Sclerotherapy in Bursitis: Theory and Clinical Evidence

Initial reports of using injectable caustic agents to accomplish sclerodesis in refractory bursitis date back to the 1930s. Sclerodesis for recalcitrant bursitis fell out of favor with the increased popularity of surgical resection, percutaneous drain placement, or autologous blood injection (“blood patch”). However, surgical resection is not without significant complications, including recurrent bursitis, iatrogenic infection, chronic sinus tract formation, nerve damage, scar formation, increased pain, reduced range of motion (ROM), and delayed return to sport. ^, In the past 10 years, there has been a reemergence of interest in percutaneous sclerotherapy as a treatment for refractory bursitis.

In 2009, Ike detailed a case series of two patients (one with systemic lupus erythematosus, the other healthy) with chronic post-traumatic prepatellar bursitis refractory to rest, nonsteroidal antiinflammatory drugs (NSAIDs), compression bandage, and bursa aspiration in conjunction with a corticosteroid injection. Both patients had resolution of prepatellar swelling after blind aspiration and injection of the sclerosing agent sodium morrhuate. The agent was combined with methylprednisone and lidocaine to prevent previously described post-injection flares. At a 17-month follow-up, there was no recurrence of prepatellar swelling or pain. ^,

In 2016, Hong et al. completed a case series of two patients with aseptic olecranon bursitis and 22 patients with aseptic malleolar bursitis at the ankle with over 4 months of symptoms refractory to NSAIDs, bandaging, and aspiration with corticosteroid injection. All patients were treated with ultrasound (US)-guided bursa aspiration followed by irrigation with 50% dehydrated ethyl alcohol. After 1 minute the alcohol was aspirated and a compressive bandaging applied. This was repeated weekly if the bursa was not smaller on follow-up. In 13 of 24 study participants (54%), decreased bursal size was noted after one injection and patients went on to have complete resolution of the bursitis. The remaining 11 patients began to show clinical response after the second injection and these patients went on to a partial resolution of their bursitis. The mean follow-up period was 16 months, with no recurrence of bursa fluid or pain after initial resolution, with “local heat with tolerable pain” the only side effect reported in 4 of 24 patients. Patients with >3 months of symptoms required fewer injections (2.4 ± 1.7 injections) compared to those with <3 months of symptoms (4.7 ± 5.5 injections), suggesting ethyl alcohol sclerotherapy be reserved for patients who have failed >3 months of conservative therapy.

In 2016, Berkoff et al. published a case report on the novel use of fibrin glue for persistent aseptic olecranon bursitis for patients who failed four prior aspirations and one steroid injection with compressive wrapping. In this case report, after aspiration of the olecranon bursa 2 mL of TISSEEL fibrin glue was injected using US guidance and compression wrap was applied. Follow-up evaluation at 3 weeks, 2 months, and 6 months showed no recurrence of the bursitis or pain.

In 2018, Parker and Leggit authored a case report of a soldier with an 8-month history of refractory prepatellar bursitis treated successfully with two rounds of US-guided aspiration, injection with the sclerosing agent polidocanol (based on hospital formulary), and compression bandage. Improved function was reported at the 2-week follow-up visit, and at the 10-month follow-up no bursal fluid had reaccumulated and the patient had returned to prior level of function with no adverse effects.

Concomitantly in 2018, Close and Hill published a case series of three patients with aseptic olecranon bursitis, including one with recurrent bursitis after a surgical bursectomy, refractory to over 1 month of conservative treatment. All patients had a single-blind injection with doxycycline 100 mg diluted in 10 mL sterile saline and compressive wrap for 2 weeks, and had improvement in bursal swelling and pain within 3 weeks. One patient reported mild burning at the injection site, controlled with over-the-counter analgesics. At the 6-month follow-up, no patient had recurrence of pain or swelling.

Sclerotherapy in Morel-Lavallee Lesions and Seromas: Theory and Clinical Evidence

Morel-Lavallee lesions (MLLs) result from traumatic shearing forces to the tissue plane between subcutaneous fat and underlying muscle. The closed degloving-type injury disrupts the vessels that penetrate the fascia, leading to rapid accumulation of blood within the potential space between the subcutaneous fat and fascia. Complications include risk of secondary infection, fat necrosis and resultant deformity, or persistent pseudocyst formation. Although MLL has historically been treated with open debridement and healing by secondary intention or drain placement, there is an emerging push toward minimally invasive treatments to avoid disturbing the subdermal arterial plexus. This plexus is the only remaining vascular supply to the overlying cutaneous flap, and its disruption can result in tissue flap necrosis. ^{, , ,} Drainage and sclerotherapy is one proposed alternative to surgery for MLL, and includes sclerodesis with talc, bleomycin, and doxycycline. Talc can lead to severe pain as well as increased infection risk and bleomycin is very costly, making doxycycline is an appealing sclerosing agent for treating MLL. ^,

In 2007, Tejwani et al. reported a case series of 24 National Football League players who sustained a MLL to their knee(s) after a shearing blow from field impact or a tackle. Players presented an average of 3 days from the date of injury, and a total of 27 knees were included in this study. All 27 lesions were initially treated with ice, compression wrapping of the knee and thigh, and immediate passive/active ROM exercises; 13 lesions ultimately required aspiration. Three lesions (11%) persisted after three aspirations, but all subsequently resolved with one intralesional injection with 20 mg/mL doxycycline and compression wrapping. The doxycycline sclerodesis group had a successful full return to play within 1 day post-injection, but no extended follow-up was reported.

In 2013, Bansal et al. focused on chronic MLL in a case series of 16 patients with MLL persisting for greater than 6 months. Patients had lesions located at the thigh, greater trochanter, gluteus, lower back, or abdominal wall. Most patients had undergone conservative therapy and multiple aspirations, and all patients underwent a blind MLL aspiration and sclerotherapy with 25 mL of doxycycline. The doxycycline was left in the lesion for 60 minutes with position changes every 10 minutes to ensure distribution, followed by aspiration of the sclerosing agent and compression wrapping for 4 weeks. At 4-week follow-up, 11 of the 16 patients (69%) had complete resolution of MLL. Four of the five remaining patients had MLL located on the anterior abdominal wall and were instructed to continue continuous compression wrapping. At 8-week follow-up, 15 of the 16 patients (94%) had complete resolution of MLL. The remaining patient was found to be noncompliant with compression therapy, and 13 of the 16 patients had no recurrent swelling or pain at the 3-year follow-up. The remaining three patients were lost to follow-up. Side effects included mild to moderate post-procedural pain and low-to-high grade fever for the first day post-procedure in the first 3 subjects. The remaining patients were treated with 1 day of Tylenol (acetaminophen) prophylaxis and reported no adverse effects.

Fibrin agents have also been used over the years in various surgeries and procedures. Berkoff et al. reported successfully using US-guided fibrin glue sclerodesis for a chronic post-arthroscopic knee seroma. In a 2013 case report, a persistent 7.5 × 7 cm seroma over the posterolateral knee that did not resolve with three US-guided aspirations and a corticosteroid injection was treated with aspiration and fibrin glue injection across the fascial defect and adjacent stalk. There was complete resolution at 2 weeks, with no re-accumulation at the 1-year follow-up. In 2017, Koc et al. described the use of fibrin glue injection following endoscopic debridement of a suprapatellar MLL in a professional soccer player following failed conservative management, including doxycycline sclerodesis. The patient returned to sport at 6 weeks following treatment. US at 6 weeks showed complete resolution of MLL, with no recurrence at the 1-year follow-up.

Sclerotherapy in Tendinosis and Tenosynovitis: Theory and Clinical Evidence

Sclerosing agents have also been investigated for treatment of chronic, refractory tendinopathy. Neonerves usually travel with neovessels inside the tendon. These sensory nerves have been implicated as possible pain generators, and it has been hypothesized that destroying the local neonerves adjacent to neovessels can decrease pain. Polidocanol is an analgesic and vascular irritant with established tolerability and efficacy in the treatment of varicose veins at various sites such as lower extremity varicosities, esophageal varices, telangiectasias, and hemorrhoids.

In 2002 and 2003, two case series by Öhberg and Alfredson reported the effects of polidocanol injections at sites of neovascularization in chronic Achilles tendinosis with a symptom duration greater than 4 months. The polidocanol was injected under US-guided and Doppler imaging into the area adjacent to the neovessels as they entered the Achilles tendon until all vessels were sclerosed and no further Doppler flow was visualized. These pilot studies both revealed clinically and statistically significant improvements in visual analog scale (VAS) pain levels, patient satisfaction ratings, and Achilles tendon neovascularization for the first 6 months after polidocanol sclerotherapy. ^, Unpublished follow-up data for the 2002 case series revealed all eight patients had no recurrence of pain or neovascularization at 2 years, with normalization of tendon diameter and fibrillar structure on US.

Öhberg and Alfredson also conducted a double-blind randomized controlled trial that randomized 20 consecutive patients with chronic mid-portion Achilles tendinopathy to US-guided polidocanol injections versus US-guided lidocaine injections into sites of tendon neovascularization. At 3 to 6 weeks post-injection, VAS pain scores with Achilles-loading activity, patient satisfaction ratings, and neovascularization were significantly improved ( P < .005) in 5 of the 10 patients (50%) randomized to polidocanol compared to 0% of patients in the control group ( P < .878). Neovascularization was fully resolved in all polidocanol subjects who reported no pain but remained present in all patients with persistent pain. At the trial’s completion, subjects were allowed to cross over to the polidocanol group; 14 of the 15 crossover subjects (93%) noted statistically significant ( P < .04) improvement in pain, satisfaction, and neovascularization on US. No adverse effects were reported by any patients. Similar improvements in pain and return to preinjury level of activity have been reported after US-guided polidocanol sclerotherapy in seven elite and eight recreational-level athletes with chronic patellar tendinosis refractory to more than 3 months of rest and NSAIDs.

Polidocanol also showed promising results in a 2006 case series as a treatment for chronic shoulder impingement syndrome. Alfredson et al. reported the results of US-guided polidocanol injections at sites of supraspinatus or subacromial bursa neovascularization in 15 patients who had failed rest, NSAIDs, physical rehab, and/or multiple subacromial corticosteroid injections. After a median of two polidocanol injections and gentle ROM exercises over at least 4 months, 14 of 15 patients (93%) reported clinically and statistically significant ( P < .05) improvement in VAS shoulder pain scores with daily movements. No adverse outcomes were reported.

There is one case report of a 56-year-old male with chronic idiopathic finger flexor tenosynovitis successfully treated with two injections of 50% ethyl alcohol. Injections were 10 months apart with initial improvement in pain after first injection and gradual resolution of swelling after two injections. Follow-up at 22 months revealed no adverse effects, pain-free normal ROM, and complete resolution of symptoms.

Few studies have examined the association between neovascularization and pain, and results have been conflicting. Due to the conflicting results and limited high-quality evidence, it is difficult to make a recommendation for sclerosing injection. In addition, while fibrin products and fibrin carriers have been extensively studied in animal models for promotion of postsurgical healing of tendons, tendinopathy, and tendon ruptures, no research has been published with human subjects for tendonitis or tendinosis.

Sclerotherapy in Intraosseous Lesions: Theory and Clinical Evidence

Although limited evidence exists, doxycycline has been used for treatment of postoperative lymphoceles, head and neck lymphatic malformations, and intramuscular and intraosseous vascular lesions with good results. In 2009, Wible and Mitchell published a case report of a 19-year-old male with a chronic, severely painful intraosseous lymphatic malformation. Following two sequential injections with doxycycline under US guidance, the patient’s pain decreased from a pre-injection rating of 9 on a 10-point pain scale to 2/10 at rest 9 months after injection and 3/10 after running 1 mile at the same time point; his lymphatic lesion filling dimensions on magnetic resonance imaging (MRI) were also slightly reduced as well. No adverse effects were found or reported after 9 months of follow-up.