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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 6
| Issue : 2 | Page : 169-173 |
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Functional outcome of autologus platelet rich plasma injection as treatment for patients with lateral epicondylitis
Akshay R Halkude1, CN Manjappa1, SS Shivaprakash1, NH Shivakumar2
1 Department of Orthopaedics, Mandya Institute of Medical Sciences, Mandya, Karnataka, India
2 Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, India
| Date of Submission | 29-Nov-2022 |
| Date of Decision | 09-Feb-2023 |
| Date of Acceptance | 10-Feb-2023 |
| Date of Web Publication | 3-May-2023 |
Correspondence Address:
Akshay R Halkude
Mandya Institute of Medical Sciences, Mandya, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jodp.jodp_122_22
Background: Lateral epicondylitis is the most common chronic disabling painful condition affecting 1% to 3% of the population predominantly those between 35 and 55 years of age. Elbow pain with tenderness and restricted wrist extension is its common manifestations. Although a few conservative methods of treatment are available, recent studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy in relieving pain and improving function for tennis elbow. Aim: This study aims to study the efficacy of autologous PRP in tennis elbow. Materials and Methods: A prospective observational study was conducted in our hospital. Fifty patients with chronic lateral epicondylitis aged above 18 years were included in the study. All the patients had a minimum of 3 months of symptoms, were selected based on the inclusion and exclusion criteria and underwent the same method of treatment. All patients had a baseline assessment of numerical pain score and were repeated at 2 weeks, 4 weeks, 8 weeks, 3 months, and 6 months posttreatment. The PRP was prepared from venous whole blood. All patients had a single-dose injection of autologous PRP in their extensor tendons at the elbow through a peppering needling technique. Results: The patients were more often successfully treated. When baseline numerical pain scores were compared with those at 8 weeks, 12 weeks, and 24 weeks follow-up, they showed improvement over time. There were no complications observed related to the use of PRP. The difference between 1-, 2-, 4-, and 6-month pain reduction was tested for significance by Friedman's test and found that there was no significant difference in pain reduction between 2 months and 3 months, 2 months and 6 months, and 3 months and 6 months scores. However, there was a statistically significant difference in pain score in 1 and 2 months. Duration of symptoms suggests the chronic nature of disease. In this study, analysis was done based on the duration of symptoms. Thirty-two out of the 50 patients had pain for <6 months, 16 out of 50 patients between 6 and 12 months, and 2 out of 50 had symptoms of >1 year. In our study, it was found that mean pain score at the end of 6 months for patients with symptoms <6 months was 0.59, whereas the mean pain score of patients with symptoms from 6 to 12 months was 1.81. This indicates that duration of symptoms had a significant correlation with the clinical outcome after injection. Conclusion: Autologous PRP injection is a safe and useful modality of treatment in the treatment of tennis elbow. Maximum benefit after PRP injection was observed at 2 months and had sustained for at least 6 months. More trials are required to optimize the technique for separating PRP. These improvements were maintained over in our follow-up period without any significant complications. Long-term follow-up with more number of patients is needed to evaluate the lasting benefits of pain relief and functional improvement in lateral epicondylitis.
Keywords: Functional outcome, lateral epicondylitis, platelet-rich plasma
How to cite this article:
Halkude AR, Manjappa C N, Shivaprakash S S, Shivakumar N H. Functional outcome of autologus platelet rich plasma injection as treatment for patients with lateral epicondylitis. J Orthop Dis Traumatol 2023;6:169-73 |
How to cite this URL:
Halkude AR, Manjappa C N, Shivaprakash S S, Shivakumar N H. Functional outcome of autologus platelet rich plasma injection as treatment for patients with lateral epicondylitis. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 4];6:169-73. Available from: https://jodt.org/text.asp?2023/6/2/169/375543 |
| Introduction | |  |
Lateral epicondylitis is an inflammatory condition that occurs at the origin of the common extensor tendon of the forearm over the lateral epicondyle. It is the most common chronic disabling painful condition of the elbow. It causes symptoms in 1% to 3% of the general population. It is common in people whose occupation requires frequent rotary motion of the forearm such as carpenters, gardeners, computer workers, and knitting workers. The age of the onset of lateral epicondylitis is between 35 and 50 years with equal male-to-female sex ratio. The dominant upper limb is most affected.[1],[2],[3]
The actual cause of lateral epicondylitis is not clearly understood. Now, it is considered that degenerative process occurs at the common extensor tendon origin of the wrist and fingers due to overuse and abnormal microvascular responses.[4],[5],[6] Nirschl observed that the basic pathology was in the origin of the extensor carpi radialis brevis tendon. However, sometimes the anteromedial edge of extensor digitorum communis and the deep surface of extensor carpi radialis longus may also be involved.
Various modalities of treatment have been recommended for lateral epicondylitis such as rest, activity modification, nonsteroidal anti-inflammatory drugs, counterforce braces, massage, physiotherapy, laser treatment, extracorporeal shockwave treatment, acupuncture, ultrasound treatment, and botulinum toxin type A injection. Previously, injection of corticosteroids was thought to be the gold standard treatment in lateral epicondylitis.
The autologous blood injection and different types of open and arthroscopic operative treatment are also advised for lateral epicondylitis.[7],[8],[9],[10],[11] At present, platelet-rich plasma (PRP) is considered an ideal biological autologous blood-derived component. It can be injected to different tissues where platelet is activated and it releases high levels of transforming growth factor-beta (TGF-β), platelet-derived growth factors (PDGF), fibroblast growth factors (FGF), vascular endothelial growth factors (VEGF), and cytokines at the injected site.
These growth factors released from PRP promote the healing of wounds, tendons, and bone at cellular level.[12] In addition, PRP has high antimicrobial potency, and this property may prevent infections.[13] These details make us to conduct this study. There are studies which suggest that PRP can be used in other conditions such as plantar fasciitis, osteoarthritis knee, and frozen shoulder.
Aims and objectives
The aim of this study is to compare pre- and postinfiltration pain by numerical pain score.
| Materials and Methods | | |
The study was conducted at the department of orthopedics at our hospital including 50 patients from October 2019 to May 2021. All patients included in the study were assessed clinically and confirmed radiologically to avoid any other pathologies. Plain radiograph of the elbow in AP and lateral view of the affected site was obtained. After diagnosis, the patients are selected for the study depending on inclusion and exclusion criteria. Patients are assessed based on the numerical pain scoring system. Regular outpatient department follow-up will be done at 2 weeks, 4 weeks, 8 weeks, 12 weeks, and 24 weeks.
Inclusion criteria
- Patients should have minimum 3-month duration of symptoms
- Patients should have undergone conservative treatment for a minimum period of 3 months
- Patients should have pain score >7 at the time of PRP injection
- Patients should not have had a local steroid injection in the past 2 months
- Age-18 years and above.
Exclusion criteria
- Pain score <7
- Recent local steroid injection. Infection or ulcer at the injection site
- Rheumatoid arthritis
- Seronegative spondyloarthritis
- Pregnant women
- Patients younger than 18 years.
| Results | | |
PRP mixture being injected into the point of maximal tenderness [Figure 1], [Figure 2], [Figure 3].
In the study, out of 50 patients, 25 patients were female and 25 patients were male. Twenty-seven were right-sided lateral epicondylitis and 23 were left-sided lateral epicondylitis. In our study of 50 cases, maximum number of patients had symptoms for <6 months and only two patients for more than 1 year [Figure 4].
The mean pain score at the 3rd and 6th month was found to be significantly equal but pain score at 2 weeks, 4 weeks, and 8 weeks was not significantly equal. When comparing the significance of pain reduction, it was found that there was significant pain reduction till 2 months and further the reduction was not significant [Figure 5]. | Figure 5: Mean NPS scores between different time intervals among patients. NPS: Neuropathic pain scale
Click here to view |
It was found that pain scores in males were significantly lower at every follow-up compared to the females.
Percentage reduction of pain
Patients were analyzed for percentage reduction of pain. Percentage reduction of pain is obtained by calculating the percentage of the difference of pain score at every follow-up from initial pain score at the time of injection. It was observed that the pain was decreased by 50.16% at the end of 1 month, 71.58% by 2 months, and 89.60% on average at the end of 6 months [Figure 6] and [Figure 7].
Duration of symptoms and pain relief
Analysis was done based on the duration of symptoms. Thirty-two out of the 50 patients had pain for <6 months, 16 out of 50 patients between 6 and 12 months, and 2 out of 50 had symptoms of >1 year. In our study, it was found that mean pain score at the end of 6 months for patients with symptoms <6 months was 0.59, whereas the mean pain score of patients with symptoms from 6 to 12 months was 1.81. This indicates that duration of symptoms had a statistically significant correlation with the clinical outcome after injection.
| Discussion | | |
Lateral epicondylitis is a common inflammatory condition at the origin of the extensor tendon of the forearm muscles over the lateral epicondyle. It is the most common chronic disabling painful condition of the elbow. It causes symptoms in 1% to 3% of the general population.
The autologous blood injection and different types of open and arthroscopic operative treatment are also advised for lateral epicondylitis.[7],[8],[9],[10],[11] At present, PRP is considered an ideal biological autologous blood-derived component.
PRP has been utilized and studied since 1970. It can be injected in different tissues where platelet is activated and it releases high concentrations of TGF-β, PDGF, FGF, VEGF, and cytokines at the injected site. These growth factors play significant roles in cell proliferation, chemotaxis, cell differentiation, and angiogenesis. Bioactive factors such as serotonin, histamine, dopamine, calcium, and adenosine are also stored in the dense granules in platelets. These nongrowth factors play an important role in the biological aspects of wound healing. In addition, PRP has high antimicrobial potency and this property may prevent infections. The main outcome parameters considered were pain and functional activities of the elbow. Currently, long-term follow-up data regarding the effectiveness of PRP are lacking. This study shows 6-month follow-up results using the same outcome parameters.
This was a prospective trial by study design conducted on 50 patients with tennis elbow. Our patients were selected based on the inclusion and exclusion criteria described. Patients having chronic inflammatory conditions like rheumatoid arthritis are excluded from the study. Assessment of progression was done based on the numerical pain scoring system.
Following are some studies conducted on tennis elbow patients.
- Christos Thanases et al. by comparing PRP to whole blood for tennis elbow[14]
- Samuel A Taylor et al. on 100 tennis elbow patients compared between PRP and steroid injection.[15]
- Keith s Hetchman et al. on 31 elbows which was not responded for conservative treatment by single PRP injection.[16]
In this study, the numerical pain score among the PRP group has declined from preinjection score of 8.06–5.94 at 2 weeks, 4.00 at 4 weeks, 2.28 at 8 weeks, 1.08 at 12 weeks, and 1.12 at 24 weeks which is almost similar to the study by Christos Thanases et al.[14] in tennis elbow where the mean injection score was reduced from 6.1 to 2.35 at the end of 6 weeks, at 3 months 1.9, and 6 months 1.7.
In this study, the Neuropathic pain scale (NPS) score among males and females were found to be 8.12 and 8.0 at baseline, whereas it was 5.56 and 6.32 at 2nd week, 3.72 and 4.28 at 4 weeks, 2.08 and 2.48 at 8th week, 0.92 and 1.24 at 12th week, and 1.12 at 24th week, respectively. While comparing the results at 2 weeks, 1-, 2-, 4-, and 6-month follow-up, it was found that patients got relief at 1 month. However, the maximum relief of symptoms was at 2 months. The results obtained at 2 months were sustained till the end of the study except in one patient. One patient had a recurrence of symptoms at 6 months. No patients had repeat injections. The above results were comparable with Aksahin et al. and Christos Thanases et al.'s study.[14],[15] The study of Christos Thanasas et al.[14] in tennis elbow the mean injection score was reduced from 6.1 to 2.35 at the end of 6 weeks, at 3 months 1.9, and 6 months 1.7.
The difference between 1-, 2-, 4-, and 6-month pain reduction was tested for significance by Friedman's test and found that there was no significant difference in pain reduction between 2 months and 3 months, 2 months and 6 months, and 3 months and 6 months scores. However, there was a significant difference in pain score in 1 and 2 months. Duration of symptoms suggests the chronic nature of disease. In this study, analysis was done based on the duration of symptoms. Thirty-two out of the 50 patients had pain for <6 months, 16 out of 50 patients between 6 and 12 months, and 2 out of 50 had symptoms of >1 year. In our study, it was found that mean pain score at the end of 6 months for patients with symptoms <6 months was 0.59, whereas the mean pain score of patients with symptoms from 6 to 12 months was 1.81. This indicates that duration of symptoms had a significant correlation with the clinical outcome after injection.
| Conclusion | | |
Autologous PRP injection is a safe and useful modality in the treatment of chronic tennis elbow. Maximum benefit after PRP injection was observed at 2 months and sustained for at least 6 months. More trials are required to optimize the technique for separating PRP. These improvements were maintained over in our follow-up period without any significant complications. Long-term follow-up with more number of patients is needed to evaluate the lasting benefits of pain relief and functional improvement in lateral epicondylitis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am 1979;61:832-9.
Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg 1994;2:1-8.
Hong QN, Durand MJ, Loisel P. Treatment of lateral epicondylitis: Where is the evidence? Joint Bone Spine 2004;71:369-73.
Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11:851-70.
Smith RW, Papadopolous E, Mani R, Cawley MI. Abnormal microvascular responses in a lateral epicondylitis. Br J Rheumatol 1994;33:1166-8.
Wang JH, Iosifidis MI, Fu FH. Biomechanical basis for tendinopathy. Clin Orthop Relat Res 2006;443:320-32.
Assendelft WJ, Hay EM, Adshead R, Bouter LM. Corticosteroid injections for lateral epicondylitis: A systematic overview. Br J Gen Pract 1996;46:209-16.
Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg Am 2003;28:272-8.
Smidt N, Assendelft WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, et al. Effectiveness of physiotherapy for lateral epicondylitis: A systematic review. Ann Med 2003;35:51-62.
Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet 2002;359:657-62.
Wong SM, Hui AC, Tong PY, Poon DW, Yu E, Wong LK. Treatment of lateral epicondylitis with botulinum toxin: A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2005;143:793-7.
Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: A review. Curr Rev Musculoskelet Med 2008;1:165-74.
Everts PA, Overdevest EP, Jakimowicz JJ, Oosterbos CJ, Schönberger JP, Knape JT, et al. The use of autologous platelet-leukocyte gels to enhance the healing process in surgery, a review. Surg Endosc 2007;21:2063-8.
Thanasas C, Papadimitriou G, Charalambidis C, Ilias Paraskevopoulos, Athanasios Papanikolaou: Platelet rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis; the American journal of sports medicine 2011;39:2130-4.
Akşahin E, Doğruyol D, Yüksel HY, Hapa O, Doğan O, Celebi L, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg 2012;132:781-5.
Hechtman KS, Uribe JW, Botto-vanDemden A, Kiebzak GM. Platelet-rich plasma injection reduces pain in patients with recalcitrant epicondylitis. Orthopedics 2011;34:92.
JODP_122_22F1
Figure
Figure 1: Clinical image of the patient's elbow after preparation
[Figure 1]
JODP_122_22F2
Figure
Figure 2: PRP prepared for injection
[Figure 2]
JODP_122_22F3
Figure
Figure 3: Injection of PRP at the lateral epicondyle
[Figure 3]
JODP_122_22F4
Figure
Figure 4: Duration of pain
[Figure 4]
JODP_122_22F5
Figure
Figure 5: Mean NPS scores between different time intervals among patients. NPS: Neuropathic pain scale
[Figure 5]
JODP_122_22F6
Figure
Figure 6: Mean pain score at different time intervals
[Figure 6]
JODP_122_22F7
Figure
Figure 7: Percentage in reduction of pain
[Figure 7]
| References | | |
| 1. | Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am 1979;61:832-9.  |
| 2. | Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg 1994;2:1-8. |
| 3. | Hong QN, Durand MJ, Loisel P. Treatment of lateral epicondylitis: Where is the evidence? Joint Bone Spine 2004;71:369-73. |
| 4. | Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11:851-70. |
| 5. | Smith RW, Papadopolous E, Mani R, Cawley MI. Abnormal microvascular responses in a lateral epicondylitis. Br J Rheumatol 1994;33:1166-8. |
| 6. | Wang JH, Iosifidis MI, Fu FH. Biomechanical basis for tendinopathy. Clin Orthop Relat Res 2006;443:320-32. |
| 7. | Assendelft WJ, Hay EM, Adshead R, Bouter LM. Corticosteroid injections for lateral epicondylitis: A systematic overview. Br J Gen Pract 1996;46:209-16. |
| 8. | Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg Am 2003;28:272-8. |
| 9. | Smidt N, Assendelft WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, et al. Effectiveness of physiotherapy for lateral epicondylitis: A systematic review. Ann Med 2003;35:51-62. |
| 10. | Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet 2002;359:657-62. |
| 11. | Wong SM, Hui AC, Tong PY, Poon DW, Yu E, Wong LK. Treatment of lateral epicondylitis with botulinum toxin: A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2005;143:793-7. |
| 12. | Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: A review. Curr Rev Musculoskelet Med 2008;1:165-74. |
| 13. | Everts PA, Overdevest EP, Jakimowicz JJ, Oosterbos CJ, Schönberger JP, Knape JT, et al. The use of autologous platelet-leukocyte gels to enhance the healing process in surgery, a review. Surg Endosc 2007;21:2063-8. |
| 14. | Thanasas C, Papadimitriou G, Charalambidis C, Ilias Paraskevopoulos, Athanasios Papanikolaou: Platelet rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis; the American journal of sports medicine 2011;39:2130-4. |
| 15. | Akşahin E, Doğruyol D, Yüksel HY, Hapa O, Doğan O, Celebi L, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg 2012;132:781-5. |
| 16. | Hechtman KS, Uribe JW, Botto-vanDemden A, Kiebzak GM. Platelet-rich plasma injection reduces pain in patients with recalcitrant epicondylitis. Orthopedics 2011;34:92. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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