Case Studies

Case Study 1: SportVis™ and Tennis Elbow

Patient L (Male) Age - 38 Right handed

PMSH - Left tennis elbow 2009, Low Back Pain
DH - nil
SH - Medical Sales, Gym 5x / week including 3 x 45min upper body weights programmes
HPC - Feb 2012 started with right lateral elbow pain following weight training more intensively than usual. The pain was fairly localized around the epicondyle area but also felt deep inside the bone. Activities that aggravated Mr L's pain were gripping and lifting. He scored his initial pain on a VAS as 1/10 at rest and 8/10 on activity.
O/E - Full elbow ROM was present. Pronation and supination were stiff at the end of range. Resisted wrist extension was mildly painful. On deep palpation of the common extensor origin (CEO) there was tenderness.

Clinical Impression - Right lateral epicondyle degenerative tendonopathy.

Treatment - Initially treatment included rest from the gym, soft tissue massage to the right forearm extensors, ultrasound, eccentric exercise, taping and dry needling acupuncture. The symptoms were very up and down at this stage. As there were no contraindications to using SportVis and the patient was keen to try it we started a course of 2 injections. The first in mid April 2012. A fanning technique was used at the CEO. One week later the patient reported the pain had improved and was now 0/10 at rest and 6/10 on activity. A 2nd injection was carried out. The patient then took 10 days rest from the gym. By mid May the patient stated that he was almost pain free with 0/10 at rest and 2/10 on exercise. He has now returned to the gym and we are working on mobilizing the superior radio ulnar joint to regain the end of range pro and supination that was restricted. A year later and the patient has resumed normal intense gym activities and is symptom free.

Case Study 2: SportVis™ and Ankle Sprain

Patient A (Female) Age - 37

PMSH - 17 years ago sprained right ankle, thyroid dysfunction
DH - Thyroxine
SH - Physiotherapist, cycling and walking
HPC - May 2012 sprained right ankle whilst stepping down. Ankle turned into inversion and plantar flexion. Immediate pain felt on lateral joint line. The following day the ankle was moderately swollen and painful on weight bearing, inversion and plantar flexion. She scored her initial pain on a VAS as 5/10 at rest and 9/10 on activity.
O/E - Moderate swelling was noted over the anterior part of the lateral malleolus. Plantar flexion and inversion were limited by 50% with pain at end of range. The patient was walking with an antalgic gait. The anterior draw test was moderately positive. The anterior talofibular ligament (ATFL) was tender on palpation.

Clinical Impression - Right acute grade II anterior talofibular ligament strain.

Treatment - As there were no contraindications to using SportVis and the patient was keen to try it we started a course of 2 injections. The first the day after injury. A fanning technique was used at the ATFL. The patient reported that she felt an almost immediate effect as the needle was withdrawn and surprise at how little pain was felt when the injection was administered. The following day the patient reported the pain was 3/10 at rest and 5/10 on activity. At 48 hrs post injection a 2nd injection using the same approach was carried out. By a week later the patient stated that she was almost pain free with 0/10 at rest and 2/10 on exercise and was extremely pleased with the speed of recovery and the immediate effects of the injection.

Case Study 3: RenehaVis™ and Osteoathritis in both knees

Patient Z (Male) Age - 68

PMSH - Long standing bilateral OA knees, generalized OA, previous unsuccessful synovial injection treatment with another brand, Sept 2011 RIGHT knee injections by private prescription by GP with RenehaVis x2 one week apart. Outcome was satisfactory and patient was interested to pursue similar progress in LEFT knee.
DH - Thyroxine, Omeprazole, Bendroflurazide, Statin
SH - Retired Pharmacist
HPC - Patient is awaiting Stem Cell treatment. Patient was complaining of LEFT knee stiffness and medial joint line ache. On a VAS the patient stated his LEFT knee pain was 1/10 at rest and 8/10 on activity.
O/E - On examination he had 10-120 degree ROM. There was minimal swelling on the joint line. The quadriceps and hamstrings were functioning reasonably.

Clinical Impression - Outstanding degeneration, probably osteoathritis, to LEFT knee.

Treatment - In October 2011 Mr Z received his first LEFT knee intra-articular injection of ReneHaVis using a medial approach. This was followed by reviewing Mr Z’s home exercise programme which included static quads, inner range quads and knee flex exercises. Mr Z planned to continue these on a daily basis as normal. One week post injection Mr Z stated that the LEFT knee had improved and was now 0/10 at rest and 5/10 on activity. A second injection was performed using a medial approach. 3 weeks following this injection the patient stated he was much improved again and was now 0/10 at rest and 1/10 on activity. Mr Z had received 2 injections into his RIGHT osteoarthritic knee in September 2011 administered by his GP and although he initially felt they had improved he stated that he did not feel the significant improvement that he had felt on the LEFT side. In November 2011 he requested that I re-inject the RIGHT knee with ReneHaVis. Mr Z also stated that the RIGHT knee had always been more problematic and he scored his pain prior to the re-injection as 0/10 at rest and 7/10 on activity. Activities that aggravated his pain included walking and stairs. On examination his ROM was now more limited than the now treated LEFT knee at 10-100 degrees. The lateral joint line was tender on palpation. Again a medial approach was used to administer the intra-articular injection. One week post injection the patient reported the RIGHT knee had improved significantly and scored his pain at 0/10 and 5/10 respectively. A further intra-artcular injection was given and again this helped Mr Z’s pain and was reported a week later at 0/10 and 4/10. On telephone follow up in February 2012 (+5 months) Mr Z stated that his LEFT knee was 90% better than pre-injection and that he was walking well without his stick now. The only time he gets symptoms in this knee is when the weather is extremely damp. He also reported (+4 months after retreatment) that the RIGHT knee was still 75% better in general. Similar sentiments were reported mid-April 2012 (+6 months with LEFT and +5 months retreatment with RIGHT). He is now walking without his stick and stairs are much easier and was very happy. Mr Z decided he could now commit to an overseas vacation April-May 2012, but based on the pain he had experienced pre-RenehaVis treatment was still concerned about any possible relapse. He therefore requested one more (prophylactic) injection (also via private prescription) in both knees. He has now returned from that vacation, and is still active with no need for a stick and noted only minor discomfort in his RIGHT knee. He is continuing with his home exercise programme.
Comment 1: Why did the patient feel that the results of the first series (performed by the GP) of right knee injections were not as effective as the follow up injections? There could be a number of factors: 1. Needle placement differences 2. Having had more success with the LEFT knee although it was less severely painful initially the patient may have had more faith in the subsequent injections in the RIGHT knee as anxiety due to chronic pain is a significant factor here. Or perhaps the patient was walking better after the LEFT knee improved and therefore the load was taken from the RIGHT knee 3. Perhaps the RIGHT knee just needed 3 x injections from the start?
Comment 2: Chronic and apparently unresponsive knee pain is clearly a source of anxiety for patients such as Mr Z. Having obtained significant relief via RenehaVis he was clearly keen to maintain effect. However, if administered correctly, it is clear RenehaVis works quickly and provides longer term pain relief and activity improvement. Therefore it is possible to achieve a customised treatment according to severity of initial and ongoing symptoms which may have been less intensive even than that reported here once physicians and patients develop greater confidence and awareness of RenehaVis effects.

Case Study 4: SportVis™ and Shoulder Injury

Patient X (Male) Age - 62

PMSH - Longstanding LBP, Bowel cancer 2004
DH - Eteorcoxib, paracetomol, phenytoin and alfuzoin
SH - Retired, carer of wife with Parkinson’s Disease
HPC - Mr X has a 5 year history of intermittent right shoulder problems following falling from a roof where he was left suspended by his arms. In June 2011 he aggravated the pain without a specific cause, therefore in July his GP injected the shoulder joint with steroid and this aggravated matters further. Therefore Mr X asked for a physio assessment 1 week later. On examination he complained of anterior/lateral shoulder pain in the C5 distribution which was aggravated in abduction and medially rotated positions. He complained that he was unable to sleep on the left and his sleep was generally disturbed by pain. He had no significant cervical pain and no paraesthesia or anaesthesia.
O/E - His right shoulder was anteriorly translated with reasonable wastage of the supraspinatus and infraspinatus. He had a GIRD present, and positive Hawkins Kennedy and was generally weak on resisted test specifically abduction and lateral rotation.

Clinical Impression - Mr X may have a partial rupture of his supraspinatus and a secondary irritation of his subacromial bursa.

Treatment - We commenced physiotherapy including soft tissue work, strengthening exercise, postural correction and kinesiotaping. Although this initially helped a little the symptoms did not subside. By October 2011 Mr X was struggling with the pain and not sleeping at night. He scored his pain as 5/10 at rest and 9/10 on activity. Therefore Mr X agreed to try a course of SportsVis injections into the subacromial space of right shoulder using a lateral approach under the acromion with a fanning technique. Mr X continued gentle rehab exercises between the 2 injections. At 2 weeks post first injection he stated that the pain was now 3/10 at rest and 6/10 on activity and therefore we repeated the injection using the same procedure. A further month later he stated his pain is 2/10 at rest and 4/10 on activity. He was now sleeping much better and his clinical tests were improved. Mr X was seen by an Orthopaedic Surgeon in December 2011 who had a similar clinical opinion to myself and referred Mr X for a MRI scan. The MRI showed no obvious tear but some fluid and swelling in the sub acromial space. Clinically the surgeon commented at follow up in February 2012 that the strength in the shoulder is improving. As there are still some signs of inflammation both in terms of MRI scan and with the patients pain we have modified the rehab regime with the surgeons input and plan that a further course of injections may be helpful in the future, however the patient was showing yet further signs of improvement in March 2012.

Case Study 5: SportVis™ and Tennis Elbow

Patient Y (Male) Age - 70 Left handed

PMSH - L+R knee surgery, hernia op, otherwise fit and well
DH - nil
SH - Retired joiner, golf 3x per week, swimming 5x per week
HPC - Aug 2011 started with left lateral elbow pain following playing golf more intensively than usual. The pain was fairly localized around the epicondyle area. Activities that aggravated Mr Y’s pain were gripping and playing golf. He also complained of some mild pain when swimming. He scored his initial pain on a VAS as 0/10 at rest and 9/10 on activity.
O/E - Full elbow ROM was present. Resisted wrist extension was mildly painful. On deep palpation of the common extensor origin (CEO) there was tenderness.

Clinical Impression - Left lateral epicondyle degenerative tendonopathy.

Treatment - Initially treatment included soft tissue massage to the left forearm extensors, ultrasound, eccentric exercise and dry needling acupuncture. The patient was not very compliant with the home exercise and after 1 month the elbow was not settling and the patient visited the GP requesting a steroid injection as he was keen to play golf. The GP said this was not a good plan and that the patient should rest from golf for 2 years and the elbow should resolve. As there were no contraindications to using SportsVis and the patient was keen to try it we started a course of 2 injections. The first was at the end of September 2011. A fanning technique was used at the CEO. Two weeks later the patient reported the pain had improved and was now 0/10 at rest and 6/10 on activity. A 2nd injection using the same approach was carried out. By mid November 2011 the patient reported that he was pain free and was back playing golf. He now wished to consider having HA in his knee as he felt so pleased with the results. At last contact in May 2012 (+8 months) he was still pain free and playing golf.

Case Study 6: SportVis™ and chronic ankle strain in young athlete

Patient JA (Female) Age – 13

PMSH - Otherwise in good health her mother was concerned about problems with her daughter’s left ankle and specifically requested SportVis. Two and a half years previously JA had injured the lateral aspect of her ankle. She could not recall a specific incident.
DH - No ongoing medication
SH - Schoolgirl. Advanced standard county gymnast
HPC - She had struggled to recover from injury, seeking the help of a physiotherapist and orthopaedic paediatric consultant. She had x-rays and two MRI scans that were normal. She had also tried ice, heat, braces for the foot and ankle and also prolonged periods of rest. She subjectively complained of pain over the lateral aspect of the ankle referring into the shin and also into the foot. This pain was aggravated by jumping, bounding, tumbling and landing onto the ankle. She explained how the pain reduced her to tears and was 9/10 at worst.
O/E - On examination she stood in pronation and her left leg was ½ “shorter than the right and the left foot was also shorter than the right. She had a stiff subtalar joint and midtarsal. The lateral gastrocnemius was tight with numerous trigger points. There was no instability in the ankle joint on testing. The anterior talofibular ligament was extremely sensitive and tender on palpation.

Clinical Impression - A provisional diagnosis of a chronic sensitised anterior talofibular ligament strain was made. JA and her mother were keen to try a course of injections as she felt that she had tried all avenues at that point. Her mother had researched SportVis and they felt in a position to give informed consent. In combination it was decided to address the stiffness in the ankle and gastrocnemius. JA was instructed as to how to mobilise her foot and do stretches for the calf and her mother instructed how to do regular calf massage.

Treatment - It was agreed JA would completely rest for one month from gymnastics whilst she had the two injections one week apart and then to do a gradual return avoiding any heavy landing for another few weeks. The SportVis injection was administered using a fanning technique into the anterior talofibular ligament. After week one JA said she felt there had been some improvement as the lateral ankle area was not as tender or sensitive but she had not tested it so was uncertain. She was also taught inversion and eversion strengthening with a resistance band at this point and her home exercises were reviewed. The 2nd injection was administered. At six weeks post injection JA had fully returned to gymnastics including vaulting and beam work. At 7 months she is now able to train fully again and is pain and symptom free.
Comment: whilst the injections were used in combination with other treatments and exercises and rest SportVis seemed to give a definite platform for JA to rehabilitate her ankle by reducing her pain. Whilst only approved for chronic ankle sprain SportVis may be a logical inclusion for treatment of chronic ankle sprain.