Botulinum Toxin Injection in TFL for LPOS

[Laura Thornton]

Interesting article discussed at the journal club with the orthopedists this morning. Wanted to share and get everyone’s thoughts.

The Use of Sonographically Guided Botulinum Toxin Type A (Dysport) Injections Into the Tensor Fasciae Latae for the Treatment of Lateral Patellofemoral Overload Syndrome
Joanna M. Stephen, David W.J. Urquhart, Richard J. van Arkel, Simon Ball, Matthew K.J. Jaggard, Justin C. Lee and J.S. Church
Am J Sports Med 2016 44: 1195

– Inclusion criteria included both pain reproduced with modified Ober test, failed previous course of PT, and MRI confirmation of injury. What are your thoughts on these inclusion criteria?

– Gluteus medius and TFL had a inverse relationship in activity and strength. Do you commonly see this in the clinic? Could this indicate other inhibitory methods that we could use if we are trying to increase Glute Med activity?

– It was mentioned that at a 5 year follow-up, the 69% of people with complete resolution of symptoms that outlasts the expected duration of the drug. What are some thoughts on why these outcomes maintained for long-term?

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[Nick Law]

Laura,

Thanks for posting this. I read this a few months back and almost wrote up my monthly research review on it. Botux for knee pain was certainly a new concept for me.

Your questions all point the right direction in my mind. The inclusion criteria is certainly VERY specific, and the good results may be from such specific criteria as the intervention is very pointedly directed towards the potential tissue at fault. What should be obvious is that we can’t take the results of this study and then say that botux into the TFL is the solution for everyone with PFP.

Modified ober test reproducing pain? Maybe I am doing the test wrong, but rarely is this test itself actually provocative. Have you guys found this test to be pain producing?

Again, MRI confirmation of injury is HIGHLY specific. How many of my patients with PFP would have grossly normal MRI (grossly normal meaning only findings that are present even in the vast majority of patients without pain)? >80%?

Your second question also went through my mind. I wonder if ihibitory soft tissue work to the TFL combined with exercise emphasizing glute med>TFL activation would have yielded similarly beneficial results? I Know the patients had prior PT – wonder if this was part of it. Do any of you routinely do manual work in attempts to inhibit TFL? Any results? I am sure many of us are working on glute med>TFL activation.

Why were symptoms improved for such a long period of time? Because of a highly specific impairment with a very tailored intervention followed by, “single leg strength and control work exercises.” No way botux injection alone is responsible for the improvement. No change in movement pattern and almost certainly the symptoms would have returned.

The authors found that botux into the TFL increased ober length. Interesting in light of this study where ITB was transected and resulted in no change in Ober length. #deadpeoplestudies

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[Laura Thornton]

I was thinking the same thing with the Ober test. I haven’t ever seen the Ober test reproduce knee pain, only as a measure of IT band length. I was surprised that they recruited 55 patients who fit the inclusion criteria, but then again it doesn’t state how long the recruiting process was. The authors mention that we can only apply these results to that very specific subgroup of PFPS because it is such a broad group and many, many factors can be at play, I certainly wouldn’t suggest a TFL injection to every anterior knee pain patient that walks through the door.

I think it’s a valid thought in working inhibitory soft tissue to TFL with subsequent gluteus medius strengthening. I was even thinking dry needling as well as an inhibitory method, followed up by gluteus medius strengthening. I do focus a lot on gluteus medius and I tend to catch this pattern of TFL/hip flexor dominance when you do gluteus medius MMT, but I have missed a lot of potential use of inhibitory methods when just purely focusing on facilitating the other glute musculature.

I also agree that the combination of the two interventions was most likely the cause of the 5 year substantial improvement. I have a hard time imagining that the injection alone would have had as big of an impact if they go back to the same mechanics and motor patterns as previously, but then again there was no control group so we can’t say for certain.

That is a really interesting study, thanks for posting! It warrants to keep this in mind when performing the Ober’s test and not forget the TFL as a player.

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