of Lateral Epicondylitis With Platelet-Rich Plasma, Glucocorticoid, or Saline:
A Randomized, Double-Blind, Placebo-Controlled Trial. 

Krogh TP, Fredberg U, Stengaard-Pedersen
K, Christensen R, Jensen P, Ellingsen T.. Am J Sports Med. 2013 Jan 17. [Epub
ahead of print]       

Home Message: Among patients with chronic lateral epicondylitis, glucocorticoid
injections were more effective at reducing elbow pain than platelet-rich plasma
or placebo injections at 1 month post-injection but all three treatments had
similar effects at 3 months post injection.

Lateral epicondylitis (tennis elbow) continues to be a common
musculoskeletal disorder that is associated with substantial costs, health care
use, and frustration among patients competing in sports or activities that
involve the upper extremities  Recent
research has focused on platelet-rich plasma (PRP) injections for epicondylitis,
but very few studies have compared PRP and glucocorticoid injections to a
placebo injection.  Therefore, the purpose
of this double-blind, randomized clinical trial was to compare the
effectiveness of PRP, glucocorticoid, or isotonic saline injections for
reducing elbow symptoms among patients with lateral epicondylitis (tennis
elbow).  Patients were included if they
had symptoms of lateral epicondylitis for more than 3 months and signs of
tendinopathy on ultrasound.  Each
injection was performed under ultrasound guidance, with the glucocorticoid
injection being injected in one pass, while the PRP and saline were injected
using a peppering technique with 7 tendon perforations.  All 60 patients received the same
post-treatment protocol, which included minimal use of the affected arm for 3-4
days, use of acetaminophen for pain control if needed, and then starting a
standard tennis elbow stretching and training home program once the pain level
was acceptable.  The primary efficacy
outcome was changes in pain intensity 1 and 3 months after the injection using
the pain section of the Patient-Rated Tennis Elbow Evaluation questionnaire (Scale
of 0-50).  The original goal of the study
was to collect data at 6 and 12 months as well, but there was a large drop-out
rate that did not allow this.  At the one
month follow-up, the glucocorticoid group had a mean decrease in pain of 9.8,
which was better than the saline group (-1.7) and the PRP group (-0.5).  At 3 months there were no differences between
the 3 groups: glucocorticoid group (-7.1), PRP group (-6.0), and saline group

This study matches
results to previous studies showing that glucocorticoid
injections have a benefit in the short-term, but that effect does not last.
Unfortunately, with the large dropout rate, the authors were not able to assess
if there were any long-term benefits of PRP or placebo at 6 and 12 months. This
may be relevant since the Hart et al review found that it was at the long-term
follow-up visits that physical therapy was more effective than a glucocorticoid
injection.  As the authors mentioned,
this is one of the first randomized clinical trials for lateral epicondylitis
that included a placebo group for PRP. 
By having the placebo group undergoing the same needling procedure,
there was potential to assess if the PRP itself makes a difference, rather than
just the needling or tenotomy.  This also
brings up a limitation to the study since the glucocorticoid group only had 1
needle pass into the tendon.  One could
argue that this would be less painful than the 7 tendon perforations in the
other groups, and be a reason for the results. However, the PRP group had more
post-injection pain than the saline group. 
This study also had a large dropout rate, which may have been attributed
to patients having the option of discontinuing the study after 3 months if they
were not satisfied with their results. 
Patients are looking for treatments that will take away their pain as
soon as possible and allow them to return to work or sport quicker.  It can be hard for a patient to think about
waiting a year for improvement, when there’s a chance to have a short-lived
relief of pain.  This study does not support
PRP injections for short-term pain relief of lateral epicondylitis compared to a
placebo or glucocorticoid injection. Further studies will have to examine if
long-term relief is possible and will hopefully be able to include a true
placebo group, such as a physical therapy only group that does not receive an
injection.  Does this study change your
recommendation of treatment for your patients or your view on PRP injections?

Written by: Kris Fayock,
Reviewed by: Jeffrey Driban

Related Posts:

Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, & Ellingsen T (2013). Treatment of Lateral Epicondylitis With Platelet-Rich Plasma, Glucocorticoid, or Saline: A Randomized, Double-Blind, Placebo-Controlled Trial. The American Journal of Sports Medicine PMID: 23328738