Platelet Rich Plasma (PRP) and Lateral Epicondylitis
Lateral epicondylitis is one of the most commonly treated conditions in a primary care sports medicine clinic. Patient’s typically complain of lateral elbow pain that is worse with activity. Certain activities like holding a jug of milk or turning over their hand are likely to worsen the pain. Fortunately, we have multiple treatment modalities to offer them. First line typically includes a period of activity modification and physical therapy with focus on eccentric strengthening the cornerstone of treatment and prevention. Physicians may also offer palpation guided lateral epicondyle injections to patients with acute lateral epicondylitis. Patients tend to have immediate relief with corticosteroid injections but the injection lacks long term benefit. However, over the last couple of years multiple other treatment modalities have emerged. These include needle tenotomy under ultrasound guidance and platelet rich plasma injections. This review is going to look at the role of platelet rich plasma for the treatment of lateral epicondylosis.
Image 1. Illustration of lateral epicondylitis injection (courtesy of sciencedirect.com)
The theory behind using platelet rich plasma for lateral epicondylosis is delivering a large amount of growth factors to an area of tendon that is marred by necrosis, neovascularization, and inflammation 1. One difficulty we had when looking at data with PRP injections was the lack of uniformity in processing the PRP. Currently there are multiple different kits that can be used to process PRP and they all provide different numbers of platelets and white blood cells. A meta analysis published in the American Journal of Sports Medicine attempted to look at the role of PRP in tendinopathy. However, they found that the processing of PRP influenced the results of the study 2.
Despite the potential drawbacks of PRP studies we have some evidence that make us more likely to use PRP in our patients. A hospital in the UK in 2012 began to offer PRP to their patients prior to offering them arthroscopic lateral release. The hospital then counted how many lateral releases they performed in the three years after PRP was initiated in the hospital and compared the counts to those in the prior three years. What they found was a statistically significant decrease in number of lateral releases from 52 to 17. This study helps show that there is long term benefit from PRP and that as primary care sports doctors we can help save the health system money by decreasing unnecessary surgeries 3.
The final paper we want to present is a study comparing PRP injection to surgical release that was published in 2016 in the Journal of Orthopaedics. A group of patients who had already failed conservative measures were either offered surgical release or PRP injection. What they found was that the group that received the PRP injection had both better short and long term pain scores 4.
The role and evidence for PRP as treatment for chronic tendinopathy is growing. The goal of this brief review of the literature was to point out some of the limitations in analyzing the data of PRP trials. More research is needed but the role of PRP in tendinopathy is promising.
1. Karim Khan, J. C. (1999). Histopathology of Common Tendinopathies. Sports Medicine, 393-408
2. Jane Fitzpatrick, M. B. (2017). The Effectiveness of Platelet-Rich Plasma in the Treatment of Tendinopathy: A Meta-Analysis of Randomized Controlled Clinical Trials. The American Journal of Sports Medicine, 226-233.
3. Mert Karaduman, M. C. (2016). Platelet-rich plasma versus open surgical release in chronic tennis elbow: A retrospective comparative study. Journal of Orthopaedics, 10-14.
4. Graham Hastine, M. S. (2018). Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention. Journal of Orthopaedics, 239-241.