C.K. Saadeh1, L.G. Ramos 1 , J.M. Malacara 1 , N. Christian 2 , A. Mitchell 2 , D. Shelton 2 , C. Hunkapillar 2 , M. Gaylor 3. 1Medical, Allergy ARTS, ACCR, 2Medical, Allergy ARTS, 3Medical, ACCR, Amarillo, United States

Background: In patients with chronic localized tendon or nerve sheath involvement, steroid injection may be either ineffective or short response duration (less than 6 weeks) particularly after repeated steroids injections. Surgical intervention may not be an option in some of these patients either because of patient unwillingness or other complicating intercurrent illness that may interfere with the surgery outcome. Tendon or nerve sheath teasing was considered in these patients under ultrasound guidance.
Objectives: In this study, we used tendon or nerve sheath teasing in a subgroup of patients who failed previous injections of steroids and were unable to undergo surgery at the time of the injection. We only included patients who showed no evidence of inflammation via color doppler ultrasonography and who had evidence of thickening of the tendon sheath or the nerve capsule as noted by ultrasound. Our primary objective was to study immediate outcome within six weeks of injection while addressing the patient''s comfort and any potential side effects.
Methods: Twenty patients underwent tendon teasing were included. Thickening of the tendon and nerve sheath was documented and, in some cases, in comparison to the contralateral site. Titan (sonosite), with 10 MHz transducer, was used in the localization and ultrasound guidance of teasing. Lidocaine was used for local infiltration of the area of interest, along with ethyl chloride spray for topical anesthesia.
Results: Sixteen of these twenty patients noted some immediate improvement in their pain and range of motion when tendon teasing was done. There were five with lateral epichondylitis, six with supraspinatus, three with peroneus brevis, three medial knee (MCL)and inguinal ligament sheath and 2 with bicipital tendon sheath and one ulnar nerve capsule involvement. Of the patients with lateral epicondylitis involvement four responded to teasing while only two of the shoulder responded . there was poor response in all patients with knee involvment.There was excellent response in the medial epicondyles around the ulnar nerve sheath and only one of the bicipital tendon involvement improved. Repeat teasing was done in three of the elbow pathology after six weeks with still good response. Home physical therapy or outpatient therapy was very helpful in maintaining remitting response.
Conclusion: Tendon and nerve sheath teasing under ultrasound guidance can be an effective and alternative management in select patients who have chronic tendinopathy who failed traditional steroid injection. It appears to be most effective in small and medium sized tendons such as the biceps and more importantly the elbow. It is very safe and well tolerated when performed under ultrasound guidance.
References: 1. Musculoskeletal ultrasonography: what is it and should training be compulsory for rheumatologists? Rheumatology (Oxford). 2004 Jul;43(7):821-2. Epub 2004 Jun 01.
2. Percutaneous ultrasound-guided injections in the musculoskeletal system Adler RS, Sofka CM. Ultrasound Q. 2003 Mar;19(1):3-12
Citation: Ann Rheum Dis 2005;64(Suppl III):187

Session: Rheumatoid arthritis – Clinical aspects


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