tratamiento con ozono de las tendinitis

Rivista Italiana di Ossigeno-Ozonoterapia 2: 67-71, 2003
67
Conservative Treatment of Acute or Chronic
Tendonitis with Oxygen-Ozone Mixture
A Double Blind Clinical Trial
ST. IKONOMIDIS, EM. ILIAKIS*, A. ELEFTHERIADOU,D. BRATANIS, R.THOMAIDIS**
Orthopaedic Dept and Radiologic** Lab, General Hospital of Edessa, Northern Greece
* Orthopaedic Clinic, 1st General Hospital of I.K.A Athens, Greece
SUMMARY – Acute or chronic tendonitis are common pathological conditions best treated by conservative
measures.
In acute tendonitis (such as of the tendon of the long head of the biceps, subscapularis, tendo calcaneus
etc.), we begin with local infiltration of topical anaesthetics and (not always) cortisone, plus total application
of ice packs.
Then (after 1st day) we proceed with O2-O3 Therapy (10-15 μgr/ml ) every 3rd day. In chronic cases,
we begin with O2-O3 Therapy of the same mixture and emphasizing a strenuous rehabilitation program.
Trattamento conservativo delle tendiniti acute
e croniche con miscela ossigeno-ozono
Uno studio in doppio cieco
Key words: oxygen-ozone therapy, tendonitis
RIASSUNTO – Le tendiniti (acute e chroniche) sono delle condizioni patologiche molto frequenti che
vengono trattate nella maggiore parte dei casi con terapie conservative.
Nelle tendiniti acute (capo lungo del bicipite, del sopraspinato, del tendine d’achille, del semimebranoso,
del quadricipite, dei muscoli abduttori dell’anca, ecc.). La terapia si basa nell’attenuazione del dolore
acuto con infusione cocktail di anestetico locale e a volte di cortisonici con simultanea applicazione di impacchi
freddi per 2-3 sedute ogni tre giorni.
Nei casi cronici dove il deterioramento del tendine è gia presente grande e il ruolo delle infusioni topiche
sul tendine con miscela di O2-O3 con concentrazione 10-15 μgr/ml due volte alla settimana per 4-5 sedute
con un simultaneo abbreviato programma con esercizi distensivi ed un acurato programma di reinserimento
nelle precedenti attivita lavorative e/o atletiche.
Ricevuto il 02.10.2002
Conservative Treatment of Acute or Chronic Tendonitis with Oxygen-Ozone Mixture St. Ikonomidis
68
Introduction
Tendonitis, as an inflammation after an injury
(acute or repetitive), usually occurs in the hypovascular
area of a tendon susceptible to repetitive
trauma. Eccentric loading of a fatigued muscletendon
unit from insufficient running shoes, running
on uneven terrain or over-training often results
in tendonitis and peritendonitis (tenosynovitis).
Muscle strain may coexist along with trigger
points in chronic cases.
Repetitive activity (overuse injury) or overload
(sudden increase in activity) often accentuates tendonitis
and may even lead to rupture of the tendon.
At other times, chronic tendonitis may lead to local
necrosis within tendon mass and calcific deposits near
the tendon attachment to bone which are very
painful at the onset of the deposition.
Tendon ruptures are more common in middleaged
and elderly patients. Intrinsic weakness of
the tendon secondary to repetitive microtrauma
and incomplete healing in a hypovascular area
lead to chronic tendonitis which with sudden overload
injury may result in tendon rupture. Tenocyte
viability, genetic factors, hormonal environment
and growth factors, play an important role in the
healing process 3.
The most commonly ruptured tendons are
supraspinatus, biceps (long head) and tendo calcaneus
4. In young athletes, ruptures of the patella
tendon with preexisting tendonitis of the tendo osseous
junctions at the inferior pole of the patella
(Jumper’s knee) are common 5. In addition, local steroid
injections into or onto the tendons during
the onset of tendonitis and some pathological conditions
such as hyperbetalipoproteinemia, hyperparathyroidism,
renal failure, rheumatoid arthritis,
lupus erythematosus, diabetes, gout, degenerative
changes of the nearby joint with subluxation,
chondromalacia andosteophytes predispose to
chronic tendonitis and rupture.
On the other hand, tendo calcaneus tendonitis is
seen as posterior heel pain syndrome when microscopic
repetitive tears of the collagen fibrils occur
as a result of overload injuries with local inflammation
and incomplete healing.
We must also mention the trochanteric tendonitis
of hip abductors with refered pain suggestive
of a ruptured lumbar intervertebral disk.
Above all the most frequently observed and cured
tendonitis of the elderly is supraspinatus tendonitis
(R.C. impingement syndrome).
Therapeutic Strategy
Tendonitis from all of the above mentioned
causes and in all the tendons usually responds to
relative rest, ice packs, antiinflammatory medications,
and physiotherapy (deep friction massage
ultrasound, phonophoresis) taking great care to
correct, during the rehabilitation phase, muscle
imbalance and flexibility with stretching exercises
and strengthening training program in an athlete
or restoring foot abnormalities (such as excessive
supination or pronation in tendo-calcaneus tendonitis),
leg length inequality and leg malalignment
2.
Infiltrations with local anaesthetic agent supplemented
- if desired – with 40 mg methylprednisolone
(DepoMedrol) produces immediate relief.
This treatment is absolutely necessary for
painful intratendinous calcifications but not advised
for chronic tendonitis because of the danger
of a ruptured tendon 10.
If all these methods of therapy for chronic tendonitis
fail to resolve the pathologic process, we
proceed to surgery which is specialized for the
specific tendon involved. In general, we must incise
the tendon sheath (and excise it if it is thickened
and inflammed) locate the foci of necrosis in
the tendon mass and debride them as well as the
nearby bursa if they are also inflamed.
If there is no obvious necrotic tissue we perfom
several longitudinal incisions into the tendon to
stimulate a healing hyperamic reaction, also
drilling its insertion into bone with a small kirshner
wire. In long head of biceps tenosynovitis we
perform tenodesis if fraying of the tendon is extensive
and adequate cuff repair can also be obtained
at the same time. In tendo calcaneus tendonitis
we also excise (if needed) the impinging
posterosuperior angle of the os calcis.
On the other hand, using O2-O3 injections over
the suffering tendon (even in the presence of calcium
deposits) we can promote healing of an acute
or chronic tendonitis without any other theraputic
tools. Ozone stimulates many biochemical reactions
1 by the tendon cells (increases ATP, produces
several cytokines and collagen fibrils) and by the
endothelial cells (produces new capillaries). Ozone
promotes absorption of the calcium deposits
and destroys arachidonic acid having a massive
anti-inflammatory effect with no systemic or topical
adverse reactions (except mild pain at the infiltration
site) 7.
Material and Methods
In our double blind multicenter clinical study
we included any kind of acute or chronic well-established
tendonitis. The tendons involved were:
45 supraspinatus, 32 longhead of biceps, 13 semimembranosus,
12 jumper’s knee, 18 tendons of Q
femori, 31 tendocalcaneus tendonitis, 18 adductor
Rivista Italiana di Ossigeno-Ozonoterapia 2: 67-71, 2003
69
Path Level Symptoms O2-O3 Therapy (P109) (Group A) Classical Therapy (P94) (Group B)
0 No pain Full activity – -
1 Pain only after activity Ice Ozone Ice Paracetamol Physiotherapy
(3 sessions every 3rd day)
2 Pain during and after activity Ice Ozone IceReduction of activity to
without significant impairment (4 sessions every 3rd day) 25%-75% Paracetamol
of the resulting workout Cortisone infiltration if needed
3 Pain during and after activity Ice Ozone Ice Reduction of activity
with impairment of (6 sessions every 3rd day) to 25%-75% NSAID
the resulting workouz Cortisone infiltration if needed Paracetamol Physiotherapy
Cortisone infiltration almost always
4 Constant pain with severe Ice Ozone Ice Total rest
impairment of daily activities (6-8 sessions every 3rd day) NSAID
Cortisone infiltration Vigorous Physiotherapy
almost always Cortisone infiltration almost always
Total Number of Patients
Males Females
Group A O2-O3 Patients 109 39 70
Group B Classical Therapy 94 31 63
O2-O3 Therapy (10-15 μgr/ml) (Group A) Classical Therapy (Group B)
Levels Levels
0 1 2 3 4 0 1 2 3 4
Number of Patients Number of Patients
At the Beginning of therapy 0 11 33 41 24 0 8 22 34 30
At 1st week of therapy 3 11 35 40 20 0 6 20 47 21
At 2nd week of therapy 29 32 10 27 11 1 21 33 20 19
At 3rd week of therapy 35 11 38 21 4 2 24 30 20 18
At 4th week of therapy 80 17 6 4 2 19 40 15 12 8
Total number of patients 109 94
Table 1 Levels of clinical status at the onset of therapy and selected methods of treatment
Tabella 1 Cinque diversi livelli clinici all’inizio della terapia e tecniche di trattamento per ogni livello
Table 2 Categorization and classification of the patients with acute or chronic tendonitis according to table 1 data
Tabella 2 Classificazione dei pazienti con tendiniti acute e croniche nelle categorie previste nella tabella 1
longus, 18 peronei, 21 De Quervain disease of the
1st osteoligamentous compartment of the hand.We
excluded chronic autoimmune inflammatory conditions
as well as pain resulting from nearby
anatomical structures such as bursae, muscles, fascie,
joints, ligaments. All of our patients had a history
of acute or repetitive injury.
The total number of patients who received therapy
was 203. Mean age 38, 39 laborers, 75 athletes
(60 competitive). 109 received O2-O3 Therapy and
the others the classical therapeutic protocol with
rest, NSAID, and physiotherapy. In every acute
case we started the therapy with infiltration of local
anaesthetic-glycocortisone mixture of approConservative
Treatment of Acute or Chronic Tendonitis with Oxygen-Ozone Mixture St. Ikonomidis
70
priate volume onto the tendon area plus the use of
ice packs. On the first or second day after the insult
and if the incapacitating pain level had been
diminished enough, we started O2-O3 Therapy
every 3rd day (10-15 μgr/ml) or the classical repertoire
during the period of inflammation.
We excluded the possibility of a ruptured tendon
with copious clinical investigation and/or ultrasonography,
arthrography, or MRI if needed.
All the patients from every occupational group (especially
the athletes) received individual rehabilitation-
exercising program after their pain level
had been stabilized and typical daily activities regained
(because the inflammation subsided during
a therapy period of four weeks at the most).
In measuring the inability from the start to the
end of therapy we used a simple pain-activity scale
with five different levels according to the classification
of the arthritis foundation Atlanda Georgia
for chronic overuse syndromes 11 (table 1).
Each patient was categorized to one of the
above five levels (table 1) at the beginning (onset
of therapy), during (1st, 2nd, 3rd, 4th week) and at the
end of the acute or chronic tendonitis therapy program.
After that period (2 to 4 weeks) rehabilitation
program was initiated if needed. If the patients
became pain-free they entered level 0 (totally
cured) (table 2).
Results
Statistical analysis of the above data help us to
draw four interesting conclusions:
1. The total number of patients entering level 0
at the end of therapy is much higher in Ozone
Therapy.
2. The improvement is faster with Ozone Therapy
even from the 2nd week (4-5) sessions.
3.The recalcitrant-difficult cases (levels 3 and 4)
are improved much more with Ozone Therapy.
4. The majority of patients seeking therapy are
at the beginning of the therapy at levels 2 and 3
(subacute or chronic tendonitis sufferers). They
have noticeable improvement. The ten patients
who remained at levels 3 and 2 at the end of the 4th
week (8-9 sessions) came from level 4. Prognosis
of levels 2, 3 and 4 patients to enter level 0 and 1 is
much better when ozone therapy is used.
Follow-up at three and six months after therapy
supports the use of O2-O3 instead of classical therapy
(table 3).
As we can see, after six months 68 patients from
Group B (72.34%) entered levels 2, 3 and 4 but
only 14 from 109 Group A patients (12.84%) entered
levels 2, 3 and 4, although at the beginning
levels 2, 3 and 4 patients from Group B were statistically
the same.
Conclusions
The authors prefer O2-O3 Therapy as a useful
tool in treating acute, subacute and chronic tendonitis
of all kinds of tendons because it gives
long-standing better results, is cheaper and needs
less aggressive equipment and less effort by the
patient.
The medical practitioner must always keep in
mind that the best possible results depend of the
right technique in doing punctures and infiltrations
8 in terms of accurate right placement of the
needle and the right amount of insulfated mixture
(3 cc to small areas to 20 cc to greater ones).
Except for instantaneous pain at the site of infiltration,
no other side-effects has been observed
(even though we can eliminate the pain by previous
infiltration with 2-5 cc of Novocaine 1%).
After O2-O3 Therapy (Group A) After Classical Therapy (Group B)
Levels Levels
0 1 2 3 4 0 1 2 3 4
Number of Patients Number of Patients
Level at the end of therapy 80 17 6 4 2 19 40 15 12 8
At 3 months after 69 26 10 0 4 26 30 10 24 4
At 6 months after 70 25 8 1 5 10 16 38 12 18
Total number of patients 109 94
Table 3 Follow-up at 3 and 6 months with level categorization
Tabella 3 Controlli a 3 e 6 mesi correlati al livello di malattia
Rivista Italiana di Ossigeno-Ozonoterapia 2: 67-71, 2003
71
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Dr St. Ikonomidis
General Hospital of Edessa
Orthopaedic Department
Edessa, Greece

Written by

Dr. Ángel Hernández Galán, responsable de este proyecto y médico del Hospital de Navarra, compagina su trabajo en la consulta de ozonoterapia con su actividad en la sanidad pública como médico de urgencias del Hospital de Navarra.

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