Tennis Elbow: Blood and Platelet-Rich Plasma (PRP) Injections

Fig. 8.1

Combination injection: autologous blood and 1 ml local anesthesia in one injection

Fig. 8.2

Single-shot or peppering technique

There have been a number of randomized controlled trials evaluating autologous blood injections for lateral epicondylitis, although only one with comparison to a placebo injection. Wolf et al. performed a randomized controlled trial (RCT) of 28 patients comparing autologous blood, corticosteroid, and a saline injection [13]. The study was double-blinded and patients were evaluated at 2 weeks, 2 months, and 6 months after injection with Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH), and the patient-related forearm evaluation. Although all of these outcomes demonstrated improvement from baseline in each group, there were no significant differences in any of the groups. However, the authors point out that the small number of patients in the study may limit their power to detect a difference between groups.

In 2010, Ozturan compared autologous blood injection to both corticosteroid injection and extracorporeal shock wave therapy in a three-armed randomized trial of 60 patients [14]. Although corticosteroid treatment showed the best outcomes at 4 weeks, success rates at 1 year were greatest for the autologous blood (83 %) and extracorporeal shock wave therapy (90 %) compared to only 50 % for corticosteroids. This study concluded that while corticosteroid injections provided better short-term relief of symptoms, autologous blood injections showed significantly better long-term results with decreased recurrence.

Kazemi directly compared autologous blood to corticosteroid injections in a short-term RCT of 60 patients [15]. As opposed to Ozturan et al.’s study, the authors found improved outcomes measures in the short-term for autologous blood. At 4 weeks, autologous blood was significantly more effective at decreasing pain scores at rest and with grip, as well as increasing QuickDASH scores (p > 0.001, p = 0.002, p = 0.004). These results persisted at 8 weeks (p < 0.001 for all measures).

Dojode performed a randomized study with 60 patients comparing autologous blood with local corticosteroid injection in a labor-intensive population [16] with 6 month follow up. Patients receiving corticosteroid injections had significantly decreased pain and Nirschl stage at 1 week (p < 0.001, both) and 4 weeks (p = 0.002, p = 0.018). However, outcomes were reversed as time went on. At 12 weeks and 6 months, patients who had received autologous blood had significantly lower pain and Nirschl stage scores (p = 0.013, p = 0.018 at 12 weeks, p = 0.006, p = 0.006 at 6 months, respectively). At the 6 month time follow up, 90 % of patients who had received autologous blood injection reported complete relief of pain, compared to 47 % of patients receiving steroid injection. This study concluded that autologous blood injections provide improved long-term relief of symptoms compared to corticosteroid injections.

There have been few side effects demonstrated from autologous blood injections. Most commonly authors cite the pain after injection as the most difficult side effect for patients. Ozturan describes 89 % of patients having cessation of pain within 2 days, and the remaining 11 % of patients had pain from 4 to 6 days[14]. In addition, 21 % had elbow erythema, 16 % had swelling, and 21 % had nausea. Wolf et al. and Kazemi et al. described no side effects [13, 15]. Dojode reported 60 % of patients having pain after the injection that resolved within a few days after injection [16].

In summary, autologous blood injections offer numerous factors to stimulate a healing cascade in the degenerative tendinous origin. Studies have shown beneficial effects for patients receiving these injections in the short- and long-term, predominantly compared to steroid injections. However, in the only placebo-controlled study, no significant benefit was observed for autologous blood injection. Additionally, one study showed no difference between autologous blood injections and extracorporeal shock wave therapy. Further investigation comparing autologous blood injections to placebo injections or conservative treatment with larger patient groups will shed more light on their efficacy.

Platelet Rich Plasma (PRP)

Autologous PRP is a concentrated source of platelets and platelet-derived growth factors that has been used for numerous musculoskeletal diagnoses. PRP is theorized to enhance the healing of wounds, bone, and tendons through release of specific growth factors upon platelet activation [17]. PRP has the theoretical advantage of increased concentration of platelets and therefore platelet-derived growth factors [17].

PRP is prepared by drawing 20–60 cc of blood from the patient. An FDA-approved blood separation device is used to centrifuge the blood for 15 min to isolate PRP [17]. This produces 3–6 mL of PRP (Fig. 8.3), which can be combined with or given after injection of 1–2 mL of local anesthetic (Fig. 8.4). Carofino et al. reported that lidocaine can cause inhibitory effects on tenocyte proliferation after exposure to PRP in vitro [18]. However, as the most common side effect from this injection is pain, it is standard to inject at least a small amount of local anesthetic into the skin with or prior to the injection.

Fig. 8.3

Platelet-rich plasma (PRP). 20–60 cc of blood will, after 15 min centrifuge, produce 3–6 mL PRP

Fig. 8.4

Platelet-rich plasma (PRP) can be administered after local anesthetic, or be combined with it

Mishra et al. were the first to study the efficacy of PRP for lateral epicondylitis treatment [19]. In an unblinded prospective study, the authors treated 20 patients with chronic lateral epicondylitis using PRP in 15 and control bupivacaine in 5 [19]. At 8 weeks, patients who received PRP injections had significantly better VAS scores than the bupivacaine group. At final follow up of 1–3 years, 93 % had reduction in VAS pain scores.

There have been a number of randomized controlled trials evaluating PRP in the treatment of tennis elbow. Peerbooms et al. compared PRP with corticosteroid injection in a double-blind randomized trial of 100 patients [20]. Successful treatment was defined as > 25 % reduction in VAS score with no reintervention. The authors found that at the early 4-week time point, patients in the corticosteroid group showed slightly more improvement. However, at 26 and 52 weeks, VAS and DASH scores were significantly better for the PRP group (p < 0.001 and p = 0.005), with resolution in 73 % of the PRP group vs. 49 % the corticosteroid group. At 2 years, 81 % of PRP patients reported successful outcomes compared to 40 % of the corticosteroid group [21].

Krogh et al. compared PRP to corticosteroid and placebo injections with 60 patients in a short-term, randomized, double-blind trial [22]. Similar to the results of Peerbooms et al., improved pain relief was demonstrated at 1 month in the corticosteroid group compared to PRP and placebo. However, at 3 months follow up, there were no significant differences between the three groups using the patient-related tennis elbow evaluation (PRTEE).

Stenhouse et al. performed a randomized trial comparing 2 ml PRP injection with dry needling in 28 patients with refractory tennis elbow, with a mean duration of symptoms of 19 months [23]. The authors found that there was a trend towards greater clinical improvement, as measured by reduction in VAS scores, at 2 and 6 months for the PRP group compared to dry needling, but the differences were not significant. However, the small cohort sizes may have impacted power to determine a difference.

Mishra et al. recently reported the largest randomized controlled study to date, in which 230 patients were blinded and randomized to either needling the extensor origin with either PRP or nothing, after injection of lidocaine in both groups [24]. At 12 weeks with 83 % follow up, the groups were not significantly different with regards to improvement in pain scores. However, for the 119 patients who had data available at 24 weeks, those receiving PRP had a 71 % improvement in their pain scores compared to 56 % for the control group (p = 0.027). The percentage with remaining significant elbow tenderness was 29 % for the PRP group vs. 54 % for the control group (p < 0.001).

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