Platelet-Rich Plasma versus Corticosteroid Injection for Recalcitrant Lateral Epicondylitis: Clinical and Ultrasonographic Evaluation

Abstract

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.

Full text

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
REFERENCES
1. Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11:851–70.
2. Smith RW, Papadopolous E, Mani R, Cawley MI. Abnormal microvascular responses in a lateral epicondylitis. Br J Rheumatol
1994;33:1166–8.
3. Wang JH, Iosifidis MI, Fu FH. Biomechanical basis for tendinopathy. Clin Orthop Relat Res 2006;443:320–32.
4. Sharma H, Thomas S. Percutaneous tenotomy of common extensor origin for lateral epicondylitis resistant to conservative
treatment. J Clin Orthop Trauma 2010;1:23–5.
5. Altay T, Günal I, Oztürk H. Local injection treatment for lateral epicondylitis. Clin Orthop Relat Res 2002;398:127–30.
6. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of
tendinopathy: a systematic review of randomised controlled trials. Lancet 2010;376:1751–67.
7. Orchard J. Corticosteroid injection for lateral epicondylalgia is helpful in the short term, but harmful in the longer term; data
for non-corticosteroid injections and other tendinopathies are limited. Evid Based Med 2011;16:116–7.
8. Stefanou A, Marshall N, Holdan W, Siddiqui A. A randomized study comparing corticosteroid injection to corticosteroid
iontophoresis for lateral epicondylitis. J Hand Surg Am 2012;37:104–9.
9. Gandhi A, Dumas C, O’Connor JP, Parsons JR, Lin SS. The effects of local platelet rich plasma delivery on diabetic fracture
healing. Bone 2006;38:540–6.
10. Pietrzak WS, Eppley BL. Platelet rich plasma: biology and new technology. J Craniofac Surg 2005;16:1043–54.
11. Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA. Platelet-rich plasma: current concepts and application in sports
Studies No. of patients Follow-up Re-inter-
vention
Improvement in outcome (PRP vs. CS)
Peerbooms et
al.,23 2010
51 PRP vs. 49 CS 1 year - Visual analogue scale (VAS) for pain (25–73% vs. 49%),
Disabilities of the Arm, Shoulder and Hand Scale (DASH) score
(25–73% vs. 51%)
Gosens et al.,24
2011
51 PRP vs. 49 CS 2 years 6 vs. 14 VAS for pain (25–77% vs. 43%), DASH score (25–73% vs. 39%)
Krogh et al.,25
2013
20 PRP vs. 20 CS
vs. 20 saline
3 months - CS is superior to PRP at one month, but no significant difference
at 3 months; decrease in tendon thickness after CS and increase
in thickness after PRP
Current study 15 PRP vs. 15 CS 6 months - VAS for pain (77% vs. 59%), DASH score (54% vs. 41%),
modified Mayo score (26% vs. 8%), Oxford Elbow Score (50%
vs. 16%), hand grip strength (40% vs. 21%)
Table 3
Studies of platelet-rich plasma (PRP) versus corticosteroid (CS) injection for lateral epicondylitis
PRP initially inhibits the inammatory process and
then stimulates proliferation and maturation of the
healing process. It enhances stromal and mesenchymal
stem cell proliferation19 and prevents the brous
scar tissue healing that occurs with macrophage-
mediated tendon-to-bone healing.20 PRP may also
suppress macrophage proliferation and interleukin-1
production within the rst 72 hours.21,22 PRP injection
is superior to CS injection for chronic LE (Table 3).22
The recurrence rate and need for repeated injection
or surgery are higher in the CS than PRP group.23,24
Ultrasonography revealed a decrease in thickness
of the tendon after CS injection and an increase in
thickness after PRP injection.25 Increase in tendon
vascularity following PRP injection is associated with
improved tendon morphology.26 Autologous blood
injection reduces the total number of interstitial cleft
formations and anechoic foci, tendon thickness, and
neovascularity.27
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.

Vol. 23 No. 1, April 2015 Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis 5
medicine. J Am Acad Orthop Surg 2009;17:602–8.
12. Mishra A, Gosens T. Clinical indications and techniques for the use of platelet-rich plasma in the elbow. Oper Tech Sports
Med 2011;19:170–6.
13. Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid, and saline injection
in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am
2011;36:1269–72.
13. Connell D, Burke F, Coombes P, McNealy S, Freeman D, Pryde D, et al. Sonographic examination of lateral epicondylitis.
AJR Am J Roentgenol 2001;176:777–82.
14. Levin D, Nazarian LN, Miller TT, O’Kane PL, Feld RI, Parker L, et al. Lateral epicondylitis of the elbow: US findings.
Radiology 2005;237:230–4.
15. Anitua E, Andia I, Sanchez M, Azofra J, del Mar Zalduendo M, de la Fuente M, et al. Autologous preparations rich in
growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in culture. J Orthop
Res 2005;23:281–6.
16. de Mos M, van der Windt AE, Jahr H, van Schie HT, Weinans H, Verhaar JA, et al. Can platelet-rich plasma enhance tendon
repair? A cell culture study. Am J Sports Med 2008;36:1171–8.
17. Kajikawa Y, Morihara T, Sakamoto H, Matsuda K, Oshima Y, Yoshida A, et al. Platelet-rich plasma enhances the initial
mobilization of circulation-derived cells for tendon healing. J Cell Physiol 2008;215:837–45.
18. Lucarelli E, Beccheroni A, Donati D, Sangiorgi L, Cenacchi A, Del Vento AM, et al. Platelet-derived growth factors enhance
proliferation of human stromal stem cells. Biomaterials 2003;24:3095–100.
19. Kawamura S, Ying L, Kim HJ, Dynybil C, Rodeo SA. Macrophages accumulate in the early phase of tendon-bone healing.
J Orthop Res 2005;23:1425–32.
20. Woodall J Jr, Tucci M, Mishra A, Asfour A, Benghuzzi H. Cellular effects of platelet rich plasma: interleukin-1 release from
PRP treated macrophages. Biomed Sci Instrum 2008;44:489–94.
21. Woodall J Jr, Tucci M, Mishra A, Benghuzzi H. Cellular effects of platelet rich plasma: a study on HL-60 macrophage-like
cells. Biomed Sci Instrum 2007;43:266–71.
22. Mishra A, Collado H, Fredericson M. Platelet-rich plasma compared with corticosteroid injection for chronic lateral elbow
tendinosis. PMR 2009;1:366–70.
23. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis
in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up.
Am J Sports Med 2010;38:255–62.
24. Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid
injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med
2011;39:1200–8.
25. Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with
platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med
2013;41:625–35.
26. Chaudhury S, de La Lama M, Adler RS, Gulotta LV, Skonieczki B, Chang A, et al. Platelet-rich plasma for the treatment
of lateral epicondylitis: sonographic assessment of tendon morphology and vascularity (pilot study). Skeletal Radiol
2013;42:91–7.
27. Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis
elbow. Skeletal Radiol 2006;35:371–7.