Advertisement

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

      Abstract

      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.
      Lateral epicondylitis is a commonly occurring, painful condition characterized by activity-related pain and tenderness at the origin of the extensor carpi radialis brevis muscle. Despite its prevalence, however, the best treatment for such patients remains controversial. Multiple treatment interventions are commonly used, including physical therapy, corticosteroid injections, nonsteroidal anti-inflammatory drugs, bracing, acupuncture, and ultrasound-guided percutaneous tenotomy,
      • Borden A.L.
      • Scott M.T.
      • Dalwadi P.P.
      • Mautner K.
      • Mason R.A.
      • Gottschalk M.B.
      Platelet-rich plasma versus Tenex in the treatment of medical and lateral epicondylitis.
      ,
      • Carlier Y.
      • Bonichon F.
      • Peuchant A.
      Recalcitrant lateral epicondylitis: Early results with a new technique combining ultrasonographic percutaneous tenotomy with platelet-rich plasma injection.
      as well as both open and arthroscopic surgical debridement.
      • Murray D.J.
      • Javed S.
      • Jain N.
      • Kemp S.
      • Watts A.C.
      Platelet-rich-plasma injections in treating lateral epicondylosis: A review of the recent evidence.
      • McMurtrie A.
      • Watts A.C.
      Tennis elbow and golfers elbow: A review article.
      • Szabo S.J.
      • Savoie III, F.H.
      • Field L.D.
      • Ramsey J.R.
      • Hosemann C.D.
      Tendinosis of the extensor carpi radialis brevis: An evaluation of three methods of operative treatment.
      More recently, the role of platelet-rich plasma (PRP) injections in the management of lateral epicondylitis has been examined. Both PRP
      • Murray D.J.
      • Javed S.
      • Jain N.
      • Kemp S.
      • Watts A.C.
      Platelet-rich-plasma injections in treating lateral epicondylosis: A review of the recent evidence.
      ,
      • Mishra A.
      • Pavelko T.
      Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.
      ,
      • Brkljac M.
      • Conville J.
      • Sonar U.
      • Kumar S.
      Long-term follow-up of platelet-rich plasma injections for refractory lateral epicondylitis [published erratum appears in J Orthop 2020;23:275].
      and autologous blood
      • Edwards S.G.
      • Calandruccio J.H.
      Autologous blood injections for refractory lateral epicondylitis.
      injections have been introduced and recommended by some investigators as effective alternative treatments. PRP is known to improve osteochondral healing both macroscopically and microscopically in animal models.
      • Sun Y.
      • Feng Y.
      • Zhang C.Q.
      • Chen S.B.
      • Cheng X.G.
      The regenerative effect of platelet-rich plasma on healing in large osteochondral defects.
      ,
      • Altan E.
      • Aydin K.
      • Erkocak O.
      • Senaran H.
      • Ugras S.
      The effect of platelet-rich plasma on osteochondral defects treated with mosaicplasty.
      Some clinical research has, in fact, shown that PRP injections may play an effective role in the treatment of this condition and have a very low complication rate.
      • Krogh T.P.
      • 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.
      • Thanasas C.
      • Papadimitriou G.
      • Charalambidis C.
      • et al.
      Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis—A randomized controlled clinical trial.
      • Hechtman K.S.
      • Uribe J.W.
      • Botto-vanDemden A.
      • Kiebzak G.M.
      Platelet-rich plasma injection reduces pain in patients with recalcitrant epicondylitis.
      • Ahmad Z.
      • Brooks R.
      • Kang S.N.
      • et al.
      The effects of platelet-rich plasma on clinical outcomes in lateral epicondylitis.
      Other studies, however, dispute the efficacy of PRP injections for the treatment of chronic lateral epicondylitis.
      • Krogh T.P.
      • 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.
      ,
      • Mishra A.K.
      • Skrepnik N.V.
      • Edwards S.G.
      • et al.
      Efficacy of platelet-rich plasma for chronic tennis elbow: A double-blind, prospective, multicenter, randomized controlled trial of 230 patients.
      ,
      • Linnanmäki L.
      • Kanto K.
      • Karjalainen T.
      • Leppänen O.V.
      • Lehtinen J.
      Platelet-rich plasma or autologous blood do not reduce pain or improve function in patients with lateral epicondylitis: A randomized controlled trial.
      In their systematic review entitled “To Improve Pain and Function, Platelet-Rich Plasma Injections May Be an Alternative to Surgery for Treating Lateral Epicondylitis: A Systematic Review,” Hardy, Tori, Fuchs, Larson, Brand, and Monroe
      • Hardy R.
      • Tori A.
      • Fuchs H.
      • Larson T.
      • Brand J.
      • Monroe E.
      To improve pain and function, platelet-rich plasma injections may be an alternative to surgery for treating lateral epicondylitis: A systematic review.
      seek to determine whether PRP injections offer patients comparable outcomes versus surgical intervention for lateral epicondylitis. After a search of various databases, more than 7,000 articles were identified, but only 3 articles met the authors’ inclusion criteria (1 Level II and 2 Level III studies). Regrettably, varying PRP volumes, formulations, buffering agents, and manufacturers’ devices were used to produce the PRP in these respective studies. In addition, unfortunately, the surgical techniques used to accomplish lateral epicondylitis debridement in these 3 studies varied significantly and included both open and arthroscopic techniques.
      The patient outcomes reported for these 3 studies varied substantially as well. One of the studies noted that, at each of the follow-op periods, the group that received PRP injections reported significantly more pain relief compared with the surgical group.
      • Karaduman M.
      • Okkaoglu M.C.
      • Sesen H.
      • Taskesen A.
      • Ozdemir M.
      • Altay M.
      Platelet-rich plasma versus open surgical release in chronic tennis elbow: A retrospective comparative study.
      Conversely, another of the studies found that, although patients consistently showed a reduction in pain complaints and showed improved elbow function after PRP injections at shorter follow-up intervals, long-term clinical benefits were much more likely to occur among the surgically managed patients.
      • Merolla G.
      • Dellabiancia F.
      • Ricci A.
      • et al.
      Arthroscopic debridement versus platelet-rich plasma injection: A prospective, randomized, comparative study of chronic lateral epicondylitis with a nearly 2-year follow-up.
      Specifically, in the PRP group in this study, progressively worsening pain during activity developed at 1 and 2 years of follow-up in contradistinction to the surgically managed patients. In fact, Merolla et al.
      • Merolla G.
      • Dellabiancia F.
      • Ricci A.
      • et al.
      Arthroscopic debridement versus platelet-rich plasma injection: A prospective, randomized, comparative study of chronic lateral epicondylitis with a nearly 2-year follow-up.
      stated, pertaining to the PRP group, that “the poor clinical outcomes found at 2 years in our study are consistent with other research findings showing that PRP is not effective in long term pain reduction.”
      In this systematic review, Hardy et al.
      • Hardy R.
      • Tori A.
      • Fuchs H.
      • Larson T.
      • Brand J.
      • Monroe E.
      To improve pain and function, platelet-rich plasma injections may be an alternative to surgery for treating lateral epicondylitis: A systematic review.
      conclude from their investigation that PRP injections are an appropriate alternative for the treatment of lateral epicondylitis. Indeed, PRP injections have shown efficacy in some previous studies,
      • Murray D.J.
      • Javed S.
      • Jain N.
      • Kemp S.
      • Watts A.C.
      Platelet-rich-plasma injections in treating lateral epicondylosis: A review of the recent evidence.
      ,
      • Mishra A.
      • Pavelko T.
      Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.
      ,
      • Brkljac M.
      • Conville J.
      • Sonar U.
      • Kumar S.
      Long-term follow-up of platelet-rich plasma injections for refractory lateral epicondylitis [published erratum appears in J Orthop 2020;23:275].
      but not all studies have made similar determinations.
      • Ahmad Z.
      • Brooks R.
      • Kang S.N.
      • et al.
      The effects of platelet-rich plasma on clinical outcomes in lateral epicondylitis.
      • Mishra A.K.
      • Skrepnik N.V.
      • Edwards S.G.
      • et al.
      Efficacy of platelet-rich plasma for chronic tennis elbow: A double-blind, prospective, multicenter, randomized controlled trial of 230 patients.
      • Linnanmäki L.
      • Kanto K.
      • Karjalainen T.
      • Leppänen O.V.
      • Lehtinen J.
      Platelet-rich plasma or autologous blood do not reduce pain or improve function in patients with lateral epicondylitis: A randomized controlled trial.
      ,
      • Tang S.
      • Wang X.
      • Wu P.
      • et al.
      Platelet-rich plasma vs autologous blood vs corticosteroid injections in the treatment of lateral epicondylitis: A systematic review, pairwise and network meta-analysis of randomized controlled trials.
      Likewise, previously published systematic reviews and meta-analyses comparing PRP use with other interventions for the treatment of lateral epicondylitis have reached variable conclusions.
      • Tang S.
      • Wang X.
      • Wu P.
      • et al.
      Platelet-rich plasma vs autologous blood vs corticosteroid injections in the treatment of lateral epicondylitis: A systematic review, pairwise and network meta-analysis of randomized controlled trials.
      • Xu Q.
      • Chen J.
      • Cheng L.
      Comparison of platelet rich plasma and corticosteroids in the management of lateral epicondylitis: A meta-analysis of randomized controlled trials.
      • Simental-Mendía M.
      • Vilchez-Cavazos F.
      • Álvarez-Villalobos N.
      • et al.
      Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: A systematic review and meta-analysis of randomized placebo-controlled clinical trials.
      • Houck D.A.
      • Kraeutler M.J.
      • Thornton L.B.
      • McCarty E.C.
      • Bravman J.T.
      Treatment of lateral epicondylitis with autologous blood, platelet-rich plasma, or corticosteroid injections: A systematic review of overlapping meta-analyses.
      • Arirachakaran A.
      • Sukthuayat A.
      • Sisayanarane T.
      • Laoratanavoraphong S.
      • Kanchanatawan W.
      • Kongtharvonskul J.
      Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: Systematic review and network meta-analysis.
      • Ford R.D.
      • Schmitt W.P.
      • Lineberry K.
      • Luce P.
      A retrospective comparison of the management of recalcitrant lateral elbow tendinosis: Platelet-rich plasma injections versus surgery.
      Hardy et al. also commented on the low complication rate after PRP injections. In fact, no patient in any of the 3 included studies sustained a complication after either receiving a PRP injection or undergoing surgical intervention. The authors also remark on the potential cost savings related to PRP injections when compared with surgical intervention and state that “a single injection of PRP costs $1,000 or more for each injection while surgery costs $4,000 or greater.” Certainly, 1 PRP injection, if successful in adequately alleviating a patient’s symptoms long term, would potentially be a cost-effective alternative to surgical intervention. However, multiple injections are often recommended for and performed in an individual with lateral epicondylitis, and third-party payers have historically rarely paid the medical claims for such treatment, thus placing an increased financial burden on the patient.
      PRP injections may ultimately be found to be an equivalent treatment alternative for lateral epicondylitis. Patients in whom more traditional conservative measures have failed, including activity modification, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy, may benefit from PRP injections, although long-term outcomes after such injections are unclear. The systematic review appraised here does contribute valuable, additional information for surgeons and other stakeholders to consider when making treatment decisions on behalf of their patients with lateral epicondylitis, but this research alone will not strongly influence our current decision-making algorithm of care for lateral epicondylitis patients. Certainly, as additional research is completed and published, the most appropriate role, if any, and best formulation (including the timing and volume of PRP injections) in the management of chronic lateral epicondylitis will be better defined.

      Supplementary Data

      References

        • Borden A.L.
        • Scott M.T.
        • Dalwadi P.P.
        • Mautner K.
        • Mason R.A.
        • Gottschalk M.B.
        Platelet-rich plasma versus Tenex in the treatment of medical and lateral epicondylitis.
        J Shoulder Elbow Surg. 2019; 28: 112-119
        • Carlier Y.
        • Bonichon F.
        • Peuchant A.
        Recalcitrant lateral epicondylitis: Early results with a new technique combining ultrasonographic percutaneous tenotomy with platelet-rich plasma injection.
        Orthop Traumatol Surg Res. 2021; 107: 102604
        • Murray D.J.
        • Javed S.
        • Jain N.
        • Kemp S.
        • Watts A.C.
        Platelet-rich-plasma injections in treating lateral epicondylosis: A review of the recent evidence.
        J Hand Microsurg. 2015; 7: 320-325
        • McMurtrie A.
        • Watts A.C.
        Tennis elbow and golfers elbow: A review article.
        Orthop Trauma. 2012; 26: 297-366
        • Szabo S.J.
        • Savoie III, F.H.
        • Field L.D.
        • Ramsey J.R.
        • Hosemann C.D.
        Tendinosis of the extensor carpi radialis brevis: An evaluation of three methods of operative treatment.
        J Shoulder Elbow Surg. 2006; 15: 721-727
        • Mishra A.
        • Pavelko T.
        Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.
        Am J Sports Med. 2006; 34: 1774-1778
        • Brkljac M.
        • Conville J.
        • Sonar U.
        • Kumar S.
        Long-term follow-up of platelet-rich plasma injections for refractory lateral epicondylitis [published erratum appears in J Orthop 2020;23:275].
        J Orthop. 2019; 16: 496-499
        • Edwards S.G.
        • Calandruccio J.H.
        Autologous blood injections for refractory lateral epicondylitis.
        J Hand Surg Am. 2003; 28: 272-278
        • Sun Y.
        • Feng Y.
        • Zhang C.Q.
        • Chen S.B.
        • Cheng X.G.
        The regenerative effect of platelet-rich plasma on healing in large osteochondral defects.
        Int Orthop. 2010; 34: 589-597
        • Altan E.
        • Aydin K.
        • Erkocak O.
        • Senaran H.
        • Ugras S.
        The effect of platelet-rich plasma on osteochondral defects treated with mosaicplasty.
        Int Orthop. 2014; 38: 1321-1328
        • Krogh T.P.
        • 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: 625-635
        • Thanasas C.
        • Papadimitriou G.
        • Charalambidis C.
        • et al.
        Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis—A randomized controlled clinical trial.
        Am J Sports Med. 2011; 39: 2130-2134
        • Hechtman K.S.
        • Uribe J.W.
        • Botto-vanDemden A.
        • Kiebzak G.M.
        Platelet-rich plasma injection reduces pain in patients with recalcitrant epicondylitis.
        Orthopedics. 2011; 34: 92
        • Ahmad Z.
        • Brooks R.
        • Kang S.N.
        • et al.
        The effects of platelet-rich plasma on clinical outcomes in lateral epicondylitis.
        Arthroscopy. 2013; 29: 1851-1862
        • Mishra A.K.
        • Skrepnik N.V.
        • Edwards S.G.
        • et al.
        Efficacy of platelet-rich plasma for chronic tennis elbow: A double-blind, prospective, multicenter, randomized controlled trial of 230 patients.
        Am J Sports Med. 2014; 42: 463-471
        • Linnanmäki L.
        • Kanto K.
        • Karjalainen T.
        • Leppänen O.V.
        • Lehtinen J.
        Platelet-rich plasma or autologous blood do not reduce pain or improve function in patients with lateral epicondylitis: A randomized controlled trial.
        Clin Orthop Relat Res. 2020; 478: 1892-1900
        • Hardy R.
        • Tori A.
        • Fuchs H.
        • Larson T.
        • Brand J.
        • Monroe E.
        To improve pain and function, platelet-rich plasma injections may be an alternative to surgery for treating lateral epicondylitis: A systematic review.
        Arthroscopy. 2021; 37: 3360-3367
        • Karaduman M.
        • Okkaoglu M.C.
        • Sesen H.
        • Taskesen A.
        • Ozdemir M.
        • Altay M.
        Platelet-rich plasma versus open surgical release in chronic tennis elbow: A retrospective comparative study.
        J Orthop. 2016; 13: 10-14
        • Merolla G.
        • Dellabiancia F.
        • Ricci A.
        • et al.
        Arthroscopic debridement versus platelet-rich plasma injection: A prospective, randomized, comparative study of chronic lateral epicondylitis with a nearly 2-year follow-up.
        Arthroscopy. 2017; 33: 1320-1329
        • Tang S.
        • Wang X.
        • Wu P.
        • et al.
        Platelet-rich plasma vs autologous blood vs corticosteroid injections in the treatment of lateral epicondylitis: A systematic review, pairwise and network meta-analysis of randomized controlled trials.
        PM R. 2020; 12: 397-409
        • Xu Q.
        • Chen J.
        • Cheng L.
        Comparison of platelet rich plasma and corticosteroids in the management of lateral epicondylitis: A meta-analysis of randomized controlled trials.
        Int J Surg. 2019; 67: 37-46
        • Simental-Mendía M.
        • Vilchez-Cavazos F.
        • Álvarez-Villalobos N.
        • et al.
        Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: A systematic review and meta-analysis of randomized placebo-controlled clinical trials.
        Clin Rheumatol. 2020; 39: 2255-2265
        • Houck D.A.
        • Kraeutler M.J.
        • Thornton L.B.
        • McCarty E.C.
        • Bravman J.T.
        Treatment of lateral epicondylitis with autologous blood, platelet-rich plasma, or corticosteroid injections: A systematic review of overlapping meta-analyses.
        Orthop J Sports Med. 2019; 7 (2325967119831052)
        • Arirachakaran A.
        • Sukthuayat A.
        • Sisayanarane T.
        • Laoratanavoraphong S.
        • Kanchanatawan W.
        • Kongtharvonskul J.
        Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: Systematic review and network meta-analysis.
        J Orthop Traumatol. 2016; 17: 101-112
        • Ford R.D.
        • Schmitt W.P.
        • Lineberry K.
        • Luce P.
        A retrospective comparison of the management of recalcitrant lateral elbow tendinosis: Platelet-rich plasma injections versus surgery.
        Hand (N Y). 2015; 10: 285-291