Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence

Corticosteroid injections for the treatment of lateral epicondylitis are superior to platelet-rich plasma at 1 month but platelet-rich plasma is more effective at 6 months: an updated systematic review and meta-analysis of level 1 and 2 studies

BACKGROUND

The purpose of this study was to perform a systematic review and meta-analysis of studies comparing local injections of either platelet-rich plasma (PRP) or corticosteroid for the treatment of lateral elbow epicondylitis.

METHODS

A systematic review of MEDLINE, Embase, Scopus, and Google Scholar was performed, and all level 1 and 2 randomized studies from 2000 to 2022 were included. Clinical symptoms, patient perceived outcomes, and pain were assessed by the DASH (disabilities of the arm, shoulder and hand questionnaire) and pain by the visual analog scale (VAS). Publication bias and risk of bias were assessed using the Cochrane Collaboration's tools. The modified Coleman Methodology Score (CMS) and the GRADE system were used to assess the quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics.

RESULTS

Thirteen studies were included in the analysis. Five studies had a high risk of bias, and the risk of bias across studies was assessed as unclear. There was no publication bias identified. Two of the four GRADE domains (inconsistency of results, imprecision of results) were downgraded to low quality, and the final GRADE assessment was downgraded to a low quality of evidence. The mean CMS score was 62.8, indicating fair quality. The pooled estimate for VAS at 1 month favored corticosteroids (P = .75) but favored PRP at three (P = .003) and six months (P = .0001). The pooled estimate for the DASH score favored corticosteroids at 1 month (P = .028) but favored PRP at three (P = .01) and six months (P = .107) CONCLUSION: The results of this meta-analysis suggest that PRP has no advantage over steroid injections within the first month of treatment, but that it is superior to steroids at both 3 and 6 months. These results also suggest that corticosteroids have a short-term beneficial effect during the early treatment period, although the quality of the available evidence is not very robust in support of this finding. However, these findings must all be viewed with caution as the high risk of bias and moderate to low quality of the included studies may not justify a recommendation of one treatment over another.

The aging athlete

Aging athletes, those 60 years and older, are a growing population of mature, active individuals who value sports and exercise participation throughout their lifespan. Although recommendations for younger and masters athletes have been extrapolated to this population, there remains a paucity of specific guidelines, treatment algorithms, and considerations for aging athletes. The benefits of living an active lifestyle must be weighed against the risks for unique cardiovascular, metabolic, and musculoskeletal injuries requiring diagnostic and therapeutic interventions. In this article, we review the unique cardiovascular and muscular physiology of aging athletes and how it influences the risk of specific medical conditions. We also discuss general prevention and treatment strategies. Finally, we identify areas of future research priorities and emerging treatments.

Management of Lateral Epicondylitis: A Prospective Comparative Study Comparing the Local Infiltrations of Leucocyte Enriched Platelet-Rich Plasma (L-aPRP), Glucocorticoid and Normal Saline

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.

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.

Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain

BACKGROUND

Autologous whole blood or platelet-rich plasma (PRP) injections are commonly used to treat lateral elbow pain (also known as tennis elbow or lateral epicondylitis or epicondylalgia). Based on animal models and observational studies, these injections may modulate tendon injury healing, but randomised controlled trials have reported inconsistent results regarding benefit for people with lateral elbow pain.

OBJECTIVES

To review current evidence on the benefit and safety of autologous whole blood or platelet-rich plasma (PRP) injection for treatment of people with lateral elbow pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase for published trials, and Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal for ongoing trials, on 18 September 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs comparing autologous whole blood or PRP injection therapy to another therapy (placebo or active treatment, including non-pharmacological therapies, and comparison between PRP and autologous blood) for lateral elbow pain. The primary comparison was PRP versus placebo. Major outcomes were pain relief (≥ 30% or ≥ 50%), mean pain, mean function, treatment success, quality of life, withdrawal due to adverse events, and adverse events; the primary time point was three months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 32 studies with 2337 participants; 56% of participants were female, mean age varied between 36 and 53 years, and mean duration of symptoms ranged from 1 to 22 months. Seven trials had three intervention arms. Ten trials compared autologous blood or PRP injection to placebo injection (primary comparison). Fifteen trials compared autologous blood or PRP injection to glucocorticoid injection. Four studies compared autologous blood to PRP. Two trials compared autologous blood or PRP injection plus tennis elbow strap and exercise versus tennis elbow strap and exercise alone. Two trials compared PRP injection to surgery, and one trial compared PRP injection and dry needling to dry needling alone. Other comparisons include autologous blood versus extracorporeal shock wave therapy; PRP versus arthroscopic surgery; PRP versus laser; and autologous blood versus polidocanol. Most studies were at risk of selection, performance, and detection biases, mainly due to inadequate allocation concealment and lack of participant blinding. We found moderate-certainty evidence (downgraded for bias) to show that autologous blood or PRP injection probably does not provide clinically significant improvement in pain or function compared with placebo injection at three months. Further, low-certainty evidence (downgraded for bias and imprecision) suggests that PRP may not increase risk for adverse events. We are uncertain whether autologous blood or PRP injection improves treatment success (downgraded for bias, imprecision, and indirectness) or withdrawals due to adverse events (downgraded for bias and twice for imprecision). No studies measured health-related quality of life, and no studies reported pain relief (> 30% or 50%) at three months. At three months, mean pain was 3.7 points (0 to 10; 0 is best) with placebo and 0.16 points better (95% confidence interval (CI) 0.60 better to 0.29 worse; 8 studies, 523 participants) with autologous blood or PRP injection, for absolute improvement of 1.6% better (6% better to 3% worse). At three months, mean function was 27.5 points (0 to 100; 0 is best) with placebo and 1.86 points better (95% CI 4.9 better to 1.25 worse; 8 studies, 502 participants) with autologous blood or PRP injection, for absolute benefit of 1.9% (5% better to 1% worse), and treatment success was 121 out of 185 (65%) with placebo versus 125 out of 187 (67%) with autologous blood or PRP injection (risk ratio (RR) 1.00; 95% CI 0.83 to 1.19; 4 studies, 372 participants), for absolute improvement of 0% (11.1% lower to 12.4% higher). Regarding harm, we found very low-certainty evidence to suggest that we are uncertain whether withdrawal rates due to adverse events differed. Low-certainty evidence suggests that autologous blood or PRP injection may not increase adverse events compared with placebo injection. Withdrawal due to adverse events occurred in 3 out of 39 (8%) participants treated with placebo versus 1 out of 41 (2%) treated with autologous blood or PRP injection (RR 0.32, 95% CI 0.03 to 2.92; 1 study), for an absolute difference of 5.2% fewer (7.5% fewer to 14.8% more). Adverse event rates were 35 out of 208 (17%) with placebo versus 41 out of 217 (19%) with autologous blood or PRP injection (RR 1.14, 95% CI 0.76 to 1.72; 5 studies; 425 participants), for an absolute difference of 2.4% more (4% fewer to 12% more). At six and twelve months, no clinically important benefit for mean pain or function was observed with autologous blood or PRP injection compared with placebo injection.

AUTHORS' CONCLUSIONS

Data in this review do not support the use of autologous blood or PRP injection for treatment of lateral elbow pain. These injections probably provide little or no clinically important benefit for pain or function (moderate-certainty evidence), and it is uncertain (very low-certainty evidence) whether they improve treatment success and pain relief > 50%, or increase withdrawal due to adverse events. Although risk for harm may not be increased compared with placebo injection (low-certainty evidence), injection therapies cause pain and carry a small risk of infection. With no evidence of benefit, the costs and risks are not justified.

Platelet-rich plasma injections for hip osteoarthritis: a review of the evidence

Osteoarthritis is a significant cause of chronic pain in the elderly population with hip osteoarthritis as one of the main causes of functional disability and joint pain in adults older than 55 years. Recently, platelet rich plasma (PRP) injections have been introduced for treatment of osteoarthritis. The aim of this systematic review is to assess its effectiveness in the management of hip osteoarthritis. We performed a search of the literature for published prospective studies that assessed the effectiveness of PRP injections in the treatment of hip osteoarthritis, with a minimum follow-up of 3 months. Primary outcome measures were WOMAC and VAS scores. Five trials were identified with 185 patients undergoing treatment with ultrasound-guided intra-articular injections of PRP, compared with patients treated with hyaluronic acid alone (n = 148) or hyaluronic acid combined with PRP (n = 31) in one study. PRP was shown to improve patient outcome scores at follow-up at 6 and 12 months; however, there was no significant difference seen between patients treated with PRP or hyaluronic acid alone. Following this systematic review, we cannot currently recommend the use of intra-articular injections of PRP for the treatment of hip OA. Given that intra-articular steroid injections are the only such injection recommended by international guidelines for the treatment of hip OA, further studies comparing PRP to steroid would be of benefit to determine the value of PRP injections in hip OA.

Evidence for the use of PRP in chronic midsubstance Achilles tendinopathy: A systematic review with meta-analysis

BACKGROUND

Platelet-rich plasma (PRP) injections have been proposed as an additional therapy in the treatment of chronic midsubstance Achilles tendinopathy (AT). The use of PRP injections as pharmacological treatment added to a conservative approach has gained growing interest, but the efficacy remains highly debated. The varying methodological quality of the available studies may contribute to these contradictory results. The aim of this systematic review with meta-analysis was to establish the existing evidence of PRP injections for chronic midsubstance AT on the functional outcome, with a risk of bias assessment of each included study.

METHODS

According to the PRISMA guidelines systematic searches were performed in Embase, the Cochrane library and Pubmed on June 12, 2020 for relevant literature. Only clinical trials comparing PRP injections with placebo, additional to an eccentric training program, in midsubstance AT were included. The primary outcome was Victorian Institute of Sport Assessment - Achilles (VISA-A) score at 3, 6 and 12 months post-injection. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (Rob 2). As secondary outcome we assessed reported changes in tendon structure after PRP injections.

RESULTS

A total of 367 studies were identified with the initial database search. Finally, four randomized controlled trials (RCTs) met inclusion criteria for systematic review and meta-analysis with data of 170 patients available for pooling. Results showed no difference in clinical outcome between the PRP and placebo group at different points in time using the VISA-A score as outcome parameter (3 months 0.23 (CI -0.45, 0.91); 6 months 0.83 (CI -0.26, 1.92); 12 months 0.83 (CI -0.77, 2.44)). The bias analysis showed a low or intermediate risk of bias profile for all studies which supports the good methodological quality of each included article. Finally, it is unclear whether PRP injections cause an improvement in tendon structure. However, no direct relationship between tendon structure and clinical presentation of AT could be found.

CONCLUSION

PRP has no clear additional value in management of chronic midsubstance Achilles tendinopathy and therefore should not be used as a first-line treatment option.

Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial

BACKGROUND

Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow.

METHOD

Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months.

RESULTS

Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection.

CONCLUSION

L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention.

Management of lateral epicondylitis

Lateral epicondylitis is the most common cause of lateral elbow pain. Although also known as tennis elbow, lateral epicondylitis often develops as a work-related condition and therefore constitutes a major public health issue. This article reviews the pathophysiological factors involved in lateral epicondylitis, as well as the tools available for establishing the diagnosis and ruling out other causes of lateral elbow pain. Finally, the non-operative and surgical treatment options are discussed in detail.

Number of botulinum toxin injections needed to stop requests for treatment for chronic lateral epicondylar tendinopathy. A 1-year follow-up study

BACKGROUND

Epicondylar tendinopathy ("tennis elbow") is a serious issue in manual labourers. Symptoms can persist over months or even more than 1 year, even when treated with trinitrine patches, acupuncture, sclerosis of neovessels, shock-wave therapy, autologous blood injections, platelet-rich plasma or hyaluronic acid. Botulinum toxin (BoNT-A) injections showed promising short-term results, but the long-term beneficial effects are not yet known.

OBJECTIVE

We aimed to assess the long-term effect, side effects and recurrence rate after BoNT-A injections on chronic lateral epicondylar tendinopathy during 1 year.

METHODS

This open study followed a 3-month randomized controlled trial. We included 50 patients followed at day 0 (V0), 90 (V1), 180-270 (V2) and 365 (V3). The main judgment criterion was the number of BoNT-A injections required to achieve pain relief with no further request for treatment by the patient.

RESULTS

After one BoNT-A injection, 22/50 (44%) patients did not ask for further treatment during follow-up because of complete pain relief, and 20/50 (40%) asked for a second BoNT-A injection. For 20 patients with a second injection, 18 (90%) did not ask for further treatment during follow-up. Only 1 patient had a recurrence of pain after an initial pain relief of greater than 75%. Quality of life, and painful and maximal gripping force improved significantly at V1, V2 and V3 as compared with V0, and repercussions on daily and professional activities decreased significantly (P<0.05).

CONCLUSIONS

One or 2 BoNT-A injections has favourable results for chronic epicondylar tendinopathy.

Platelet-rich plasma versus Tenex in the treatment of medial and lateral epicondylitis

BACKGROUND

Medial epicondylitis and lateral epicondylitis are among the most common elbow pathologies affecting people aged between 40 and 50 years. Although epicondylitis is often a self-limiting condition that improves with conservative treatment, the condition can be difficult to eradicate. The purpose of this study was to compare the effectiveness of platelet-rich plasma (PRP) injections and ultrasound-guided percutaneous tenotomy (Tenex) for the treatment of medial or lateral epicondylitis. Our hypothesis was that the Tenex procedure would not be inferior to PRP injections in the treatment of medial or lateral epicondylitis.

METHODS

In this retrospective review, 62 of 75 patients were available for contact via phone and e-mail to complete post-procedure patient-reported outcome surveys. Subjective assessment of pain and function included a visual analog scale for pain; the Quick Disabilities of the Arm, Shoulder and Hand questionnaire; and the EuroQol-5D questionnaire. The inclusion criteria included age of 18 years or older and previous failure of nonoperative treatment.

RESULTS

The average ages in the PRP and Tenex groups were 47 years and 51 years, respectively. The PRP cohort (n = 32) included 10 female and 22 male patients, whereas the Tenex cohort (n = 30) included 12 female and 18 male patients. The PRP and Tenex groups both demonstrated clinical and statistical improvement in visual analog scale pain scores; Quick Disabilities of the Arm, Shoulder and Hand scores; and EuroQol-5D scores. No statistically significant difference was found between the 2 treatment modalities.

CONCLUSION

The PRP and Tenex procedures were both successful in producing clinically and statistically significant improvements in pain, function, and quality of life.

Platelet-rich Plasma for Skin Rejuvenation and Treatment of Actinic Elastosis in the Lower Eyelid Area

Background

Treatment of the lower eyelid region to rejuvenate the skin or treat actinic elastosis often proves difficult. Established treatment options, such as hyaluronic acid injections, botulinum toxin injections, microneedling, skin resurfacing (microdermabrasion, chemical peel (exfoliation), laser treatment), as well as blepharoplasties and autologous fat transfers, can be associated with significant risks and increased patient burden. Furthermore, they may not be effective for treating the signs of skin aging or actinic elastosis, including dark rings under the eyes, a lack of volume and cutis laxa. A minimally invasive treatment approach which visibly improves the above-mentioned conditions and which involves minimal risk and patient burden would be a desirable alternative.

Materials & methods

Twenty patients were treated a total of three times at monthly intervals with PRP (platelet-rich plasma). The patients were examined on the days of treatment and one month after the third injection. The PRP was obtained directly prior to treatment using the Arthrex ACP double syringe at the point of care. The injections (2 ml PRP per side) were administered laterally using 27 G 38 mm cannulas. Accurate photographic documentation and skin elasticity measurements using a cutometer were performed to objectify the subjective assessments from the patient and practitioner questionnaires.

Results

A progressive improvement in the esthetic outcome and a high level of patient satisfaction were determined. The cutometer measurements showed a statistically significant higher level of skin firmness (due to increased collagen production) and a statistically significant increase in skin elasticity (thanks to increased elastin production). Other than the anticipated visible swelling directly after the PRP injection, no other undesirable side effects or complications occurred. The typical burning sensation during the injection had not been reported.

Conclusion

The results indicate that a series of PRP injections in the lower eyelid region is a safe, efficient, virtually pain-free, simple and rapid treatment option for an area with otherwise limited treatment alternatives.

Golf Injuries: Epidemiology, Pathophysiology, and Treatment

Increasing numbers of people are playing golf. Golf is a unique sport in that the ability to participate at a high level is not limited by age. In addition, participants tend to play more rather than less as they grow older. Injuries can occur at any point during the golf swing, from takeaway through follow-through. Upper extremity injuries can affect the hands, elbow, and shoulder and are usually a result of the golf swing at impact. Injuries are also common in the lower back as well as the lower extremities. Most injuries are the result of overuse and poor swing mechanics. When treating golfers, it is important to have a good understanding of the biomechanics and forces of the golf swing to diagnose and manage the vast spectrum of injuries incurred in this sport.

Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention

Objective

We aimed to assess the effectiveness of PRP injections in lateral epicondylitis of the elbow as it was felt after PRP introduction the numbers of patients requiring surgery for had reduced.

Methods

We conducted a retrospective review of cases from the 1^st January 2008 to 31st December 2015. The numbers of patients undergoing surgical release and the numbers of patients requiring PRP injections were recorded each year and the numbers of patients requiring surgery was compared pre and post PRP injection to ascertain if PRP introduction reduced surgical intervention.

Results

Prior to PRP, a yearly mean of 12.75 patients underwent surgery, since PRP this reduced to 4.25 patients, P < 0.001. This leads to an absolute risk reduction of 0.773 and number needed to treat of 1.3. PRP injection successfully reduced symptoms in 56/64 (87.5%) patients in our study.

Conclusion

We consider PRP injection, for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms and have shown it has reduced the need for surgical intervention in this difficult cohort of patients.

Editorial Commentary: The Needle or the Knife? Platelet-Rich Plasma Versus Surgery for Lateral Epicondylitis

The most efficacious treatment for patients with lateral epicondylitis who have not adequately improved despite being treated for extended periods with commonly used nonoperative measures is controversial. Are locally applied platelet-rich plasma (PRP) injections more effective than a surgical procedure, such as arthroscopic lateral epicondylitis debridement, in reducing symptoms for such patients? Level II evidence shows that long-term clinical benefits are much less likely to occur in patients receiving PRP injections. Moreover, in patients treated with PRP injection, progressively worsening pain is more likely to develop during activity at 1 and 2 years of follow-up in contradistinction to arthroscopically managed patients.

Investigating the Effect of Intra-articular Platelet-Rich Plasma Injection on Union: Pain and Function Improvement in Patients with Scaphoid Fracture

Introduction Fracture of the scaphoid bone is the most common fracture of the carpus. However, the fracture union occurs late or may not heal. Sometimes, fracture healing requires prolong immobilization. Because of potential for joint stiffness, muscle atrophy, or the inability to use the hand during and after prolonged immobilization, there is great incentive to develop therapies that will accelerate bone healing and allow a quick return to work. To date, the effect of platelet-rich plasma (PRP) on scaphoid fracture has not been studied. We aimed to assess the effect of intra-articular PRP injection on union: pain, range of motion, and function in patients with scaphoid fracture. Hypothesis Union: pain reduction and functional improvement can be noticed after PRP use in scaphoid fracture. Materials and Methods A randomized controlled trial was designed with 14 patients with scaphoid fractures (Herbert type B2). Casting was done for them. Seven patients received intra-articular autologous PRP. Patients were followed up 2 weeks after casting using radiography and then at 2 months using radiography and computed tomography (CT) scan to check bone healing. Then patients were followed up for 3 and 6 months and after evaluation of healing by CT scan, the patient-rated wrist evaluation questionnaire was completed and the range of motion of the wrist was measured. Results Analysis revealed significant improvement in pain at rest, as well as during specific and usual activities following PRP injection in the case group. However, no statistically significant difference in wrist motion including radial and ulnar deviation, flexion, and extension was found in 6 months follow-up except some improvement in ulnar deviation after 3 months. However, this study showed that scaphoid union occurred earlier in the case group, but it was not statistically significant. Conclusion PRP may have a significant effect on pain reduction at rest and amount of difficulty in functions including specific and usual activities in patients with scaphoid fractures. Level of Evidence This is a level III, therapeutic trial.