Lateral epicondylitis (tennis elbow) is a frequent cause of elbow pain; most patients (80%–90%) are successfully treated with standard nonoperative methods (rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy). Autologous blood injections and platelet-rich plasma injections are the two most frequently used orthobiologic techniques in the treatment of lateral epicondylitis. Studies of the effectiveness of autologous blood injections and platelet-rich plasma report varying outcomes, some citing significant clinical relief and others reporting no beneficial effect. More research is needed to determine how to best use orthobiologics in the treatment of lateral epicondylitis.
Key points
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Lateral epicondylitis (tennis elbow) is a frequent cause of elbow pain; most patients (80%–90%) are successfully treated with standard nonoperative methods (rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy).
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Autologous blood injections (ABI) and platelet-rich plasma (PRP) injections are the two most frequently used orthobiologic techniques in the treatment of lateral epicondylitis (tennis elbow).
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Studies of the effectiveness of ABI and PRP report varying outcomes, some citing significant clinical relief and others reporting no beneficial effect.
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More research is needed to determine how to best use orthobiologics in the treatment of lateral epicondylitis.
Lateral epicondylitis (tennis elbow) is a common cause of elbow pain, affecting approximately 2% to 3% of the general population and up to 40% of athletes participating in overhead sports, such as tennis. A recent large-scale, population-based study estimated that nearly 1 million individuals in the United States develop lateral epicondylitis each year. In 80% to 90% of patients, the condition is self-limiting and resolves within a year. Walker-Bone and colleagues, however, found that 27% of patients with lateral epicondylitis had severe difficulties with activities of daily living, and the current consensus is that a year is too long for the patient to wait for relief from pain, disability, and loss of economic productivity.
Pathology
Generally, lateral epicondylitis results from microtrauma to the extensor carpi radialis brevis, but may involve other tendons within the forearm extensor muscles, such as the extensor digitorum communis. Nirschl described four stages based on severity of tendon involvement: (1) initial inflammatory reaction, (2) angiofibroblastic degeneration, (3) structural failure or rupture, and (4) structural failure plus fibrosis and calcification. Most patients who present with sports-related lateral epicondyitis have stage 2 involvement (angiofibroblastic degeneration).
Patient evaluation/examination
The most common complaint of patients with lateral epicondylitis is pain around the bony prominence of the lateral epicondyle that radiates along the forearm within the area of the common extensor mass. Typically, pain is exacerbated by repetitive activities that involve contraction of the forearm extensors. Nirschl described seven stages based on pain severity ( Table 1 ).
| Phase 1 | Mild pain with exercise, resolves within 24 h |
| Phase 2 | Pain after exercise, exceeds 48 h |
| Phase 3 | Pain with exercise, does not alter activity |
| Phase 4 | Pain with exercise, alters activity |
| Phase 5 | Pain with heavy activities of daily living |
| Phase 6 | Pain with light activities of daily living, intermittent pain at rest |
| Phase 7 | Constant pain at rest, disrupts sleep |
Pathology
Generally, lateral epicondylitis results from microtrauma to the extensor carpi radialis brevis, but may involve other tendons within the forearm extensor muscles, such as the extensor digitorum communis. Nirschl described four stages based on severity of tendon involvement: (1) initial inflammatory reaction, (2) angiofibroblastic degeneration, (3) structural failure or rupture, and (4) structural failure plus fibrosis and calcification. Most patients who present with sports-related lateral epicondyitis have stage 2 involvement (angiofibroblastic degeneration).
Patient evaluation/examination
The most common complaint of patients with lateral epicondylitis is pain around the bony prominence of the lateral epicondyle that radiates along the forearm within the area of the common extensor mass. Typically, pain is exacerbated by repetitive activities that involve contraction of the forearm extensors. Nirschl described seven stages based on pain severity ( Table 1 ).
| Phase 1 | Mild pain with exercise, resolves within 24 h |
| Phase 2 | Pain after exercise, exceeds 48 h |
| Phase 3 | Pain with exercise, does not alter activity |
| Phase 4 | Pain with exercise, alters activity |
| Phase 5 | Pain with heavy activities of daily living |
| Phase 6 | Pain with light activities of daily living, intermittent pain at rest |
| Phase 7 | Constant pain at rest, disrupts sleep |
Nonoperative treatment
Traditional nonoperative methods include rest, nonsteroidal anti-inflammatory drugs (NSAIDs), bracing, and physical therapy. Because of reports in the literature that corticosteroid injections, although they provide short-term pain relief, may actually have deleterious effects, efforts have increased to evaluate biologics that may enhance healing of the degenerated extensor tendons.
Autologous Blood Injection
Autologous whole blood injections (ABI) have been widely used for treatment of lateral epicondylitis. The rationale is that ABI can initiate an inflammatory reaction around the tendon, which leads to cellular and humoral mediators to induce a healing cascade. Another hypothesis is that ABI allows delivery of growth factors that increase vascularity and new collagen formation. In studies comparing ABI with corticosteroids or platelet-rich plasma (PRP), results have been mixed ( Table 2 ).
| Author/Date | Compared with | # Patients | Results |
|---|---|---|---|
| Sirico et al, 2016 | CC | Meta-analysis | Currently available data offer no support for the effectiveness of ABI in medium- and long-term follow-up. |
| Tsikopoulos et al, 2016 | CC | Meta-analysis | ABI provided significant clinical relief of epicondylopathy at 8–24 wk. |
| Qian et al, 2016 | CC | Meta-analysis | CSIs were more effective than ABIs for pain relief in the short term; however, in the intermediate term, ABIs exhibited a better therapeutic effect for pain relief. ABIs seemed to be more effective at restoring function in the intermediate term. |
| Chou et al, 2016 | CC, PRP | Meta-analysis | ABI more effective than steroid injection, but not more effective than PRP. |
| Arirachakaran et al, 2016 | CC, PRP | Meta-analysis | Both ABI and PRP can improve pain and function; ABI has higher risk of complications. |
| Arik et al, 2014 | CC | 80 | ABI was more effective in improving pain, function, and grip strength. It is recommended as a first-line injection treatment because it is simple, cheap, and effective. |
| Jindal et al, 2013 | CC | 50 | ABI was more effective than steroid injection in the short-term follow-up in tennis elbow. |
| Dojode, 2012 a | CC | 60 | The corticosteroid injection group showed a statistically significant decrease in pain compared with ABI group in visual analogue scale and Nirschl stage at 1 wk and at 4 wk. At the 12-wk and 6-mo follow-up, the ABI group showed statistically significant decrease in pain compared with corticosteroid injection group. At the 6-month final follow-up, a total of 14 patients (47%) in the corticosteroid injection group and 27 patients (90%) in ABI group were completely relieved of pain. |
| Ozturan et al, 2010 | CC ECSWT | 60 | Corticosteroid injection gave significantly better results for all outcome measures at 4 wk; success rates in the three groups were 90%, 16.6%, and 42.1%, respectively. ABI and ECSWT gave significantly better Thomsen provocative test results and upper extremity functional scores at 52 wk; the success rate of corticosteroid injection was 50%, which was significantly lower than the success rates for ABI (83.3%) and ECSWT (89.9%). Corticosteroid injection provided a high success rate in the short term. However, ABI and ECSWT gave better long-term results, especially considering the high recurrence rate with corticosteroid injection. Authors suggested that the treatment of choice for lateral epicondylitis is ABI. |
| Wolf et al, 2011 | CC, saline | 28 | No differences in DASH scores at 2- and 6-mo follow-up. All three groups had improved outcomes at 6 mo. |
| Stenhouse et al, 2013 | Dry needling | 28 | Trend toward greater clinical short-term improvement with ABI, but no significant difference demonstrated at each follow-up interval. |
a Prospective, randomized trial; CC, corticosteroid; CCI, corticosteoid injection; DASH, Disabilities of the Arm, Shoulder, and Hand; ECSWT, extracorporeal shock wave therapy.
Two recent meta-analyses came to contradictory conclusions. Tsikopolous and colleagues determined that ABI provides significant clinical relief at 8 to 24 weeks, whereas Sirico and colleagues concluded that currently available data offer no support for the effect of ABI in medium- or long-term follow-up. Several studies found better pain relief at 4 weeks with corticosteroid injections but better long-term results with ABI, whereas others found ABI more effective at short-term follow-up and others found no differences at either short-term or long-term follow-up. Based on their systematic review and network meta-analysis, Arirachakaran and colleagues concluded that, when comparing ABI, PRP, and corticosteroid injections, PRP was best at reducing pain, whereas ABI was best for functional improvements; however, ABI had the highest risk of adverse effects (injection site pain and skin reaction).
Technique (Calandruccio)
A total of 2 mL of autologous blood are drawn from the ipsilateral upper extremity and mixed with 1 mL of 2% lidocaine HCl or 1 mL of 0.5% bupivacaine HCl. The needle is introduced proximal to the lateral epicondyle along the supracondylar ridge and gently advanced into the undersurface of the extensor carpi radialis brevis while infusing the blood-anesthetic mixture extra-articularly ( Fig. 1 ).
