Hyperosmolar Dextrose Injection for Recalcitrant
Osgood-Schlatter Disease


AUTHORS: Gastón Andrés Topol, MD,a Leandro Ariel
Podesta, MD,b Kenneth Dean Reeves, MD,c Marcelo
Francisco Raya, PT,d Bradley Dean Fullerton, MD,e and
Hung-wen Yeh, PhD



ABSTRACT.
OBJECTIVE:
To examine the potential of dextrose injection versus lidocaine injection versus supervised usual care to reduce sport alteration
and sport-related symptoms in adolescent athletes with Osgood-Schlatter disease.

PATIENTS AND METHODS:
Girls aged 9 to 15 and boys aged 10 to 17
were randomly assigned to either therapist-supervised usual care or double-blind injection of 1% lidocaine solution with or without 12.5% dextrose. Injections were administered monthly for 3 months. All subjects were then offered dextrose injections monthly as needed. Unaltered sport (Nirschl Pain Phase Scale 4) and asymptomatic sport (Nirschl Pain Phase Scale 0) were the threshold goals.

RESULTS:
Sixty-five knees in 54 athletes were treated. Compared with
usual care at 3 months, unaltered sport was more common in both dextrose-treated (21 of 21 vs 13 of 22; P .001) and lidocaine-treated (20 of 22 vs 13 of 22; P .034) knees, and asymptomatic sport was more frequent in dextrose-treated knees than either lidocaine-treated (14 of 21 vs 5 of 22; P .006) or usual-care–treated (14 of 21 vs 3 of 22; P .001) knees. At 1 year, asymptomatic sport was more common in dextrose-treated knees than knees treated with only lidocaine (32 of 38 vs 6 of 13; P .024) or only usual care (32 of 38 vs 2 of 14; P .0001).
CONCLUSIONS:
Our results suggest superior symptom-reduction efficacy
of injection therapy over usual care in the treatment of Osgood-Schlatter disease in adolescents. A significant component of the effect
seems to be associated with the dextrose component of a dextrose/ lidocaine solution. Dextrose injection over the apophysis and patellar tendon origin was safe and well tolerated and resulted in more rapid and frequent achievement of unaltered sport and asymptomatic sport than usual care. Pediatrics 2011;128:e1121–e1128 Osgood-Schlatter disease (OSD) is traditionally described as “a traction apophysitis of the tibial tubercle because of repetitive strain on the secondary ossification center of the tibial tuberosity.”1 Advances in sequential radiographic examination have helped to partially clarify pathology. Sequential knee ultrasound imaging of tennis athletes going through puberty has demonstrated that ossicles (separated cartilage that ossifies) within hypoechoic cartilage are common and usually asymptomatic.2,3 An ossicle may impinge on the patellar tendon, causing long-term impairment of kneeling or running.4 However, a sequential
MRI study of adolescents with symptomatic OSD revealed 100% with patellar tendon pathology and only 32% with ossicle formation.5 Improvement in patellar tendinosis was demonstrated in those that became
asymptomatic, despite persistence of nonunion ossicles.5 Hirano et al,6 in another sequential MRI study,
found that a partial tear of the secondary ossification center was in place before patellar tendon swelling but
agreed that symptom resolution likely follows the resolution of tendon changes. Thus, although repeated microavulsion fractures may be the first radiographic finding and contribute to OSD pain and pathology,6 they do not seem to be the primary source of pain and dysfunction. 5,6 Recent MRI and ultrasound reports are also consistent with a description of OSD as “a tendinopathy/ apophysosis of the patellar tendon/tibial tubercle.”7–12 Safety and level A–C evidence of efficacy
(per US Preventive Services Task Force criteria) of injection of 10% to 25% dextrose in areas of damaged ligament, tendon, and cartilage in adults has been demonstrated in randomized controlled trials in Achilles tendinosis,
13 finger osteoarthritis,14 knee osteoarthritis, 15 lateral epicondylosis,16 sacroiliac joint pain,17 and in case series collections of patients with Achilles degeneration,18,19 anterior cruciate ligament laxity,20 coccygodynia,21 hip adductor and abdominal tendinosis,22 and plantar fasciosis.23 There are no previous reports of application of dextrose injection in a strictly pediatric population, nor are there reports of injection about an apophysis where, as described, the source of pain and pathomechanism are not yet clear. The common counsel that parents receive is that OSD is “a self-limited process that responds favorably to conservative treatment.”24 The self-limit is closure of the tibial growth plate, and thus the period of potential symptoms can be considerable.1 A succinct recent description of conservative treatment includes “rest, icing, activity modification, and rehabilitation exercises.”
1 Use of a knee strap may protect the tibia from painful contact, but no prospective trials have been reported.
25 Symptoms typically wax and wane for months to years.26 Gerulis et al,27 reporting on 178 conservatively
treated adolescents, found a mean range of 13 to 16.5 months of pain, depending on whether load restrictions were followed. Mital et al28 reported that, after a mean of 3.8 years of symptoms and conservative treatment, 12% of subjects merited surgery. Sixteen years later, Hussain and Hagroo29 reported a 9% surgical rate after a conservative therapy trial. In young adults seen for OSD who received conservative treatment only, telephone interview data a mean of 9 years after diagnosis revealed a 60% incidence of kneeling discomfort and 18% incidence of sport limitation because of pain over the tibial tubercle.30 Air Force cadets with an OSD history reported more frequent anterior knee pain and significantly diminished Sports Activity Scale scores than a cohort with no OSD history.31 Alteration of primary sport choice, altered peer group dynamics, self-esteem effects, and occasional withdrawal from all competitive sports are effects of OSD that have not been measured prospectively. Reassuring parents and athletes that OSD is time-limited is appropriate, but dismissing it as benign in effect or brief in duration seems to be at odds with
available literature. In current literature, OSD is depicted as a condition involving degeneration of both tendon and apophyseal tissue, as opposed to an isolated inflammation of the apophysis. Dextrose injection has been found to be safe and potentially effective in treatment of cartilage and tendon degenerative disorders.
The purpose of this study was to examine the potential of dextrose injection versus lidocaine injection versus supervised usual care to reduce sport-related symptoms in adolescent athletes with OSD. The hypothesis was that dextrose injection would be superior to either lidocaine injection or supervised usual care.

 



Efficacy of Dextrose Prolotherapy in Elite Male Kicking-Sport Athletes With Chronic Groin Pain


Gastón Andrés Topol, MD, K. Dean Reeves, MD, Khatab Mohammed Hassanein, PhD


ABSTRACT. Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil 2005;86: 697-702.

Objective: To determine the efficacy of simple dextrose prolotherapy in elite kicking-sport athletes with chronic groin pain from osteitis pubis and/or adductor tendinopathy.
Design: Consecutive case series.
Setting: Orthopedic and trauma institute in Argentina.
Participants: Twenty-two rugby and 2 soccer players with chronic groin pain that prevented full sports participation and who were nonresponsive both to therapy and to a graded reintroduction into sports activity.
Intervention: Monthly injection of 12.5% dextrose and 0.5% lidocaine into the thigh adductor origins, suprapubic abdominal insertions, and symphysis pubis, depending on palpation tenderness. Injections were given until complete resolution of pain or lack of improvement for 2 consecutive treatments.
Main Outcome Measures: Visual analog scale (VAS) for pain with sports and the Nirschl Pain Phase Scale (NPPS), a measure of functional impairment from pain.
Results: The final data collection point was 6 to 32 months after treatment (mean, 17mo). A mean of 2.8 treatments were given. The mean reduction in pain during sports, as measured by the VAS, improved from 6.3 1.4 to 1.0 2.4 (P .001), and the mean reduction in NPPS score improved from 5.3 0.7 to 0.8 1.9 (P .001). Twenty of 24 patients had no pain and 22 of 24 were unrestricted with sports at final data collection.
Conclusions: Dextrose prolotherapy showed marked efficacy for chronic groin pain in this group of elite rugby and soccer athletes.
Key Words: Athletic injuries; Glucose; Groin; Growth substances; Osteitis; Rehabilitation; Sports medicine; Tendinitis; Tendons.

© 2005 by American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Reha
bilitation

 

Abstract:

Topol GA, Reeves KD: Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series. Am J Phys Med Rehabil 2008;87;890-902.

Objective: To obtain multisport and long-term outcome data from the use of regenerative injection therapy on career-threatened athletes.

Design: Consecutive enrollment of elite performance-limited athletes with chronic groin/abdominal pain who failed a conservative treatment trial. The treatment consisted of monthly injections of 12.5% dextrose in 0.5% lidocaine in abdominal and adductor attachments on the pubis. Injection of the nociceptive source was confirmed by repetition of resistive testing 5 mins after injection.

Results: Seventy-five athletes were enrolled. Seventy-two athletes (39 rugby, 29 soccer, and 4 other) completed the minimum two-treatment protocol. Their data revealed a mean groin pain history of 11 (3-60) mos. Average number of treatments received was 3 (1-6). Individual paired t tests for Visual Analog Scale (VAS) of pain with sport (VAS Pain) and Nirschl pain phase scale measured at 0 and an average of 26 (6-73) mos indicated VAS Pain improvement of 82% (P < 10-10) and Nirschl pain phase scale improvement of 78% (P < 10-10). Six athletes did not improve following regenerative injection therapy treatment, and the remaining 66 returned to unrestricted sport. Return to unrestricted sport occurred in an average of 3 (1-5) mos.

Conclusions: Athletes returned to full elite-level performance in a timely and sustainable manner after regenerative injection therapy using dextrose.

(C) 2008 Lippincott Williams & Wilkins, Inc.

 

 

 

 

 
 
 


 
Dr. Gastón  Andrés Topol
Médico Especialista en Medicina Física y Rehabilitación
Presidente de la Asociación Latinoamericana de Medicina Ortopédica | www.laomed.org

 

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