Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: a systematic review and meta-analysis of randomized placebo-controlled clinical trials

Comparative Efficacy of Platelet-Rich Plasma, Corticosteroid, Hyaluronic Acid, and Placebo (Saline) Injections in Patients with Lateral Elbow Tendinopathy: A Randomized Controlled Trial

Background: Lateral elbow tendinopathy is a common condition that significantly alters the function of the upper extremities. In case of first-line treatment failure, different local injections are usually used. Due to the lack of sufficient evidence to support it, we conducted the study to compare the outcomes of different single injections, including Platelet-Rich Plasma (PRP), Corticosteroids (CS), Hyaluronic Acid (HA), and placebo (saline). Methods: Sixty patients with confirmed lateral elbow tendinopathy were enrolled in the study and divided into four groups. Pain intensity (average for the current day, at rest, during provocative tests) measured by Visual Analogue Scale (VAS), pressure pain threshold (PPT), Patient-Rated Tennis Elbow Evaluation (PRTEE), Disability of Arm, Shoulder and Hand (DASH), Subjected Elbow Value (SEV), and strength of selected muscle groups were measured before and during follow-up visits (1, 4, 12, 24, and 52 weeks after treatment). The treatment was considered successful when minimal clinically important difference (MCID) was achieved in primary outcomes (VAS, PRTEE). Results: A significant improvement was achieved in most measurements in all groups. At the final follow-up, MCID for the mean pain reduction measured with VAS and improvement in the PRTEE score were achieved in 52 and 54 patients, respectively. The complete absence of pain was achieved after 1, 4, 12, 24, and 52 weeks in 2, 5, 10, 22, and 40 patients, respectively. The comparison between the groups found a significant difference in pain intensity between CS and other groups one week after injection, between the CS and PRP group in the fourth week, and between PRP and HA in the fourth week (p < 0.05). No other significant differences were found between each group at each follow-up time point. Conclusions: We conclude that each injection treatment provides good long-term clinical outcomes, but not better than placebo. A CS injection might be regarded as a more effective treatment only within the first month post-injection.

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Elbow and Upper Extremity: An Orthoregeneration Network Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the elbow and upper extremity, including the tendons (lateral epicondylitis, medial epicondylitis, biceps tendonitis, triceps tendonitis), articular cartilage (osteoarthritis, osteochondral lesions), and bone (fractures, nonunions, avascular necrosis, osteonecrosis). Promising and established treatment modalities include hyaluronic acid; botulinum toxin; corticosteroids; leukocyte-rich and leukocyte-poor platelet-rich plasma; autologous blood; bone marrow aspirate comprising mesenchymal stromal cells (alternatively termed medicinal signaling cells and frequently mesenchymal stem cells [MSCs]) and bone marrow aspirate concentrate; MSCs harvested from adipose and skin (dermis) sources; vascularized bone grafts; bone morphogenic protein scaffold made from osteoinductive and conductive β-tricalcium phosphate and poly-ε-caprolactone with hydrogels, human MSCs, and matrix metalloproteinases; and collagen sponge. Autologous blood preparations such as autologous blood injections and platelet-rich plasma show positive outcomes for nonresponsive tendinopathy. In addition, cellular therapies such as tissue-derived tenocyte-like cells and MSCs show a promising ability to regulate degenerative processes by modulating tissue response to inflammation and preventing continuous degradation and support tissue restoration. LEVEL OF EVIDENCE: Level V, expert opinion.

Lateral Epicondylitis: Treatment Preferences from the Potential Patient Perspective

Background

Knowing the questions and concerns that patients have regarding treatment options for lateral epicondylitis may allow for shared-decision making and potentially superior patient outcomes and satisfaction. In the present study, we aimed to further delineate patient preferences with treatment of lateral epicondylitis.

Methods

An online, survey-based, descriptive study was conducted through Amazon Mechanical Turk. Survey participants were presented with a clinical scenario regarding lateral epicondylitis and asked four questions regarding treatment preferences for nonoperative treatment, whether they would consider platelet-rich plasma (PRP) injection, and whether they would consider surgical intervention for recalcitrant symptoms. A Likert scale was used for responses. McNemar chi-square test was used for paired nominal data for statistical analysis.

Results

A total of 238 survey responses were included. A majority (63%) of respondents elected to proceed with formal physical therapy. When given additional information regarding corticosteroid injections, 50.8% of respondents reported preferring physical therapy. There were no differences between groups for questions 1 and 2 (P = 0.90). Of the respondents, 75.2% were "likely" or "extremely likely" to consider PRP injection. When asked about surgical intervention, 74.8% of respondents were "likely" or "extremely likely" to proceed with continued symptoms.

Conclusions

It is important to include patient preferences in treatment discussions of lateral epicondylitis. Survey respondents preferred formal physical therapy for initial treatment. A surprising majority of respondents were likely to consider a PRP injection. With prolonged symptoms, respondents were interested in discussions of surgical intervention and thus, it should continue to be offered to patients with recalcitrant symptoms.

Treatment of Tendon Injuries in the Servicemember Population across the Spectrum of Pathology: From Exosomes to Bioinductive Scaffolds

Tendon injuries in military servicemembers are one of the most commonly treated nonbattle musculoskeletal injuries (NBMSKIs). Commonly the result of demanding physical training, repetitive loading, and frequent exposures to austere conditions, tendon injuries represent a conspicuous threat to operational readiness. Tendon healing involves a complex sequence between stages of inflammation, proliferation, and remodeling cycles, but the regenerated tissue can be biomechanically inferior to the native tendon. Chemical and mechanical signaling pathways aid tendon healing by employing growth factors, cytokines, and inflammatory responses. Exosome-based therapy, particularly using adipose-derived stem cells (ASCs), offers a prominent cell-free treatment, promoting tendon repair and altering mRNA expression. However, each of these approaches is not without limitations. Future advances in tendon tissue engineering involving magnetic stimulation and gene therapy offer non-invasive, targeted approaches for improved tissue engineering. Ongoing research aims to translate these therapies into effective clinical solutions capable of maximizing operational readiness and warfighter lethality.

Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review

Objective

The primary objective of this review was to summarize systematic reviews and meta-analyses reporting on nonoperative management of lateral epicondyle tendinopathy.

Methods

An umbrella review of all published systematic reviews and meta-analyses was performed. Three databases were searched using the key words "tennis elbow," "lateral epicondylitis," "non-operative," and "non-surgical modalities." The search was limited to English-language systematic reviews and meta-analyses between the years of 2000 and 2022.

Results

There were 114 systematic reviews/meta-analyses, of which 35 met our inclusion criteria. These articles reviewed the following nonoperative management strategies: ultrasound, shockwave therapy, injection procedures, low-level laser therapy, joint mobilizations, exercise therapy, and electrophysical modalities. Exercise therapy was beneficial in decreasing pain regardless of dosage or type. Conflicting results were seen with ultrasound, laser, and shockwave therapy. Corticosteroid injections provided the most short-term pain relief, and platelet-rich plasma and autologous blood injections were most effective in the long term.

Conclusion

A variety of nonoperative interventions were found to be effective for short- and long-term pain relief as well as functional improvement, with most interventions indicating mixed results. Due to variations in study populations and study quality, results should be interpreted with caution.

BESS patient care pathway: Tennis elbow

This article provides a guidance summary for the management of lateral elbow tendinopathy (LET) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of the rating quality of the literature and grading the strength of available evidence. The process began by assembling a guideline development group of volunteers including orthopaedic surgeons, trainees, physiotherapists, rheumatologists, radiologists and patients. Virtual meetings were organised to set out explicit PICO questions, including specification of all important outcomes (including patient reported tennis elbow evaluation (PRTEE) as an important primary outcome) to determine the clinical effectiveness of common treatment options for LET compared with no treatment or placebo. Clinical librarian searched (date 31 April 2022) for available systematic reviews and randomised controlled trials reviewing the management of the LET January 2011 onwards and evidence was collected and summarized using explicit GRADE criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations were characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of alternative management options. This informative summary provides the quality of available evidence for the management of LET.

A Clinical Overview of the Natural Course and Management of Lateral Epicondylitis

Lateral epicondylitis (LE), also often called tennis elbow, is a frequent cause of elbow pain. The most characteristic symptom of LE is pain and burning around the lateral epicondyle of the humerus that may radiate to the forearm or to the upper arm. Ultrasonography is a quick and noninvasive tool used to confirm (or exclude) the diagnosis of LE. Management of LE symptoms should be directed to the management of pain, protection of movement, and improvement of arm performance. Treatment of LE includes nonoperative techniques and surgery. [Orthopedics. 2023;46(4):e210-e218.].

Lateral Epicondylitis: Critical Analysis Review of Current Nonoperative Treatments

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Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm.

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The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time.

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Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments.

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In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

Platelet-Rich Plasma Injections Decrease the Need for Any Surgical Procedure for Chronic Epicondylitis versus Conservative Treatment-A Comparative Study with Long-Term Follow-Up

Background: Platelet-rich plasma (PRP) injections may alleviate symptoms of chronic medial or lateral epicondylitis. Methods: We retrospectively analyzed a total of 55 patients with chronic ME or LE who had undergone at least 6 months of any conservative treatment before intervention. The patients were divided into two groups: the PRP group (n = 25), who received a single injection of autologous PRP to the medial or lateral epicondyle, and the PT group (n = 30), who continued with PT and pain medication. The primary outcome measures were pain and functional outcomes measured in terms of the following: Patient Related Tennis Elbow Evaluation (PRTEE), Visual Analogue Scale (VAS), and Disabilities of the Arm, Shoulder, and Hand (DASH), which were detected at preintervention, 6-, 12-, 24-, and 36-month follow-up. Secondary outcomes included complications and the need for any surgery at follow-up. Results: Primary outcome measurements showed significantly better results favoring the PRP group (6-month PRTEE total 43.2 ± 19.2 vs. 62.8 ± 24.0, p < 0.001; 12-month PRTEE total 6.9 ± 15.0 vs. 28.1 ± 24.4, p < 0.001; 24-month PRTEE total 4.8 ± 9.8 vs. 12.7 ± 14.5, p = 0.029), and significantly better results in VAS and DASH sub-scores. The PRP group required significantly fewer surgical procedures (n = 0/0% vs. n = 6/20%, p = 0.027) at follow-up (mean 38.3 ± 12.3 months), and one case of prolonged pain after injection was detected. Conclusions: Patients who underwent PRP injections for epicondylitis resulted in better pain and functional outcomes compared to physiotherapy, and this improvement lasted at least 24 months. They required fewer surgical procedures and achieved faster recovery than the PT group. We recommend PRP for chronic epicondylitis of the elbow before considering surgery when other treatments have failed.

Position statement: nonoperative management of lateral epicondylitis in adults

We sought to compare methods of nonsurgical treatment of lateral epicondylitis in men and women older than 18 years to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane through to Mar. 9, 2021, and included all English-language studies comparing nonsurgical approaches. We compared physiotherapy versus no active treatment, corticosteroids versus placebo, platelet-rich plasma (PRP) versus placebo, and autologous blood injection versus placebo. Outcomes of interest were pain outcomes (visual analogue scale scores) and functional outcomes. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking nonsurgical intervention for lateral epicondylitis by improving counselling on nonsurgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various nonsurgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.

The use of platelet-rich plasma in management of musculoskeletal pain: a narrative review

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.

Effectiveness of Lateral Elbow Tendinopathy Treatment Depends on the Content of Biologically Active Compounds in Autologous Platelet-Rich Plasma

Autologous platelet-rich plasma (PRP) injection is an alternative treatment option for patients with lateral elbow tendinopathy. The treatment is supposed to accelerate tissue regeneration by providing high concentrations of growth factors derived from platelets. The aim of the study was to assess the relationship between the content of biologically active compounds in PRP and the clinical effect of the treatment. Thirty patients with lateral elbow tendinopathy treated with a single PRP injection, were evaluated. The pain intensity (measured by a visual analogue scale (VAS)), the pressure pain threshold (PPT), the grip strength and strength of the main arm and forearm muscle groups, and the functional outcome (measured by the Disability of Arm, Shoulder and Hand (DASH) and Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaires), were assessed before PRP injection and at one- and three-months follow-up. Flow cytometry measurements of the growth factors and inflammatory cytokines in PRP were performed, and the results were used to establish the relationship between those molecules and the clinical outcome. After three months from the intervention, the minimal clinically important difference in pain reduction and functional improvement was observed in 67% and 83% of patients, respectively. Positive correlations were found between the extent of pain reduction after three months and concentrations in the PRP of platelets, epidermal growth factor (EGF), vascular endothelial growth factor, and platelet-derived growth factors. The concentration of EGF in the PRP significantly correlated with an improvement in grip strength, strength of wrist extensors, and the size of functional improvement measured by the PRTEE. The local injection of PRP is a safe and effective treatment option for lateral elbow tendinopathy, and the clinical outcome is correlated with concentrations of its biologically active compounds.

The effect of leucocyte concentration of platelet-rich plasma on outcomes in patients with lateral epicondylitis: a systematic review and meta-analysis

HYPOTHESIS

The concentration of leukocytes influences the quality of platelet-rich plasma (PRP). However, there is no consensus on which type of PRP based on the concentration of leukocytes is the best for lateral epicondylitis (LE).

METHODS

We systematically searched the MEDLINE, Embase, and Cochrane Library databases until March 1, 2020. Studies involving randomized controlled trials, patients with LE, and treatment with PRP injections were included. PRP was classified into leukocyte-poor (LP) PRP and leukocyte-rich (LR) PRP. LR-PRP was defined as PRP with a white blood cell concentration exceeding that of whole blood (4.0-10.0 per μL³), whereas LP-PRP was defined as PRP with a lower white blood cell concentration than that of whole blood. The efficacy of PRP was assessed using the visual analog scale (VAS) and success rates.

RESULTS

Eleven randomized controlled trials (six involving LP-PRP and five involving LR-PRP) were eligible for inclusion in this review. Eight studies were included in the meta-analysis to evaluate the VAS score. Regarding short-term follow-up, there was no difference in the VAS scores between the LP-PRP and control groups (standard mean difference [SMD], 0.01; 95% confidence interval [CI], -0.29 to 0.30; P = 0.97), with no heterogeneity (I² = 0%). There was also no difference in the VAS scores between the LR-PRP and control groups (SMD, -0.19; 95% CI, -0.57 to 0.20; P = 0.34), with substantial heterogeneity (I² = 56.7%). Regarding long-term follow-up, there was no difference in the VAS scores between the LP-PRP and control groups (SMD, -0.73; 95% CI, -1.69 to 0.23; P = 0.134) with substantial heterogeneity (I² = 88.4%). The LR-PRP group had lower VAS scores than the control group (SMD, -1.06; 95% CI, -2.02 to -0.09; P = 0.032) with substantial heterogeneity (I² = 92%). In the LP-PRP group, there was no significant difference in the success rate (odds ratio, 1.08; 95% CI, 0.07-16.47; P = 0.956) with substantial heterogeneity (I² = 87.7%). In the LR-PRP group, however, the patients who received PRP had a higher success rate than those in the control group (odds ratio, 2.85; 95% CI, 1.67-4.85; P < 0.01) with substantial heterogeneity (I² = 82.9%).

CONCLUSION

LR-PRP may provide pain relief and successful outcomes for patients with LE compared with alternative local injections. Better results were observed with the use of LR-PRP than with the use of LP-PRP.

Effects of Hypertonic Dextrose Injection (Prolotherapy) in Lateral Elbow Tendinosis: A Systematic Review and Meta-analysis

OBJECTIVE

To systematic review the effectiveness of hypertonic dextrose prolotherapy (DPT) on pain intensity and physical functioning in patients with lateral elbow tendinosis (LET) compared with other active non-surgical treatments.

DATA SOURCES

Systematic search of CENTRAL, MEDLINE, EMBASE, Web of Science, PubMed, Dimensions, Global Health, NHS Health Technology Assessment, AMED and OVID nursing database from inception to 15 June 2021, without language restrictions.

STUDY SELECTION

Two reviewers independently identified parallel or cross-over RCTs that evaluated the effectiveness of DPT in LET. The search identified 245 records; data from 8 studies (354 patients) were included.

DATA EXTRACTION

Two reviewers independently extracted data and assessed included studies. The Cochrane Risk of Bias 2 tool was used to evaluate risk of bias. The Grading of Recommendation Assessment, Development, and Evaluation approach was used to assess quality of the evidence.

DATA SYNTHESIS

Pooled results favored the use of DPT in reducing tennis elbow pain intensity compared with active controls at 12 weeks post-enrollment, with standardized mean difference (SMD) of -0.44 (95% CI -0.88 to -0.01, P =0.04) and of moderate heterogeneity (I²= 49%). Pooled results also favored the use of DPT on physical functioning compared with active controls at 12 weeks, with DASH score achieving mean difference (MD) -15.04 (95% CI -20.25 to -9.82, P < 0.001) and of low heterogeneity (I²= 0.0%). No major related adverse events have been reported.

CONCLUSIONS

DPT is superior to active controls at 12 weeks for decreasing pain intensity and functioning by margins that meet criteria for clinical relevance in the treatment of LET. While existing studies are too small to assess rare adverse events, for LET patients, especially those refractory to first-line treatments, DPT can be considered a non-surgical treatment option in carefully selected patients. Further high-quality trials with comparison with other injection therapies are needed.

Nonoperative treatment of lateral epicondylitis: a systematic review and meta-analysis

Background

There is an ongoing controversy regarding the nonoperative treatment of lateral epicondylitis. Given that the evidence surrounding the use of various treatment options for lateral epicondylitis has expanded, an overall assessment of nonoperative treatment options is required. The purpose of this systematic review and meta-analysis was to compare physiotherapy (strengthening), corticosteroids (CSIs), platelet-rich plasma (PRP), and autologous blood (AB) with no active treatment or placebo control in patients with lateral epicondylitis.

Methods

MEDLINE, Embase, and Cochrane were searched through till March 8, 2021. Additional studies were identified from reviews. All English-language randomized trials comparing nonoperative treatment of patients >18 years of age with lateral epicondylitis were included.

Results

A total of 5 randomized studies compared physiotherapy (strengthening) with no active treatment. There were no significant differences in pain (mean difference: −0.07, 95% confidence interval [CI]: −0.56 to 0.41) or function (standardized mean difference [SMD]: −0.08, 95% CI: −0.46 to 0.30). Seven studies compared CSI with a control. The control group had statistically superior pain (mean difference: 0.70, 95% CI: 0.22 to 1.18) and functional scores (SMD: −0.35, 95% CI: −0.54 to −0.16). Two studies compared PRP with controls, and no differences were found in pain (SD: −0.15, 95% CI: −1.89 to 1.35) or function (SMD: 0.14, 95% CI: −0.45 to 0.73). Three studies compared AB with controls, and no differences were observed in pain (0.49, 95% CI: −2.35 to 3.33) or function (−0.07, 95% CI: −0.64 to 0.50).

Discussion

The available evidence does not support the use of nonoperative treatment options including physiotherapy (strengthening), CSI, PRP, or AB in the treatment of lateral epicondylitis.

Editorial Commentary: Elbow Lateral Epicondylitis Treatment Using Platelet-Rich Plasma

The best treatment for elbow lateral epicondylitis is controversial. Multiple treatment interventions are used commonly, including physical therapy, corticosteroid injections, nonsteroidal anti-inflammatory drugs, bracing, acupuncture, ultrasound-guided percutaneous tenotomy, open or arthroscopic surgical debridement, and recently, platelet-rich plasma (PRP) or autologous blood injections. Patients in whom more traditional conservative measures have failed may benefit from PRP injections, although long-term outcomes after such injections are unclear. The complication rates of PRP injections are low. One PRP injection, if successful, could be a cost-effective alternative to surgery, but multiple injections are often recommended and third-party payers have historically rarely paid those medical claims, thus placing an increased financial burden on the patient.