to Usha M Sudireddy for her help in translating the German into English and to Chenchen Wang and Ling Li for translating the Chinese into English.

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Cited by (41)

Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review
2023, Journal of Chiropractic Medicine
The primary objective of this review was to summarize systematic reviews and meta-analyses reporting on nonoperative management of lateral epicondyle tendinopathy.
An umbrella review of all published systematic reviews and meta-analyses was performed. Three databases were searched using the key words “tennis elbow,” “lateral epicondylitis,” “non-operative,” and “non-surgical modalities.” The search was limited to English-language systematic reviews and meta-analyses between the years of 2000 and 2022.
There were 114 systematic reviews/meta-analyses, of which 35 met our inclusion criteria. These articles reviewed the following nonoperative management strategies: ultrasound, shockwave therapy, injection procedures, low-level laser therapy, joint mobilizations, exercise therapy, and electrophysical modalities. Exercise therapy was beneficial in decreasing pain regardless of dosage or type. Conflicting results were seen with ultrasound, laser, and shockwave therapy. Corticosteroid injections provided the most short-term pain relief, and platelet-rich plasma and autologous blood injections were most effective in the long term.
A variety of nonoperative interventions were found to be effective for short- and long-term pain relief as well as functional improvement, with most interventions indicating mixed results. Due to variations in study populations and study quality, results should be interpreted with caution.
Effectiveness of different doses of botulinum neurotoxin in lateral epicondylalgia: A network meta-analysis
2023, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
First, we were the first team to conduct a network meta-analysis focusing on BoNT for the treatment of lateral epicondylalgia. This means that our study may provide more information through the additional comparisons, larger data set analyzed, and the bigger picture [32] as compared with simpler pairwise meta-analysis [8,33]. Second, our study revealed a significant dose–response relationship of BoNT in alleviating pain related to lateral epicondylalgia and that a single injection of high-dose BoNT may be as effective as corticosteroid for up to 11 to 14 weeks.
Previous studies have investigated the role of botulinum neurotoxin (BoNT) in lateral epicondylalgia, with controversial results. We hypothesized that BoNT would be effective and safe for the treatment of lateral epicondylalgia.
To investigate the effectiveness and safety of different doses of BoNT in participants with lateral epicondylalgia.
PubMed, Embase, and Cochrane Library were searched up to August 27, 2022, for randomized controlled trials (RCTs) of BoNT treatment for epicondylalgia. The Cochrane risk of bias tool was used for quality assessment. A network meta-analysis and a trial sequential analysis (TSA) were conducted on pain, grip strength and adverse events. Meta-regression was applied for high heterogeneity comparisons.
We included 8 RCTs consisting of 448 participants. Four studies scored low risk of bias in all categories, whereas the other 4 studies had unclear risk only in the selection bias category. The network meta-analysis and TSA revealed that corticosteroid (standardized mean difference [SMD]: −1.32, 95% CI: −2.13; −0.50), high-dose BoNT (SMD −1.32, −2.04; −0.61), and low-dose BoNT (SMD –0.52, −0.93; −0.10), relieved pain significantly better than placebo for up to 7 to 10 weeks. High-dose BoNT demonstrated a significantly greater reduction in pain than low-dose BoNT for up to 7 to 10 weeks (SMD −0.81, –1.39; −0.22). Finally, after low-dose BoNT, younger participants (p = 0.023) and women (p = 0.012) showed more pain decrease than older individuals and men at 2 to 6 weeks. As for grip strength and adverse events, only grip strength after low-dose BoNT versus placebo (SMD −0.49, −0.88; −0.10) and corticosteroid (SMD −1.36, −2.15; −0.57) at 2 to 6 weeks reached significance after threshold adjustment in TSA.
Our meta-analysis confirmed the effectiveness of low-dose BoNT in the reduction of pain for lateral epicondylalgia. Further conclusions cannot be drawn due to insufficient available data.
Number of botulinum toxin injections needed to stop requests for treatment for chronic lateral epicondylar tendinopathy. A 1-year follow-up study
2019, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
Nevertheless, the superiority of surgery for BoNT-A injections in patients with chronic epicondylar tendinopathy has not been proven [36]. The primary analgesic effect of BoNT-A is suggested to result from easing the tension in the whole enthesis site, including the tendon [36], thereby resulting in immobilisation of the enthesis. This procedure has been shown to improve the healing process of several tendons [40,41].
Epicondylar tendinopathy (“tennis elbow”) is a serious issue in manual labourers. Symptoms can persist over months or even more than 1 year, even when treated with trinitrine patches, acupuncture, sclerosis of neovessels, shock-wave therapy, autologous blood injections, platelet-rich plasma or hyaluronic acid. Botulinum toxin (BoNT-A) injections showed promising short-term results, but the long-term beneficial effects are not yet known.
We aimed to assess the long-term effect, side effects and recurrence rate after BoNT-A injections on chronic lateral epicondylar tendinopathy during 1 year.
This open study followed a 3-month randomized controlled trial. We included 50 patients followed at day 0 (V0), 90 (V1), 180–270 (V2) and 365 (V3). The main judgment criterion was the number of BoNT-A injections required to achieve pain relief with no further request for treatment by the patient.
After one BoNT-A injection, 22/50 (44%) patients did not ask for further treatment during follow-up because of complete pain relief, and 20/50 (40%) asked for a second BoNT-A injection. For 20 patients with a second injection, 18 (90%) did not ask for further treatment during follow-up. Only 1 patient had a recurrence of pain after an initial pain relief of greater than 75%. Quality of life, and painful and maximal gripping force improved significantly at V1, V2 and V3 as compared with V0, and repercussions on daily and professional activities decreased significantly (P < 0.05).
One or 2 BoNT-A injections has favourable results for chronic epicondylar tendinopathy.
News in the treatment of the tendinopathy
2017, Journal de Traumatologie du Sport
Les connaissances et la prise en charge des tendinopathies ont beaucoup évolué depuis ces dernières années. En effet, se substituant désormais à l’ancienne appellation « tendinites », les tendinopathies sont majoritairement décrites selon le modèle de continuum établi par Cook et Purdam. La compréhension de la physiopathologie de ces lésions a permis l’émergence de nombreux traitements dans le but d’obtenir une récupération optimale et une limitation des récidives. L’objectif de cet article est de faire une revue de l’actualité thérapeutique sur ces lésions.
Tendon injuries caused by overuse have been described as “tendinitis” for years before it was demonstrated that the histopathological process was not due to intratendinous inflammation. Cook and Purdam proposed a continuum model of tendon pathology, which provides a better understanding of the condition and the possibility to adapt the treatment. This allows a better recovery and a lower recurrence rate of the tendinopathy. This article is a review of current treatments used in clinical practice.
Comparison Between Steroid and 2 Different Sites of Botulinum Toxin Injection in the Treatment of Lateral Epicondylalgia: A Randomized, Double-Blind, Active Drug-Controlled Pilot Study
2017, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
The cost of 20U of onabotulinumtoxinA is approximately $140 in the United States. The data of meta-analyses encourage the use of minimally invasive BoNT-A injection to manage patients with chronic lateral epicondylalgia who have failed the conventional therapies.7,8 Long-term cost-effectiveness of BoNT-A injection for patients with lateral epicondylalgia needs to be evaluated in the future.
To compare the effects of 2 different injection sites of low doses of botulinum toxin type A with steroid in treating lateral epicondylalgia.
Double-blind, randomized, active drug-controlled trial.
Tertiary medical center.
Patients with lateral epicondylalgia for >6 months were recruited from a hospital-based outpatient population (N=26). A total of 66 patients were approached, and 40 were excluded. No participant withdrew because of adverse effects.
Patients were randomly assigned into 3 groups: (1) botulinum toxin epic group (n=8), who received 20U of botulinum toxin injection into the lateral epicondyle; (2) botulinum toxin tend group (n=7), who received 20U of botulinum toxin injected into tender points of muscles; and (3) steroid group (n=11), who received 40mg of triamcinolone acetonide injected into the lateral epicondyle.
A visual analog scale, a dynamometer, and the Patient-Rated Tennis Elbow Evaluation were used to evaluate the perception of pain, maximal grip strength, and functional status, respectively. Outcome measures were assessed before intervention and at 4, 8, 12, and 16 weeks after treatment. The primary outcome measure was a visual analog scale.
At 4 weeks after injection, the steroid group was superior to the botulinum toxin tend group in improvement on the visual analog scale (P=.006), grip strength (P=.03), and Patient-Rated Tennis Elbow Evaluation (P=.02). However, these differences were not observed at the 8-, 12-, and 16-week follow-up assessments. There was no significant difference between the steroid and botulinum toxin epic groups.
Injections with botulinum toxin and steroid effectively reduced pain and improved upper limb function in patients with lateral epicondylalgia for at least 16 weeks. The onset of effect was earlier in the steroid and botulinum toxin epic groups than in the botulinum toxin tend group.
Conservative treatment of tendinopathies - what helps?
2015, Sports Orthopaedics and Traumatology
Bei der Behandlung von Beschwerden im Bereich der Sehnen und Faszien stehen diverse konservative Therapiemaßnahmen zur Verfügung. Wissenschaftlich ist lediglich der Erfolg des exzentrischen Trainings, auch im Langzeitverlauf, bestätigt. Für die extrakorporale Stoßwellentherapie konnte je nach Lokalisation teilweise der Behandlungserfolg in der Literatur bewiesen werden. Für die meisten der anderen Therapiemaßnahmen ist zwar der Therapieerfolg in der täglichen Routine oftmals vorhanden, in der Literatur jedoch nicht bestätigt. Dies ist zumindest teilweise auf die schlechte Qualität der vorhandenen Studien zurückzuführen. Das Erkennen von Risikofaktoren für das Auftreten von Sehnenbeschwerden stellt somit einen wichtigen Punkt in der Betreuung von Sportlern dar.
Tendinopathies are common painful overuse disorders. Many different treatment options are available, but for most therapies the evidence concerning pain reduction and improvements in function is limited. Strong evidence was only found for the use of eccentric training in midportion achilles tendinopathy and patellar tendinopathy. For shockwave therapy different evidence depending on the location of tendinopathy is available. Preventive strategies and especially the evaluation of risk factors seem to be important in the support and care of athletes.

View all citing articles on Scopus

: The authors have no conflicts of interest to disclose.

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EpicondylitisInjection of Botulinum Toxin for Treatment of Chronic Lateral Epicondylitis: Systematic Review and Meta-Analysis

Objectives

Methods

Results

Conclusions

Section snippets

Search Strategy

Trials

Discussion

Conclusions

Acknowledgments

Lancet

Ann Readapt Med Phys

Control Clin Trials

Rehabilitación

Lancet

Prevalence of shoulder and upper-limb disorders among workers in the fish-processing industry

Scand J Work Environ Health

Prevalence and determinants of lateral and medial epicondylitis: a population study

Am J Epidemiol

Upper limb musculoskeletal disorders in highly repetitive industries: precise anatomical physical findings

Ergonomics

Prevalence and impact of musculoskeletal disorders of the upper limb in the general population

Arthritis Rheum

The prevalence of humeral epicondylitis: a survey in general practice

J R Coll Gen Pract

Tennis elbowAnatomical, epidemiological and therapeutic aspects

Int Orthop

Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both-a randomized clinical trial

Am J Sports Med

A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

Br J Sports Med

[Botulinum toxin A in orthopedic pain therapy]

Schmerz

Botulinum toxin injection versus surgical treatment for tennis elbow: a randomized pilot study

Clin Orthop Relat Res

Treatment of chronic radial epicondylitis with botulinum toxin AA double-blind, placebo-controlled, randomized multicenter study

J Bone Joint Surg Am

Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial

Ann Intern Med

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration

Ann Intern Med

The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses

Epicondylitis
Injection of Botulinum Toxin for Treatment of Chronic Lateral Epicondylitis: Systematic Review and Meta-Analysis