|Year : 2020 | Volume
| Issue : 3 | Page : 127-132
A short-term comparative analysis of the efficacy of platelet-rich plasma therapy and corticosteroid injection in lateral epicondylitis
Anant Akash1, Sanjay Gupta1, Apser Khan1, Milan Jaiswal2
1 Department of Orthopaedics, Sri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
2 Department of Pathology, Sri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
|Date of Submission||21-Nov-2020|
|Date of Decision||23-Nov-2020|
|Date of Acceptance||26-Nov-2020|
|Date of Web Publication||31-Dec-2020|
#223, F-Block, Sri Ram Murti Smarak Institute of Medical Sciences, Bareilly - 243 202, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Tennis Elbow, a common overuse syndrome, is a tendonitis of the extensor muscles of the forearm mainly due to intratendinous degeneration associated with aging, repetitive movement, and vascular compromise. Autologous platelet-rich plasma (PRP) injections represent a new therapeutic option for chronic tendinopathies including tennis elbow. The purpose of the present study was to assess the therapeutic effect, efficacy, and safety of a single injection of PRP and corticosteroid in improving pain and function in patients suffering from lateral epicondylitis over a short term. Materials and Methods: Sixty patients with lateral epicondylitis were randomized into two groups to receive one injection of PRP or corticosteroid and were followed for 3 months. The two groups were compared as regards pain and functional improvement using the visual analogue scale (VAS) and the patient-rated tennis elbow evaluation (PRTEE) Score, by assessing the patients three times postintervention. Results: VAS scale showed that both modalities were effective in pain reduction. PRTEE score represented variably improved symptoms, i.e., decrease in pain and better function along with improvement in daily activity after 3 months in both groups. Conclusion: As the degree of pain relief achieved by the respective modalities was almost similar, the most important difference between the intervention groups was the duration of their effectiveness. PRP is suggested to be superior in the duration of pain relief when compared to corticosteroids. We can propose that PRP can be administered less often and more conveniently as compared to corticosteroid for lateral epicondylitis.
Keywords: Corticosteroids, lateral epicondylitis, patient-rated tennis elbow evaluation, platelet-rich plasma, tennis elbow, Visual Analogue Scale (VAS)
|How to cite this article:|
Akash A, Gupta S, Khan A, Jaiswal M. A short-term comparative analysis of the efficacy of platelet-rich plasma therapy and corticosteroid injection in lateral epicondylitis. J Orthop Dis Traumatol 2020;3:127-32
|How to cite this URL:|
Akash A, Gupta S, Khan A, Jaiswal M. A short-term comparative analysis of the efficacy of platelet-rich plasma therapy and corticosteroid injection in lateral epicondylitis. J Orthop Dis Traumatol [serial online] 2020 [cited 2021 Jan 20];3:127-32. Available from: https://www.jodt.org/text.asp?2020/3/3/127/305740
| Introduction|| |
Lateral epicondylitis, also known as tennis elbow, is a frequently reported degenerative disorder of the tendons of the common extensor origin of the lateral humeral epicondyle in patients whose activities require strong gripping or repetitive wrist movements, often associated with jobs that involve manual work and vibrating tools. Patients often complain of pain and functional impairment in their daily activities. Runge first described this clinical entity in 1873. The annual incidence of lateral elbow pain in general practice is 4–7/1000 people. It is more common in the fourth and fifth decades of life and affects men and women equally., Previously, the disease was found in athletes, especially tennis players. However, in present-day practice, it is known to affect a wide range of professions such as painters, plumbers, carpenters, and drivers. The dominant arm is predisposed to get affected by lateral epicondylitis.
The lateral epicondyle of the humerus is a small tuberculated eminence that gives rise to the common origin of the five extensor muscles in the forearm. The suggested etiologies include repetitive wrist turning or hand gripping, tool usage, shaking hands, and twisting movements that may exceed tissue capacities. Earlier thought to be an inflammation of lateral epicondyle, the current etiopathogenesis is of an overload injury of the extensor musculature due to repetitive microtrauma that starts as a microtear in the lateral epicondylar tendons, most often from the extensor carpi radialis brevis, leading to enthesopathy. Rather than being a purely inflammatory condition, it is suggested that there is an initial inflammatory response, which is followed by degenerative changes with the production of disorganized collagen, which can then lead to structural failure or tearing of the tendon origin, termed as “angiofibroblastic hyperplasia.”
The symptoms are generally self-limited and can present in the form of acute, intermittent, or subacute pain. On clinical examination, there is tenderness without swelling along the extensor tendons, at or just below the lateral epicondyle. It can be accompanied possibly with weakness in the forearm and diminished grip strength on the affected side with almost normal range of motion at the ipsilateral elbow. Symptoms generally vary in duration from a few weeks to months. However, in some cases, there is no spontaneous resolution, and this invariably leads to a chronic condition. While most patients recover within a year, a typical episode lasts between 6 and 24 months.
A wide range of treatment options is available. The treatment is initially conservative and includes rest, nonsteroidal anti-inflammatory drugs, bracing, activity modification, physiotherapy, and watchful waiting. Injections of corticosteroids, iontophoresis, extracorporal shockwave, botulinum toxin, and various surgical techniques have been incorporated in refractory cases. However, these traditional therapies do not alter the tendon's inherent poor healing properties secondary to poor vascularization.
Historically, corticosteroid injections have been the mainstay of treatment for lateral epicondylitis. Corticosteroids inhibit fibroblast proliferation, angiogenesis, and formation of granulation tissue. They also interfere with collagen precursor ground substance sulfation and collagen repair. Signs of inflammation such as hyperemia and tendon thickness are minimized by their use. Corticosteroids also possess analgesic action by their effect on the calcitonin-gene-related peptide, neuropeptides, and substance P, which are increased in tendinopathies. Since the current etiopathogenesis is of an initial inflammatory response followed by angiofibroblastic hyperplasia, it is not possible to draw a firm conclusion regarding the long-term effectiveness of corticosteroid injection in tennis elbow. In addition, periodic corticosteroid injections do pose the potential for inadvertent side effects such as subcutaneous fat atrophy, skin de-pigmentation, and tendon rupture.
Platelet-rich plasma (PRP) is an autologous supraphysiologic concentration of platelets in a small volume of plasma, prepared by centrifugation of blood. PRP contains a three- to five-fold increase in platelet concentration and 1- to 25-fold higher concentration of cytokines and growth factors that are capable of stimulating cellular growth, vascularization, proliferation, tissue regeneration, and collagen synthesis. The release of platelet-derived factors directly at the site of cartilage disease, particularly with interest to lateral epicondylitis, may stimulate the natural regenerative signaling cascade and enhance the healing of tissue with further mediation of the anti-inflammatory response.
The aim of the present study was to compare the efficacy of PRP therapy and corticosteroid injection in the treatment of lateral epicondylitis.
| Materials and Methods|| |
This prospective randomized study was conducted in the outpatient department of our tertiary care hospital after approval of the institutional ethics committee from September 2018 to September 2019. Sixty patients of either sex, between 20 and 70 years of age, suffering from lateral epicondylitis, confirmed clinically by Cozen's, Mill's and Maudsley's tests, with duration of symptoms more than 3 months and with no response to conservative treatment with baseline platelet counts above 1.5 × 103/μl were selected. Written informed consent was obtained from all patients before treatment.
Patients with a previous history of trauma or surgery to the concerned elbow, local infection, cervical radiculopathy, ipsilateral elbow pain due to other causes such as tendon rupture, crystal arthropathies such as gout and carpal tunnel syndrome, systemic disorders such as diabetes, rheumatoid arthritis, any platelet dysfunction syndrome or coagulopathies, platelet count <1.5 × 103/μL, and recent history of aspirin or aspirin-like drug intake were excluded from the study. Baseline platelet counts, hematocrit, erythrocyte sedimentation rate, and viral markers were evaluated before the procedure in all cases.
Twenty milliliters of venous blood was drawn from the antecubital vein using an 18G needle to avoid traumatizing platelets and was collected in a sterile tube containing 2 ml of sodium citrate anticoagulant. Approximately 2 ml of whole blood was separated for a complete blood count. Centrifuge was precooled at 2500 rpm for 15 min. Then, the blood with anticoagulant was centrifuged twice: first at 2700 rpm for 12 min to separate erythrocytes and then at 3200 rpm for 6 min to concentrate the platelets. The final product was 4–5 mL of PRP-containing leukocytes with platelet concentration of 3–5 times the average normal value. This PRP was prepared in our hospital laboratory and was provided as required in a sterile form [Figure 1].
All sixty patients were randomly divided into two equal groups by random allocation sequence using a random number table. The first group included thirty patients who were treated with a single 2 ml injection of PRP prepared in our hospital. The second group included thirty patients who were treated with one injection of 2 ml of methylprednisolone acetate at 40 mg/mL.
Patients were placed in a sitting position with elbow flexed and parallel to the ground and forearm mid-pronated. The site of maximal tenderness was palpated with the surgeon's thumb, and under strict aseptic precautions, PRP solution, or corticosteroid was injected using a 22G needle through a single skin portal into the common extensor tendon using a peppering technique which involved the insertion of needle into the tendon to inject some amount, followed by retraction of needle to the subcutaneous tissue and redirection and reinsertion of the needle [Figure 2].
Postinjection, the patient was kept in a supine position without moving the arm for 15 min and was advised to take 1 day of rest and oral acetaminophen for pain, if required. A formal stretching and strengthening exercises of forearm muscles were initiated on the 2nd day after injection. An exercise program consisting of range of motion, stretching, strengthening, and gripping exercises in multiples of ten, three times per day for over 4 weeks was started. At 4 weeks after the procedure, patients were allowed to proceed with normal sporting or recreational activities as tolerated.
The 100 mm visual analog pain scale (VAS) and patient-rated tennis elbow evaluation (PRTEE) were used to assess the response to treatment at various intervals. The PRTEE was used as a self-administered test consisting of a 15-item questionnaire divided into two subscales, which measure pain (five items, score range 0–10) and functional disability based on specific and usual activities (ten items, score range 0–10). Summing up the scores for specific activities and usual activities and dividing it by two determined the functional disability subscale value. The two subscale values were added to provide the total PRTEE score in the range of 0 (best score) to 100 (worst score). With the use of PRTEE, a lower score represented a better outcome.
The VAS, which also was administered by the patient, ranged from 0 to 100 mm, with lower numbers representing less pain and higher numbers representing more pain. Both measurements were used at the time of enrollment in the study, before any injection and were measured again at 1-, 2-, and 3-month follow-up. The measurements were recorded in a pro forma and tabulated. Categorical variables between the two groups were compared using the Chi-square test. Quantitative variables with normal distribution between the groups were compared using the Student's t-test, while the paired t-test was used to compare the variables within the groups. Skewed variables between the groups were compared using the Mann–Whitney U-test. The Wilcoxon test was used to compare skewed quantitative data within the groups. The level of statistical significance was set at P < 0.05. The assessors filling out the questionnaire of PRTEE scores and assessing VAS scores and the statistician were the same and blinded to the group of the patients.
| Results|| |
The recruited subjects were randomly allocated into two treatment groups, i.e., those receiving autologous PRP injection (Group A) and corticosteroid injection (Group B). Pain and elbow function were assessed using VAS and PRTEE scores.
Among the sixty patients enrolled in our study, 36 (60%) were male and 24 (40%) were female. In Group A, 63% (n = 19) were male, while in Group B, 56.7% (n = 17) were male [Table 1]. There was no statistically significant difference in gender-based distribution of patients between the study groups (P = 0.598). The mean age of the patients in Group A was comparable to the mean age of the patients in Group B (45.93 ± 12.70 vs. 42.67 ± 13.22; P = 0.333) [Table 2]. A total of sixty patients were evaluated; there was the involvement of the right elbow in 35 (58%) patients. In the rest 25 (42%) patients, left elbow was involved. In Group A, right elbow was involved in 60% (n = 18) of patients, while in Group B, right elbow was involved in 57% (n = 17) of patients [Table 3]. Involvement of elbows was comparable between both groups (P = 0.793).
|Table 3: Distribution of elbows involved of the patients of study groups|
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The VAS score was comparable preprocedure in the PRP group (Group A) in comparison to the corticosteroid group (Group B) (8.0 [7.0, 9.0] vs. 8.0 [7.0, 9.0]; P = 0.750). At 1 month, VAS score was significantly lower in Group B in comparison to Group A (2.0 [1.0, 2.25] vs. 4.0 [3.0, 5.0]; P < 0.0001). At 2 months, VAS score was comparable in Group A in comparison to Group B (3.5 [3.0, 4.0] vs. 3.0 [3.0, 4.0]; P = 0.176). At 3 months, VAS score was significantly lower in Group A in comparison to Group B (3.0 [3.0, 4.0] vs. 5.0 [5.0, 6.0]; P < 0.0001).
We observed that, in Group A, VAS score was significantly lower at 1 month (P < 0.0001), 2 months (P < 0.0001), and 3 months (P < 0.0001) in comparison to preprocedural VAS score. VAS score was significantly lower at 2 months (P = 0.002) and 3 months (P < 0.0001) in comparison to VAS score at 1 month. Similarly, VAS score was significantly lower at 3 months (P < 0.0001) in comparison to VAS score at 2 months.
We also observed that, in Group B, VAS score was significantly lower at 1 month (P < 0.0001), 2 months (P < 0.0001), and 3 months (P < 0.0001) in comparison to preprocedural VAS score. VAS score was significantly higher at 2 months (P = 0.002) and 3 months (P < 0.0001) in comparison to VAS score at 1 month. Similarly, VAS score was significantly higher at 3 months (P < 0.0001) in comparison to VAS score at 2 months [Table 4].
|Table 4: Comparison of visual analog pain scale scores in the study groups|
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Patient-rated tennis elbow evaluation score
PRTEE score was comparable preprocedure in Group A in comparison to Group B (82.37 ± 4.71 vs. 82.90 ± 4.02; P = 0.639). At 1 month, PRTEE score was significantly lower in Group B in comparison to Group A (62.10 ± 3.22 vs. 70.17 ± 3.93; P < 0.0001). At 2 months, PRTEE score was comparable in Group A in comparison to Group B (67.85 ± 4.19 vs. 66.73 ± 3.07; P = 0.245). At 3 months, PRTEE score was significantly lower in Group A in comparison to Group B (64.75 ± 3.26 vs. 70.2 ± 3.99; P < 0.0001).
We observed that, in Group A, PRTEE score was significantly lower at 1 month (P < 0.0001), 2 months (P < 0.0001), and 3 months (P < 0.0001) in comparison to preprocedural PRTEE score. PRTEE score was significantly lower at 2 months (P = 0.003) and 3 months (P < 0.0001) in comparison to PRTEE score at 1 month. Similarly, PRTEE score was significantly lower at 3 months (P < 0.0001) in comparison to PRTEE score at 2 months.
We also observed that, in Group B, PRTEE score was significantly lower at 1 month (P < 0.0001), 2 months (P < 0.0001), and 3 months (P < 0.0001) in comparison to preprocedural PRTEE score. PRTEE score was significantly higher at 2 months (P = 0.003) and 3 months (P < 0.0001) in comparison to PRTEE score at 1 month. Similarly, PRTEE score was significantly higher at 3 months (P < 0.0001) in comparison to PRTEE score at 2 months [Table 5] and [Graph 1] and [Graph 2].
|Table 5: Comparison of patient-rated tennis elbow evaluation score scores in the study groups|
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Postinjection exacerbation of pain was seen in three out of thirty patients in the steroid group and five out of thirty patients in the PRP group. Only two patients had local skin atrophy and discoloration in the study population. All these patients were in the corticosteroid group. No patient reported elbow stiffness, infection, reflex sympathetic dystrophy, postinjection flare, facial flushing, neurovascular damage, tendon rupture, or other untoward complications.
| Discussion|| |
Lateral epicondylar tendinosis is a common problem with many possible treatments. Quick cessation of symptoms is important to patients and is economically advantageous. Corticosteroid injections have been used extensively till now, but Jobe and Ciccotti concluded that superficial injection of corticosteroid may result in subcutaneous atrophy and that intratendinous injection may lead to permanent adverse changes within the ultrastructure of the tendon. PRP is promoted as an ideal autologous, biological, blood-derived product that can be exogenously applied to various tissues, where it releases high concentrations of platelet-derived growth factors that enhance wound healing, bone healing, and tendon healing. In addition, PRP possesses antimicrobial properties that may contribute to the prevention of infections. When platelets become activated, growth factors are released and initiate the body's natural healing response.
Omar et al. and Shiri and Viikari-Juntura, in their epidemiological studies, have identified age as an important factor associated with the occurrence of tennis elbow, with onset more common, after the age of 30 years.,, The mean age of all the patients in our study was 44.3 years with a range between 21 and 69 years which corresponded with their findings. Nearly 60% of our patients were male. In PRP group, 63% were male, while in the steroid group, 56.7% (n = 17) were male. There was no significant difference in gender-based distribution (P = 0.598). A male predominance was observed in this study regardless of the group allocated. Findings were again, coherent with the epidemiological studies of Shiri and Viikari-Juntura and Omar et al., In our study, the right elbow was involved in 58% of patients. Involvement of elbows was not different between both groups (P = 0.793). Similarly, Mundla et al. have observed that the right elbow was involved in 92% of the patients in both PRP and steroid groups. They also found that side of elbow involvement was not statistically significant (P = 0.99).
Visual analog scale (VAS) for assessing pain is the most commonly used method for measuring painful conditions because it is quickly and easily applied. However, using VAS presents practical limitations within clinical scenarios, given that most patients report that they have difficulty in translating the physical intensity of their pain into a scale in millimeters. We observed that VAS score was comparable before procedure. At the first visit, VAS score was significantly lower in the corticosteroid group in comparison to the PRP group, showing acute effectiveness of corticosteroid injection. We also observed that VAS score was significantly lower in PRP group in comparison to steroid group at 3 months. Our findings are in concordance with Yadav et al., who observed that VAS score was lower at 1 month in the steroid group in comparison to PRP group of patients (P = 0.018); however, the pain was increased in the steroid group at 3 months.
Omar et al. have reported that the effect of corticosteroid injections lasts for about 3 months while that of PRP injections last for more than 6 months in providing pain relief in tennis elbow. Our findings of a significant improvement in corticosteroid group at 1 month, while significantly more improvement in pain in PRP group at 3-month follow-up, are also consistent with the work of Gosens et al. and Kazemi et al., It is possible that PRP offers a long-term healing effect on the affected tendon. The disparity in the efficacy of PRP in some studies may be attributed to the relative difference in the quantity of growth factors delivered to the degenerated tendon [Table 6]. In the study by Peerbooms et al., the corticosteroid group was better initially and then declined, whereas the PRP group progressively improved.
We observed that PRTEE score was comparable before procedure. The score was lower in steroid group at 1 month but higher at 3 months in comparison to PRP group. Our findings differ with Mishra et al., who reported that there were no major differences in the scores between the PRP and corticosteroid groups on the PRTEE questionnaire. Both groups showed improvement with time. At 8-, 12-, and 24-week follow-up, the PRP group reported more improvement over baseline, but these differences were not statistically significant. Similarly, Palacio et al. observed no significant difference in PRTEE score at 90 days and 180 days in the PRP group in their study.
| Conclusion|| |
According to results, the group of patients with tennis elbow treated with PRP showed significant improvement compared to those in the corticosteroid group, reflecting better efficacy at 3 months. However, the effect was better for corticosteroid injection at short-term follow-up of 1 month. PRP proved to be a promising form of therapy for lateral epicondylitis. It is both safe and effective in relieving pain and improving function. The available data support the evidence that corticosteroid injection is deleterious and may lead to serious consequences.
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Conflicts of interest
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]