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Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis: clinical and ultrasonographic evaluation

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To evaluate the clinical and ultrasonographic changes in the morphology and vascularity of the common extensor tendon after injecting platelet-rich plasma (PRP) or corticosteroid (CS) for recalcitrant lateral epicondylitis (LE). 30 patients aged 18 to 60 years with recalcitrant (>6 months) LE not responsive to oral medication or non-invasive treatment were randomised to receive PRP (n=15) or CS (n=15) injection. Patients were assessed using the visual analogue scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand Scale (DASH) score, Oxford Elbow Score, modified Mayo Clinic performance index for the elbow (modified Mayo score), and hand grip strength. Ultrasonography was performed by a musculoskeletal ultrasonologist to evaluate for tear at the common extensor origin, oedema at the common extensor origin, cortical erosion, probe-induced tenderness, and thickness of the tendon. The VAS for pain, DASH score, Oxford Elbow Score, modified Mayo score, and hand grip strength all improved significantly from pre-injection to the 6-month follow-up in the PRP and CS groups. However, in the CS group, the scores generally peaked at 3 months and then deteriorated slightly at 6 months indicating recurrence of symptoms, which involved 46.7% of the CS patients. At 6 months, the number of patients positive for various ulrasonographic findings generally decreased. However, in the CS group, the number of patients with reduced thickness of the common extensor tendon increased from 2 to 12, and the number of patients with cortical erosion at the lateral epicondyle increased from 9 to 11. PRP appeared to enable biological healing of the lesion, whereas CS appeared to provide short-term, symptomatic relief but resulted in tendon degeneration.
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ABSTRACT
Purpose. To evaluate the clinical and ultrasonographic
changes in the morphology and vascularity of the
common extensor tendon after injecting platelet-rich
plasma (PRP) or corticosteroid (CS) for recalcitrant
lateral epicondylitis (LE).
Methods. 30 patients aged 18 to 60 years with
recalcitrant (>6 months) LE not responsive to
oral medication or non-invasive treatment were
randomised to receive PRP (n=15) or CS (n=15)
injection. Patients were assessed using the visual
analogue scale (VAS) for pain, Disabilities of the Arm,
Shoulder and Hand Scale (DASH) score, Oxford
Elbow Score, modied Mayo Clinic performance
index for the elbow (modied Mayo score), and hand
grip strength. Ultrasonography was performed by a
musculoskeletal ultrasonologist to evaluate for tear at
the common extensor origin, oedema at the common
extensor origin, cortical erosion, probe-induced
tenderness, and thickness of the tendon.
Results. The VAS for pain, DASH score, Oxford
Elbow Score, modied Mayo score, and hand grip
Platelet-rich plasma versus corticosteroid
injection for recalcitrant lateral epicondylitis:
clinical and ultrasonographic evaluation
VK Gautam,1 Saurabh Verma,1 Sahil Batra,1 Nidhi Bhatnagar,2 Sumit Arora1
1 Department of Orthopaedic Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi,
India
2 Department of Radiology, Sanjeevan Hospital, Delhi, India
Address correspondence and reprint requests to: Sumit Arora, c/o Mr Sham Khanna, 2/2, Vijay Nagar, Delhi, 110009, India. Email:
mamc_309@yahoo.co.in
Journal of Orthopaedic Surgery 2015;23(1):1-5
strength all improved signicantly from pre-injection
to the 6-month follow-up in the PRP and CS groups.
However, in the CS group, the scores generally peaked
at 3 months and then deteriorated slightly at 6 months
indicating recurrence of symptoms, which involved
46.7% of the CS patients. At 6 months, the number
of patients positive for various ulrasonographic
ndings generally decreased. However, in the CS
group, the number of patients with reduced thickness
of the common extensor tendon increased from 2 to
12, and the number of patients with cortical erosion at
the lateral epicondyle increased from 9 to 11.
Conclusion. PRP appeared to enable biological
healing of the lesion, whereas CS appeared to provide
short-term, symptomatic relief but resulted in tendon
degeneration.
Key words: platelet-rich plasma; tennis elbow;
ultrasonography
introduction
Lateral epicondylitis (LE) is caused by mechanical
overloading and abnormal microvascular response
2 VK Gautam et al. Journal of Orthopaedic Surgery
and affects approximately 1% to 3% of the
population.1–3 Treatment options include rest, non-
steroidal anti-inammatory medication, physical
therapy, extracorporeal shock wave therapy,
ultrasound therapy, botulinum injection, and
corticosteroid (CS) injection. Recalcitrant cases
necessitate surgical release.4 Injection of biological
agents achieves a favourable long-term clinical
outcome.5–8 Histological analysis of chronic LE reveals
angiobroblastic and mucoid degeneration secondary
to a failure of natural tendon repair mechanism rather
than acute inammation. Platelet-rich plasma (PRP)
enhances healing by delivering high concentrations
of alpha-granules containing biologically active
moieties (such as vascular endothelial growth
factor and transforming growth factor-β) to the
areas of soft-tissue damage.9,10 In PRP, platelet count
increases 2- to 8-fold, and different growth factors
increase 1- to 25-fold.11 PRP injection for LE reduces
pain and induces healing of the common extensor
tendon injury and vascularisation of the diseased
tendon.12,13 Ultrasonography enables visualisation
of the tendon structures around the elbow.14,15 This
randomised, prospective study evaluated the clinical
and ultrasonographic changes in the morphology
and vascularity of the common extensor tendon after
injecting PRP or CS for recalcitrant LE.
Materials and Methods
Between May 2011 and October 2012, 30 patients
aged 18 to 60 years with recalcitrant (>6 months) LE
not responsive to oral medication or non-invasive
treatment were randomised to receive PRP (n=15)
or CS (n=15) injection. No patient had bilateral
involvement. Pregnant patients or patients with
symptoms of carpal tunnel syndrome or cervical
radiculopathy or systemic disorders (diabetes,
rheumatoid arthritis, or hepatitis) were excluded, as
were those who had undergone surgery or local CS
injection in the past 6 months.
20 ml of blood was collected in an acid citrate
dextrose vacutainer and centrifuged at 1500 rpm for
15 minutes to separate the blood into layers of red
blood cells, buffy-coat of leucocytes, and plasma.
The platelet counts for PRP and unprocessed blood
were calculated. 2 ml of PRP or methylprednisolone
(40 mg/ml) was injected at the most tender point
over the lateral epicondyle of the humerus using the
peppering technique.
After injection, patients rested for 30 minutes and
were advised against massage or hot fomentation. Ice
packs or paracetamol were advised for discomfort
rather than non-steroidal anti-inammatory drugs,
as the latter may interfere with platelet function.
Patients were assessed using the visual analogue
scale (VAS) for pain, Disabilities of the Arm, Shoulder
and Hand Scale (DASH) score, Oxford Elbow Score,
modied Mayo Clinic performance index for the
elbow (modied Mayo score), and hand grip strength
before and after treatment at 2 weeks, 6 weeks, 3
months, and 6 months. Ultrasonography (HD 11,
linear array transducer MF L12-4 MHz, Philips
Healthcare, MA) was performed before and after
treatment at 3 and 6 months by a musculoskeletal
ultrasonologist blind to the treatments to evaluate
for tear at the common extensor origin, oedema at
Table 1
The visual analogue scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand Scale (DASH) score, Oxford Elbow
Score, modified Mayo score, and hand grip strength of the platelet-rich plasma (PRP) and corticosteroid (CS) groups
Assessment VAS for pain DASH score Oxford Elbow Score Modified Mayo score Hand grip strength
PRP CS p Value PRP CS p Value PRP CS p Value PRP CS p Value PRP CS p Value
Pre-injection 7.1±0.8 7.0±0.8 0.650 69.7±6.1 67.5±6.9 0.378 27.4±3.9 31.2±4.1 0.015 56.1±6.9 56.8±5.4 0.770 18.5±5.1 19.2±4.6 0.683
Post-injection
2 weeks 4.5±1.1 2.1±0.7 0.000 51.6±6.8 39.7±6.7 0.000 34.7±4.3 39.7±3.4 0.001 61.3±3.1 68.5±3.9 0.000 22.5±6.6 25.5±4.9 0.159
6 weeks 2.7±0.8 1.4±0.5 0.000 38.6±5.7 32.7±4.1 0.003 39.3±3.1 41.5±2.5 0.045 67.7±2.6 70.4±3.2 0.017 25.5±6.3 25.5±6.0 0.976
3 months 1.8±0.6 1.7±0.5 0.493 33.6±5.1 34.3±3.3 0.675 39.3±3.3 41.7±2.4 0.029 70.2±2.2 69.6±3.5 0.578 25.5±5.6 25.8±6.7 0.884
6 months 1.6±0.5 2.9±1.2 0.001 32.0±4.5 39.6±1.0 0.012 41.2±2.7 36.3±5.9 0.007 70.7±3.0 61.5±5.8 0.000 25.9±6.2 23.3±6.5 0.258
p Value
Pre-injection vs. 2 weeks <0.001 <0.001 - <0.001 <0.001 - <0.001 <0.001 - 0.047 <0.001 - 0.087 0.001 -
2 weeks vs. 6 weeks <0.001 0.016 - <0.001 0.01 - <0.001 0.072 - <0.001 0.159 - <0.001 1.00 -
6 weeks vs. 3 months 0.001 0.104 - 0.007 0.316 - 1.00 0.788 - 0.013 0.387 - 1.00 0.907 -
3 months vs. 6 months 0.384 0.002 - 0.451 0.066 - 0.136 <0.001 - 0.546 <0.001 - 0.844 0.221 -
Pre-injection vs. 6 months <0.001 <0.001 - 0.001 <0.001 - <0.001 0.022 - 0.001 0.072 - 0.005 0.012 -
Vol. 23 No. 1, April 2015 Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis 3
the common extensor origin, cortical erosion, probe-
induced tenderness, and thickness of the tendon.
The paired t-test (or paired Wilcoxon signed
rank test) was used for detection of improvement
over time. The resulting 2-tailed p value of <0.05 was
considered statistically signicant.
results
The VAS for pain, DASH score, Oxford Elbow Score,
modied Mayo score, and hand grip strength all
improved signicantly from pre-injection to the
6-month follow-up in the PRP and CS groups.
However, in the CS group, the scores generally
peaked at 3 months and then deteriorated slightly at
6 months indicating recurrence of symptoms, which
involved 46.7% of the CS patients (Table 1).
At 6 months, the number of patients positive
for various ulrasonographic ndings generally
decreased. However, in the CS group, the number
of patients with reduced thickness of the common
extensor tendon increased from 2 to 12, and the
number of patients with cortical erosion at the lateral
epicondyle increased from 9 to 11 (Table 2).
discussion
CS injection used to be the treatment of choice for LE.
CS suppresses the immune system by suppressing the
pro-inammatory proteins. Its potential side effects
include lipodystrophy, skin pigmentation changes,
and tendon atrophy/ruptures. PRP is an increasingly
popular treatment for LE. It increases expression
of the collagen gene and production of vascular
endothelial growth factor and hepatocyte growth
factor in human tenocytes,16,17 and type-I collagen.18
Assessment VAS for pain DASH score Oxford Elbow Score Modified Mayo score Hand grip strength
PRP CS p Value PRP CS p Value PRP CS p Value PRP CS p Value PRP CS p Value
Pre-injection 7.1±0.8 7.0±0.8 0.650 69.7±6.1 67.5±6.9 0.378 27.4±3.9 31.2±4.1 0.015 56.1±6.9 56.8±5.4 0.770 18.5±5.1 19.2±4.6 0.683
Post-injection
2 weeks 4.5±1.1 2.1±0.7 0.000 51.6±6.8 39.7±6.7 0.000 34.7±4.3 39.7±3.4 0.001 61.3±3.1 68.5±3.9 0.000 22.5±6.6 25.5±4.9 0.159
6 weeks 2.7±0.8 1.4±0.5 0.000 38.6±5.7 32.7±4.1 0.003 39.3±3.1 41.5±2.5 0.045 67.7±2.6 70.4±3.2 0.017 25.5±6.3 25.5±6.0 0.976
3 months 1.8±0.6 1.7±0.5 0.493 33.6±5.1 34.3±3.3 0.675 39.3±3.3 41.7±2.4 0.029 70.2±2.2 69.6±3.5 0.578 25.5±5.6 25.8±6.7 0.884
6 months 1.6±0.5 2.9±1.2 0.001 32.0±4.5 39.6±1.0 0.012 41.2±2.7 36.3±5.9 0.007 70.7±3.0 61.5±5.8 0.000 25.9±6.2 23.3±6.5 0.258
p Value
Pre-injection vs. 2 weeks <0.001 <0.001 - <0.001 <0.001 - <0.001 <0.001 - 0.047 <0.001 - 0.087 0.001 -
2 weeks vs. 6 weeks <0.001 0.016 - <0.001 0.01 - <0.001 0.072 - <0.001 0.159 - <0.001 1.00 -
6 weeks vs. 3 months 0.001 0.104 - 0.007 0.316 - 1.00 0.788 - 0.013 0.387 - 1.00 0.907 -
3 months vs. 6 months 0.384 0.002 - 0.451 0.066 - 0.136 <0.001 - 0.546 <0.001 - 0.844 0.221 -
Pre-injection vs. 6 months <0.001 <0.001 - 0.001 <0.001 - <0.001 0.022 - 0.001 0.072 - 0.005 0.012 -
Table 2
Ultrasonographic evaluation of the platelet-rich plasma (PRP) and corticosteroid (CS) groups
Assessment No. (%) of patients with positive ultrasonographic finding
Tear of the common
extensor tendon
Oedema of the
common extensor
tendon
Reduced thickness
of the common
extensor tendon
Probe-induced
tenderness
Cortical erosion
at the lateral
epicondyle
PRP
(n=15)
CS
(n=15)
PRP
(n=15)
CS
(n=15)
PRP
(n=15)
CS
(n=15)
PRP
(n=15)
CS
(n=15)
PRP
(n=15)
CS
(n=15)
Pre-injection 10 (67) 5 (33) 7 (47) 7 (47) 3 (20) 2 (13) 15 (100) 15 (100) 14 (93) 9 (60)
Post-injection
3 months 8 (53) 4 (27) 6 (40) 3 (20) 2 (13) 4 (27) 10 (67) 9 (60) 14 (93) 11 (73)
6 months 4 (27) 5 (33) 1 (7) 2 (13) 1 (7) 12 (80) 6 (40) 10 (67) 14 (93) 11 (73)
4 VK Gautam et al. Journal of Orthopaedic Surgery
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Table 3
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conclusion
PRP appeared to enable biological healing of the
lesion, whereas CS appeared to provide short-
term, symptomatic relief but resulted in tendon
degeneration. PRP injection may be appropriate for
other forms of tendinopathies, such as plantar fasciitis
and medial epicondylitis.
disclosure
No conicts of interest were declared by the authors.
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... This includes hamstring injuries, osteoarthritis, rotator cuff tears, and a variety of tendinopathies such as lateral epicondylitis (LE). Large-scale and long-term trials are still required to prove this, although early data for using PRP to treat LE is encouraging [13][14][15][16]. PRP injections were used effectively to treat cases that failed non-surgical treatment of LE [17], and preliminary data show that they are superior to steroid injections in the short-term management of this condition [18]. ...
... presents the results of the quality assessment of included studies. In the current investigation, both included studies scored 18[16,17]. ...
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To synthesize the available information on the effectiveness of platelet-rich plasma (PRP) injections against surgery as therapy strategies for medial epicondylitis (ME). We searched the Embase, MEDLINE, and Cochrane Library databases with the relevant keywords to identify the studies comparing the efficiency of PRP injections and ME surgery. We excluded non-English articles, case reports, and conference abstracts. Only two studies met the inclusion criteria and were included in the qualitative synthesis. No conflicts were reported between both studies. Both studies were carried out in the United States of America. The outcomes of PRP and surgical interventions were similar, with no reported statistical differences. Both studies recorded an excellent outcome following the PRP and surgical interventions, where the patients returned to full movement with no pain. The current evidence shows that PRP injections are just as effective as ME surgery in relieving pain and restoring function for those with ME, especially in the short and mid-term. Therefore, the injection of PRP is a promising treatment option for ME.
... This was agreed with Gautam et al. [13] who found that pain decreased with corticosteroid injection they said that CS injection used to be the treatment of choice for LE as it suppresses the immune system by suppressing the proinflammatory proteins and improve pain. ...
... This agreed also with Gautam et al., [13] who found that ultrasound examination of common extensor tendon showed decrease tendon thickness after corticosteroid injection. ...
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Full-text available
Background: One of the most common causes of elbow pain is lateral epicondylitis (LE). ultrasound (US) is diagnostic and therapeutic method. Aim of the Work: The comparison between the effects of dextrose and corticosteroid injection guided by ultrasound in treatment of LE was the aim of this work. Patients and Methods: This research was performed on 60 cases had chronic LE (local tenderness to palpation at lateral epicondyle and pain on resisted extension of middle finger or wrist) randomly classified into two equal groups depending on the treatment line, group A involved 30 cases subjected to2 injections of dextrose solution. Group B involved 30 cases treated by 2 injections with corticosteroid solution. Both groups were US guided. Patient evaluation at base line and after one month from last injection. Results: In both groups, there was a significant improvement of the degree of tenderness, patient rated tennis elbow evaluation, visual analog scale and ultrasound changes, no significant improvement in group A more than group B. Conclusion: Dextrose prolotherapy proved to be as effective as corticosteroid in chronic LE treatment.
... Fulltexts of 44 articles were evaluated, and finally, 31 eligible papers comprising 1948 patients with lateral epicondylitis were included in this systematic review ( fig. 1). The pain intensity was investigated in 23 studies , the functional status was investigated in 16 studies (13,14,18,20,21,23,26,28,33,(36)(37)(38)(39)(40)(41)(42), and the strength was investigated in 8 studies (15,17,20,21,23,25,26,43). Out of 23 trials assessing the pain reduction outcome, 20 studies used VAS pain score only, and 3 studies used both of VAS and MNS. Out of 16 RCTs investigating the functional improvement outcome, 8 studies used DASH only, 7 studies used PRTEE only, and one study used both. ...
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Background: We aimed to compare the efficacy of local injection therapies for lateral epicondylitis in a Bayesian framework. Methods: We searched the Embase, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and ProQuest, for randomized controlled trials published from inception to February 2021 in any languages. The injection therapies included corticosteroids (CSs), autologous blood (AB), botulinum toxin (BT), and platelet-rich plasma (PRP). Placebo was the reference group for comparison. The study outcomes were pain, function, and strength, at 1, 3 and 6 months after injection. Results: Thirty-one trials were finally included in this network meta-analysis, comprising 1,948 patients. In the first month of treatment, CS and BT were more efficacious than placebo in terms of pain reduction, and CS was superior to BT. In the same follow-up time, CS was also superior to placebo in terms of functional improvement. In the third month of treatment, BT was the only intervention that was more efficient than placebo in pain relief. With regard to functional improvement, none of the treatments significantly had a higher effectiveness than placebo in the same period. Moreover, no therapies were found to be more efficient than placebo in the sixth month of treatment in terms of any study outcomes. In addition, we did not identify an intervention superior to placebo regarding strength improvement outcome in any times of follow-up. Conclusion: CSs and BT are efficient in improving clinical outcomes of lateral epicondylitis in the short term. Also, the efficacy of CSs seems to be greater than BT. On the other hand, AB and PRP were not significantly more efficient than placebo in any times of follow-up.
... Concentrated platelets of up to 1000,000 microL, indicating a three to five-fold increase in platelet count, have been shown promising in bone and soft tissue repair [2,3]. Several studies were done using PRP to treat tendon injuries or tendinopathies [4][5][6][7]. Many of the cytokines identified in PRP are involved in the signaling pathways that occur during the stages of inflammation, cellular proliferation, and subsequent tissue remodeling that occur during the healing process. ...
Article
Introduction Platelet-Rich Plasma (PRP) is an autologous human plasma preparation with a higher platelet concentration. Injection of PRP were, found to be effective in treating tendinopathy and arthritis. A few studies only focused in using PRP injection in patients with tennis elbow. This study was conducted to access the functional outcome of PRP injection in tennis elbow patients. Methodology A prospective study was done from June 2020 to June 2021, at R. L. Jalappa Hospital, Kolar, India among 80 individuals diagnosed with tennis elbow. All individuals aged between 18 to 65 years of either gender and the pain symptoms not subsided with oral analgesics or physiotherapy were included in this study. We analysed all the patients with a MAYO elbow performance score and Visual Analogue Pain Scale (VAS) during the follow-up period. Results In total, 80 individuals participated in our study, of which the mean age of the participants was 45.54. There is statistical significance in the difference of means of pain score obtained using both VAS and MAYO score at 12 weeks and 24 weeks. There is high significant positive correlation of age with the pain scores at 12th week and 24th week after the procedure. Conclusion In tennis elbow patients, PRP injection shows an effective reduction in pain according to VAS and MAYO score and especially, younger age patients have shown more benefit in terms of pain reduction with PRP treatment.
... PRP appeared to enable biological healing of the lesion, whereas corticosteroids appeared to provide short-term, symptomatic relief but resulted in tendon degeneration. Improvement in tendon morphology was greater after PRP injection than after corticosteroid injection 45 . ...
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INTRODUCTION: Lateral epicondylitis is a painful condition of the elbow, characterised by pain and tenderness with resisted wrist extension. This study was carried out to evaluate the comparative efficacy of the local infiltration of L-PRP, methylprednisolone and normal saline in patients with lateral epicondylitis. MATERIALS AND METHODS: Sixty adult patients, between the ages 30 to 50 years, diagnosed with lateral epicondylitis of more than 12 weeks, were enrolled in the prospective randomised study. Their medical history and previous conservative treatment were recorded; the clinical evaluation of the tendinitis was made with the visual analogue scale (VAS), the disabilities of the arm, shoulder, and hand (DASH) outcome scores, the modified elbow performance index (MEPS), the functional assessment by patient-rated tennis elbow evaluation (PRTEE), together with the laboratory investigations. The patients were randomised using the computer-generated alphabets into three groups of 20: group A received saline, group B received PRP, and group C received corticosteroids. RESULTS: Patients were seen at 4, 8 and 12 weeks to evaluate the post-injection status. VAS, DASH, and PRTEE scores were significantly reduced, and MEPS was significantly improved in group B compared to group A and group C. Moreover, the reductions in VAS and PRTEE were significantly different in group C compared to group A. CONCLUSION: PRP leads to superior healing with long-term therapeutic advantages compared to corticosteroids though it takes a little longer to have its effect.
Article
Tennis elbow (TE) is a painful and debilitating condition of the elbow. Recently, the use of orthobiologics, such as platelet-rich-plasma (PRP), has been proposed to promote tendon regeneration. Despite their popularity, there is a paucity of updated reviews on the use of PRP compared with other treatment modalities for treating TE. The aim of this review is to summarise high quality studies that compare the use of PRP therapy with other therapies for TE and to identify areas where further research is warranted. This systematic review was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive literature search of PubMed, Scopus and Cochrane Library databases was undertaken in May 2021. Articles were screened for the following criteria: randomised control trials (RCTs) involving PRP in at least one of the treatment arms for tennis elbow. The quality of the RCTs included were analysed for their risk of bias using the modified Cochrane Collaboration Risk of Bias Assessment Tool for randomised trials. A total of 20 RCTs of which 1520 TE patients were analysed. The RCTs included in this review compared PRP with various treatment modalities routinely used in clinical practice such as physiotherapy, steroid injections, Autologous Whole Blood (AWB) and surgical interventions. With regards to the quality of RCTs, collectively, selection bias was found to be low risk however, performance bias in terms of blinding of participants and personnel performed poorly. Of the 20 RCTs, only 5 studies were classified as low risk of bias. In these 5 studies, 2 RCTs compared PRP with steroids and reported contrasting results, 1 RCT compared PRP with AWB injections which reported both to be similarly efficacious, 3 RCTs included a placebo group and only 1 reported superior effects with PRP. There are 2 main types of PRP classified according to the number of pro-inflammatory leukocyte i.e. leukocyte-rich and leukocyte-poor PRP. However, only 8 studies documented the formulation of PRP used. While the heterogeneity of PRP formulations could in-part explain the reported differences in outcomes, overall there is limited robust evidence to recommend PRP therapy for TE. Further research is required to establish the optimal formulation and administration of PRP injections. Proper documentation of TE patients need to be standardised before concrete recommendations on the use of PRP therapy may be offered.
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Musculoskeletal pain is the most common pain reported by patients. Platelet-rich plasma (PRP) is widely used to treat musculoskeletal pain. However, the efficacy of PRP to treat this pain remains controversial. This review highlights the application of PRP in the treatment of musculoskeletal pain. PRP treatment appears to reduce pain and improve function in patients with musculoskeletal pain. However, there are limitations to the currently published studies. These limitations include the PRP preparation methods, type of activators, types of pathology to be treated, methods and times of administration, and association of PRP with other treatments.
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Background The effectiveness of platelet-rich plasma (PRP) injection in the treatment of lateral epicondylitis remains debatable. Purpose To evaluate the effectiveness of PRP in lateral epicondylitis treatment using minimal clinically important difference (MCID) values as a reference and to investigate if leukocyte content can influence the effectiveness of the therapy. Study Design Systematic review; Level of evidence, 4. Methods Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors searched the Medline and Scopus databases for studies on lateral epicondylitis and PRP therapy that used the following patient-reported outcome measures (PROMs): visual analog scale (VAS) for pain; Disabilities of the Arm, Shoulder and Hand (DASH); Patient-Rated Tennis Elbow Evaluation (PRTEE); and Mayo Clinic Performance Index (MAYO). The weighted arithmetic means for the PROMs were calculated at baseline (week 0) and follow-up weeks 4, 8, 12, 24, 52, and 104. The mean differences in outcomes (ΔVAS, ΔDASH, ΔPRTEE, and ΔMAYO) were compared with the MCID values at each follow-up point. In addition, the effectiveness of leukocyte-rich PRP (LR-PRP) versus leukocyte-poor PRP (LP-PRP) was also compared. The Student t test was used in all analyses. Results A total of 26 studies were included in the analysis. After PRP injection, all PROM scores improved with time. The scores improved significantly from baseline to each follow-up time ( P < .0001), with the exception of the PRTEE (no significant difference at follow-up weeks 12 and 52). The mean difference in scores from baseline exceeded the respective MCIDs from weeks 4 to 104 for the VAS and DASH, from weeks 4 to 52 for the MAYO, and from weeks 8 to 52 for the PRTEE. The MCID for each of the PROMs was exceeded at almost every observation period in both the LR-PRP and the LP-PRP systems. Conclusion Based on comparisons with the MCID values of commonly used outcome scores, PRP seems to be an effective form of treatment for lateral epicondylitis. Both the LR- PRP and the LP- PRP systems were effective in the context of meeting the MCID.
Article
Background Platelet-rich plasma (PRP) is reported as an effective treatment for lateral epicondylitis (LE). Theoretically, different types of PRP have different therapeutic effects. However, there is controversy on the effects of different types of PRP in the treatment of LE. Purpose To systematically compare the pain relief, functional improvement and successful rates on treatment of two different types of PRP, by reviewing and summarizing the data available in the current literature on LE after PRP injection. Methods The PubMed, Medline, Embase, Cochrane Library and Web of science were reviewed. A computerized literature search was performed for related studies published from inception to August 2021 by terms of lateral epicondylitis, tennis elbow, tendinopathy, lateral elbow pain, PRP. PRP involved in present study were divided into leukocyte-poor PRP and leukocyte-rich PRP groups according to different preparation methods. Outcomes of interest included characteristics of the subjects, types and preparations of PRP, clinical outcomes, successful rate and safety of treatment of short-term and long-term follow-up. Results A total of 33 studies included 2420 LE patients. There were 19 studies with LP-PRP, 13 studies with LR-PRP and 1 study involved both LP-PRP and LR-PRP. Patients had significant improved clinical outcomes post-treatment compared to pre-treatment in both groups of PRP. The mean of VAS was ranged from 6.1 to 8.0 before the treatment, 1.5 to 4.0 at short-term and 0.6 to 3.3 at the long-term follow-up in LR-PRP group. The mean of VAS was ranged from 4.2 to 8.4 before the treatment, 1.6 to 5.9 at short-term and 0.7 to 2.7 in the long-term follow-up in LP-PRP group. The DASH score of LR-PRP and LP-PRP were ranged from 47.0 to 54.3 and 30.0 to 67.7 separately before the treatment and 20.0 to 22.0 and 5.5 to 19.0 separately at long-term follow-up. LR-PRP and LP-PRP groups reflected successful rate ranged from 70%-100% and 36%-100% respectively. The complication rate lower in LP-PRP group (3.9%) than LR-PRP group (6.4%), with the major complication was temporary pain after PRP treatment (P = 0.029). Conclusion PRP treatment demonstrated a significant improvement with pain relief and functional improvement on lateral epicondylitis regardless types of PRP. There was no significant difference between LR-PRP and LP-PRP in pain relief and functional improvement. The major complication was temporary pain after PRP injection and the complication rate in LP-PRP was lower than LR-PRP.
Article
Résumé La pathologie tendineuse du coude, et plus particulièrement l’épicondylalgie tendineuse latérale, est fréquente dans le cadre des activités professionnelles, de loisir ou dans la pratique sportive. Dans la stratégie thérapeutique, le recours à différentes techniques de rééducation, le port d’orthèse et les traitements médicamenteux sont généralement utilisés en première intention. Les infiltrations font également partie des options thérapeutiques en deuxième ligne. Les infiltrations de corticoïdes ont généralement une efficacité à court terme mais ne sont plus recommandées en raison d’un taux de récidive élevé à long terme. Des infiltrations alternatives ont fait l’objet de nombreuses études offrant de nouvelles perspectives thérapeutiques. Les injections de plasma riche en plaquette (PRP) sont les plus étudiées montrant une efficacité supérieure à long terme aux injections de corticoïdes. D’après de nombreux travaux in vitro, le PRP, par l’intermédiaire des facteurs de croissance qu’il libère, agirait directement sur la régénération tendineuse. Les infiltrations d’acide hyaluronique ont également des résultats prometteurs mais les études sont encore trop peu nombreuses. Les injections de toxine botulique au niveau du muscle court extenseur radial du carpe (CERC) favorisent la réparation tendineuse par une mise au repos musculaire mais possèdent également une action antalgique. Les effets indésirables liés à la parésie musculaire induite ne permettent cependant pas une large utilisation. Si les infiltrations de PRP et d’acide hyaluronique constituent désormais une option dans la prise en charge des tendinopathies du coude, l’absence de consensus sur les modalités précises d’utilisation, des résultats parfois contradictoires dans la littérature scientifique et le niveau de preuve finalement insuffisant imposent encore de la prudence quant à une recommandation large. Dans tous les cas, ces thérapies s’inscrivent dans une prise en charge plus globale du patient.
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To compare the compressive strength of cannulated versus non-cannulated cancellous screws for undisplaced femoral neck fractures in synthetic bones. 18 synthetic proximal femurs simulating an AO B1 valgus impacted femoral neck fracture in osteoporotic bone were used. The fracture angles were between 55º and 63º (Pauwels grade 2). Fixation was made using 6.5-mm non-cannulated screws (n=6), 6.5-mm cannulated screws (n=6), or 7.3-mm cannulated screws (n=6). A custom-built jig was designed to guide the insertion of the screws in an identical triangular configuration. Screws were tightened by a single operator using a torquemeasuring screwdriver. The femoral head was subjected to progressive axial loading at 5 mm/min. The load to failure and displacement were recorded. The 3 groups did not differ significantly except that the load to failure was higher in the construct with 6.5-mm non-cannulated screws than that with 6.5-mm cannulated screws (1222 N vs 1008 N, p=0.003). The compressive strength of a synthetic bone hip fracture model fixed with non-cannulated screws was higher than that of cannulated screws of the same diameter.
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Objective: To investigate the efficacy of using contrast-enhanced ultrasound to assess the relationship of altered vascularity and tendon morphology following injection of platelet-rich plasma (PRP) for lateral epicondylitis. Materials and methods: This study prospectively evaluated six patients who had a baseline ultrasound confirming tendinosis of the common extensor tendon. Patients received a single 3-ml PRP injection under ultrasound guidance. Grayscale images of the injected elbow were obtained at baseline and were repeated at 1 and 6 months after injection. DEFINITY® contrast was also injected after by 2 sets of wrist-extension exercises in order to obtain contrast-enhanced images of the elbow. Qualitative and quantitative analyses of the level of enhancement to the regions of interest were performed using off-line quantitative analysis software. Results: All patients had either moderate or severe common extensor tendinosis as determined on clinical examination and baseline imaging. Five patients demonstrated improved tendon morphology using ultrasound imaging 6 months after PRP injection (one patient was lost to follow-up). At baseline, there was evidence of increased vascularity at the myotendinous junction (MT) of the common extensor tendon when compared to its footprint (FP). There was a trend towards no change in FP vascularity between baseline and 6 months (p = 0.062) and between 1 and 6 months (p = 0.288). There was a trend for increased vascularity to the MT region from baseline to 6 months (p = 0.433) and from 1 to 6 months (p = 0.783). Conclusions: Contrast-enhanced ultrasound provides a sensitive method the display alterations in vascularity in the common extensor tendon of the elbow. PRP therapy for lateral epicondylitis can improve extensor tendon morphology. Corresponding increased extensor tendon FP vascularity, however, was not seen. There is a trend for increased vascularity at the MT up to 6 months following PRP injection, based on limited pilot data.
Article
Eighteen patients (20 elbows) who underwent percutaneous tenotomy of the common extensor origin for lateral epicondylitis were evaluated. There were 11 female and 7 male patients. Two patients were operated on both the elbows. The symptoms were present for an average of 10 months before surgery. All these patients failed to respond to treatment by conservative methods i.e. activity modification, analgesics, splints, physiotherapy, and steroid injections. The mean follow-up period was 17 months. The forearm common extensor origin was released per-cutaneously under local anesthesia. The clinical results were evaluated in terms of pain relief, return to pre-pain activity level, grip strength, and patient satisfaction. Pain relief was obtained on average of 4 weeks after the surgical procedure. The results were excellent in 16 elbows and good in 4 elbows. The percutaneous tenotomy is a simple and quick procedure for lateral epicondylitis resistant to conservative mode of treatment.
Article
Platelet-rich plasma (PRP) is an emerging biological treatment option in sports medicine. Its value is best established for elbow-related disorders, such as lateral epicondylar tendinopathy. This common condition typically resolves with simple treatment modalities, such as rest, icing, anti-inflammatory medications, and physical therapy. In cases that are not resolved by these measures, other options such as cortisone injections and surgery are considered. Level one data now support the use of PRP in patients who have chronic tennis elbow. It is important to note that the formulation of PRP contains both concentrated platelets and white blood cells. The specific technical steps on how to prepare PRP and treat a patient with chronic lateral epicondylitis are outlined in this article. Using PRP to treat medial epicondylar tendinopathy, triceps tendinopathy, distal biceps tendinopathy, and partial elbow ligament injuries is under investigation.
Article
Background: Lateral epicondylitis (LE) is a common musculoskeletal disorder for which an effective treatment strategy remains unknown. Purpose: To examine whether a single injection of platelet-rich plasma (PRP) is more effective than placebo (saline) or glucocorticoid in reducing pain in adults with LE after 3 months. Study design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 60 patients with chronic LE were randomized (1:1:1) to receive either a blinded injection of PRP, saline, or glucocorticoid. The primary end point was a change in pain using the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire at 3 months. Secondary outcomes were ultrasonographic changes in tendon thickness and color Doppler activity. Results: Pain reduction at 3 months (primary end point) was observed in all 3 groups, with no statistically significant difference between the groups; mean differences were the following: glucocorticoid versus saline: -3.8 (95% CI, -9.9 to 2.4); PRP versus saline: -2.7 (95% CI, -8.8 to 3.5); and glucocorticoid versus PRP: -1.1 (95% CI, -7.2 to 5.0). At 1 month, however, glucocorticoid reduced pain more effectively than did both saline and PRP; mean differences were the following: glucocorticoid versus saline: -8.1 (95% CI, -14.3 to -1.9); and glucocorticoid versus PRP: -9.3 (95% CI, -15.4 to -3.2). Among the secondary outcomes, at 3 months, glucocorticoid was more effective than PRP and saline in reducing color Doppler activity and tendon thickness. For color Doppler activity, mean differences were the following: glucocorticoid versus PRP: -2.6 (95% CI, -3.1 to -2.2); and glucocorticoid versus saline: -2.0 (95% CI, -2.5 to -1.6). For tendon thickness, mean differences were the following: glucocorticoid versus PRP: -0.5 (95% CI, -0.8 to -0.2); and glucocorticoid versus saline: -0.8 (95% CI, -1.2 to -0.5). Conclusion: Neither injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at the primary end point at 3 months. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month in contrast to the other therapies. Injection of glucocorticoid in LE reduces both color Doppler activity and tendon thickness compared with PRP and saline.
Article
We designed a prospective, randomized study to evaluate the effects of iontophoresis delivery of dexamethasone versus corticosteroid injection therapy on patient outcomes. We randomized 82 patients to 10 mg dexamethasone via iontophoresis using a self-contained patch with a 24-hour battery; 10 mg dexamethasone injection; or 10 mg triamcinolone injection. All patients received the same hand therapy protocol. Primary outcomes tracked were change in grip strength (flexion vs extension), pain, and function scores on a validated questionnaire. The secondary outcome was return-to-work status. Patients were evaluated at baseline, completion of physical therapy, and 6-month follow-up. The iontophoresis patients had statistically significant improvement in grip strength at the conclusion of hand therapy compared with baseline. They were also more likely to get back to work without restriction. By 6-month follow-up, all groups had equivalent results for all measured outcomes. Dexamethasone via iontophoresis produced short-term benefits because for this group grip strength and unrestricted return to work were significantly better. This study suggests that this iontophoresis technique for delivery of corticosteroid may be considered a treatment option for patients with lateral epicondylitis. Therapeutic II.
Article
We compared saline, corticosteroid, and autologous blood injections for lateral epicondylitis in a prospective, blinded, randomized, controlled trial. The null hypothesis was that patient-rated outcomes after autologous blood injection would not be superior to corticosteroid and saline injections. Patients with clinically diagnosed lateral epicondylitis of less than 6 months' duration were randomized into 1 of 3 groups to receive a 3-mL injection of saline and lidocaine, corticosteroid and lidocaine, or autologous blood and lidocaine. Of 34 subjects who enrolled, 28 completed follow-up. A total of 10 were randomized to the saline group, 9 to the autologous blood group, and 9 to the steroid group. Every participant had 3 mL blood drawn, and the injection syringe was foil-covered to prevent the subject from knowing the contents. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Patients completed a pain visual analog scale, DASH, and the Patient-Rated Forearm Evaluation before injection and at 2 weeks, 2 months, and 6 months after injection. We performed statistical analysis using repeated measures of analyses of variance. There were no significant differences in DASH scores among the 3 groups at 2- and 6-month follow-up points, with the mean scores for saline at 20 and 10, respectively, compared with 28 and 20 for autologous blood and 28 and 13 for steroid injections. Secondary measures showed similar findings, with outcomes scores showing improvement in all 3 groups. In this prospective, randomized, controlled trial, autologous blood, corticosteroid, and saline injection provide no advantage over placebo saline injections in the treatment of lateral epicondylitis. Patients within each injection group demonstrated improved outcome scores over a 6-month period.