Tendinopathy Clinical Trial
Official title:
Feasability Study on the Use of Botulinum Toxin A in Primary Adductor Tendinopathies Refractory to Medical Treatment
Pubalgia is a pain syndrome located in the groin area. This syndrome is mainly described in
young male athletes and typically affect the superficial muscles defining the boundaries of
the femoral triangle, i.e. gracilis, pectineus, adductor brevis and especially adductor
longus, and less commonly the deep muscles.
Clinically, the pain is located in the inner aspect of the thigh, where the tendons attach
onto the pubic symphysis. It is usually unilateral, and sometimes associated with neuropathic
pain suggestive of obturator nerve irritation.
There is no official recommendation or expert consensus on the management of pubalgia.
However, a few protocols recommend a period of rest with Non-Inflammatory Anti-Steroidien
Drugs (NSAIDs), icing and massages, as well as rehabilitation with passive stretching and
muscle reinforcement.
The use of botulinum toxin type A could be an option in cases of treatment failure. However,
a feasibility study must be performed beforehand, and if results are positive, a controlled
study on a larger cohort could be conducted.
The major potential impact is a great effective pain relief for patients with neurological
diseases.
The incidence of pubalgia in the literature varies, with large series reporting an incidence
close to 5-10%, representing 15 to 18% of all injuries.
Recurrences are also common, affecting 30 to 35% of cases.
Once other differential diagnoses (such as spondylarthropathy, colorectal cancer, kidney
diseaseā¦) have been ruled out, athletic pubalgia is typically divided into three main
categories based on the site of the injury:
- Abdominal wall, the most common form, representing 38 to 50% of all cases;
- Pubic symphysis due to osteoarthropathy of the pubic bone caused by repetitive stress
injury, accounting for 10 to 15% of all cases of pubalgia;
- Adductor tendons, on which this study focuses, representing 22 to 38% of all cases of
pubalgia, caused by repetitive tractions on the tendon insertions.
There is no official recommendation or expert consensus on the management of pubalgia.
However, a few protocols recommend a period of rest with Non-Inflammatory Anti-Steroidien
Drugs (NSAIDs), icing and massages, as well as rehabilitation with passive stretching and
muscle reinforcement.
Neuromuscular reprogramming is then performed to stabilise the pelvis, followed by a
progressive resumption of sporting activities, guided by the pain level.
Generally, 70 to 85% of patients are able to resume their sporting activities with this
management protocol.
In 15 to 20% of cases of essential adductor tendinopathy, symptoms do not improve and the
only currently validated solution is then a tenotomy, sometimes combined with partial tendon
release in recurring cases.
Recent studies showed that the use of botulinum toxin type A (BTA) produces fairly positive
results in chronic tendinopathies, such as epicondylitis. However, the efficacy of BTA
injections in adductor tendinopathies has not been demonstrated consistently and a
feasibility study must be conducted to address this question.
The hypothetical benefit of BTA in adductor tendinopathies is based on the toxin's known
effects:
1. a purely analgesic effect, which reduces pain in the injected area within a few days.
This type of chronic tendinopathy does not involve inflammation. The pain in such cases
is most likely due to the action of neurotransmitters such as substance P and calcitonin
gene-related peptide (CGRP). As BTA is known to inhibit the secretion of these
neurotransmitters, this mechanism could explain the toxin's specific analgesic effect.
2. a muscle relaxant effect due to its action on the motor endplate, which reaches its
maximum 6 weeks after the injection, and lasts 3 to 6 months.
The resulting muscle relaxation helps improve healing of the damaged tendon, and provides
sustained analgesia.
A series including 39 cases showed that botulinum toxin is effective on hip adductor muscles
following total hip arthroplasty, providing reduced muscle contracture and improved hip
mobility without side effects.
The use of botulinum toxin type A could be an option in cases of treatment failure. However,
a feasibility study must be performed beforehand, and if results are positive, a study on a
larger cohort could be conducted.
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