Evidence for Platelet Rich Plasma/ PRP in Tennis Elbow

Platelet rich plasma also known as PRP has been used for treating tendinopathy around the elbow including tennis elbow and golfers elbow for over a decade.

Most insurances cover the treatment of PRP for treating tennis elbow and golfers elbow. However, in some cases some insurance companies may not cover it and may tell the patient that this treatment is “experimental.” This is not accurate and there are several high level randomised control trials that confirm the efficacy of PRP in treating tennis elbow.

It is widely used in private practice and also in the NHS.

In 2010 a study published by Peerbooms et al1 was published comparing the positive effect of platelet-rich plasma in lateral epicondylitis. This was a double blind randomised control trial providing a level 1 evidence comparing platelet-rich plasma (PRP) with the effects corticosteroid injections with patients with chronic lateral epicondylitis. The study concluded that although the corticosteroid was initially slightly better then the PRP, in the long-term PRP treated patients did better and progressively improved.

A follow up study by the same group published in 2011 with the same patients with two years follow up2. They concluded that those patients with treated with corticosteroid returned back to base line whereas those treated with PRP continued to improve and maintained this improvement at 2 years. They concluded that treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effects of corticosteroid injections even after a follow up of two years.

Mishra et al 3 study published study in 2013. Again, looking at the efficacy of PRP and conclude that it significantly clinically improves the outcome in patients with chronic tennis elbow.

This was a double-blind perspective multi-central control trial of 230 patients. All patients had extensor tendons needled with or without PRP. Patients were followed up and regular interval’s and at 24 weeks it was noted that patients had a significantly higher success rate when PRP was added in addition to the tendon needling.

In 2014 Tetchke et al4 published a study PRP/ACP with low level laser application. Patients had a standardised follow up and therapy. The study concluded that PRP had beneficial effects of the treatment of lateral epicondylitis.

A study published in 2015 Behera et al5 compared PRP injections versus bupivacaine injections for chronic lateral epicondylar tendinopathy (tennis elbow). At 6 months and at 1 year the results of the PRP was significantly better then the effects of bupivacaine at treating tennis elbow.

A study carried out in 2015 by Ford et al6 retrospective comparison of the management of recalcitrant lateral elbow tendonitis and compared platelet-rich injections with surgery.

It is interesting to note, that there were similar outcomes in pain improvement and returned to work with either PRP injection or surgery in chronic tennis elbow. Therefore, PRP may avoid patients having surgical intervention and therefore is a useful way of managing patients who want to avoid surgery or are poor surgical candidates.

The study carried out in 2015 by Gautam et al7 looked at the platelet-rich plasma compared to corticosteroid injection for chronic tennis elbow with clinical and ultrasonic evaluation. This study concluded that PRP appeared to enable biological healing of the legion whereas the corticosteroid injection was only able to provide short term symptomatic relief that resulted in tendon degeneration.

A study was carried out by Lebiedzinski et al8 randomised patients between PRP/ACP and Betamethasone own injections and compared their outcomes over 1 year. It concluded that PRP/ACP therapy for chronic tennis elbow allowed for better results at 12 months. Betamethasone injections give more rapid improvement, but the therapy effect was longer lasting in the PRP/ACP group.

A review article published in 2015 by Murray et al9 looked at platelet rich-plasma treating lateral epicondylitis. This review compared all the important evidence up to date. They concluded that after a review of literature PRP injections have an important and effective role in treatment of chronic lateral epicondylitis in cases where physiotherapy has been unsuccessful. They note that PRP has been shown to provide a continuing long-term benefit in cases of chronic epicondylitis in recent literature. It is confirmed to be superior to other injections including placebo/dry needling procedures. They also concluded that PRP has very few complications and very few adverse reactions compared to other treatments.

They noted that surgery does offer good results for chronic lateral epicondylitis however surgery is not without risk in terms of scars, infection, neurovascular problems as well as instability. Therefore, if PRP could be used as an alternative then the author strongly felt that this option would present a safer option for patients and may offer a more cost-effective alternative to the health care system.

A study published in 2015 by Yadav et al10 randomised patients in two groups one with PRP injections and the other one was treated with methyl-prednisolone and also concluded that PRP is a superior option with longer duration and efficacy then methyl-prednisolone.

A more recent study by Zafar et al11 looked at the use of PRP injections versus extra corporeal shockwave therapy for chronic lateral epicondylitis. This study had a minimum of a 2 years follow up was a retrospective comparison study and concluded that both PRP injections and extra corporeal shockwave therapy are safe options for treatment for chronic lateral epicondylitis and there is low risk of complications and with good long-term follow up results. However, they did note that ultrasound guided PRP injections was quicker in achieving symptom resolution. The mean time to return to active normal life was also quicker with PRP when compared to shockwave therapy.

References:

1            Positive Effect of an Autologous Platelet Concentrate in Lateral Epicondylitis in a Double-Blind Randomized Controlled Trial.  Platelet-Rich Plasma Versus Corticosteroid Injection With a 1-Year Follow-up. Joost C. Peerbooms, MD, Jordi Sluimer,MD, Danie J. Bruijn, PhD, and Taco Gosens, PhD. The American Journal of Sports Medicine, Vol. 38, No. 2, 255-262.

2            Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis A Double-Blind Randomized Controlled Trial With 2-year Follow-up Taco Gosens,  MD, PhD, Joost C. Peerbooms, MD, Wilbert van Laar and Brenda L. den Oudsten, PhD.  The American Journal of Sports Medicine, Vol. 39, No. 6.

3            Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow – A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients.  Allan K. Mishra, MD, Nebojsa V. Skrepnik, MD, PhD, Scott G. Edwards, MD, Grant L. Jones, MD, Steven Sampson, DO, Doug A. Vermillion, MD, Matthew L. Ramsey, MD, David C. Karli, MD, MBA, and Arthur C. Rettig, MD. The American Journal of Sports Medicine, Vol. XX, No. X  1-9

4            Autologous Proliferative Therapies in Recalcitrant Lateral Epicondylitis.  Tetschke E, Rudolf M, Lohmann CH, Starke C.  Am J Phys Med Rehabil 2014.

5            Leukocyte-poor platelet-rich plasma versus bupivacaine for recalcitrant lateral epicondylar tendinopathy.  Prateek Behera, Mandeep Dhillon, Sameer Aggarwal, Neelam Marwaha, Mahesh Prakash.  Journal of Orthopaedic Surgery 2015;23(1):6-10

6            A retrospective comparison of the management of recalcitrant lateral elbow tendinosis: platelet-rich plasma injections versus surgery. Ronald D. Ford, William P. Schmitt, Kyle Lineberry and Paul Luce.  HAND (2015) 10:285–291

7            Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis:  clinical and ultrasonographic evaluation.  VK Gautam, Saurabh Verma, Sahil Batra, Nidhi Bhatnagar, Sumit Arora.  Journal of Orthopaedic Surgery 2015;23(1):1-5

8            A randomized study of autologous conditioned plasma and steroid injections in the treatment of lateral epicondylitis. Radosław Lebiedziński, Marek Synder, Piotr Buchcic, Michał Polguj, Andrzej Grzegorzewski andMarcin Sibiński.  International Orthopaedics (SICOT).

9            Platelet—Rich—Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence. D. J. Murray, S. Javed, N. Jain, S. Kemp and A. C. Watts.  J Hand Microsurg (July–December 2015) 7(2):320–325

10          Comparison of Local Injection of Platelet Rich Plasma and Corticosteroids in the Treatment of Lateral Epicondylitis of Humerus.  Raman Yadav, S Y Kothari, Diganta Borah. Journal of Clinical and Diagnostic Research. 2015 Jul, Vol-9(7): RC05-RC07.

11        Autologous US-guided PRP injection versus US-guided focal  extracorporeal shock wave therapy for chronic lateral epicondylitis: A minimum of 2-year follow-up retrospective comparative study. Alessio-Mazzola M, Repetto I, Biti B, Trentini R, Formica M, Felli L. J Orthop Surg (Hong Kong) 2018 Jan-Apr; 26(1):2309499017749986. doi: 10.1177/2309499017749986.