Tonk G, Kumar A, Gupta A, Indian Journal of Orthopedics. 2014;41:390-393. Article summary by Samantha Crager SPT, CSCS from Missouri State University, Springfield, Missouri
The prospective observational study was done to assess the efficacy of autologous Platelet Rich Plasma injection in lateral epicondylitis of the elbow, and compare the result with low-level laser therapy. The study consisted of 81 participants between the ages of 20-70, with chronic lateral epicondylitis, which were divided into two groups, the Platelet Rich Plasma group (n=39) and laser therapy group (n=42). All participants presented after 7 days since onset of pain and one of the following positive clinical tests: Tenderness elicited just distal and anterior to the lateral epicondyle, pain with resisted wrist extension with an elbow in full extension, Coffee cup test – picking up a full cup associated with localized pain at lateral epicondylar region, chair test – picking up a chair with extended elbow, Thomson test-flex the patient shoulder to 60° with the elbow extended, forearm pronated, and wrist extended 30°, apply pressure to the dorsum of second and third metacarpal in the direction of flexion and ulnar deviation and the Cozens test – flex elbow and extended wrist against resistance. Exclusion criteria included: rheumatoid arthritis of the elbow, cervical radiculopathy, infective pathology, neoplastic lesion, dermatomyositis, previous trauma around the elbow, previous lateral epicondylitis surgery, or steroid injection within 3 months.
The platelet rich plasma group received an injection at the site of maximum tenderness and in the vicinity of the lateral epicondyle. The technique included 5 penetrations of the tendon. The Laser group received 10 treatments at 5 minutes each. Both groups received a treatment plan that included standardized stretching for 2 weeks, and a forearm strengthening program, and at 3 weeks patients were allowed to proceed with normal sporting or recreational activities as tolerated. Patient data were re-assessed with the Student t-test (Bonferroni correction), Chi-square test, Fisher test, and the Nirschl staging system for pain.
Lateral epicondylitis is a common diagnosis that is seen today and has several different treatment options including, but not limited to, corticosteroid injections, physical therapy, and laser therapy. This study demonstrates the possible effects of platelet rich plasma injection to the lateral elbow with the use of therapy for prolonged results. According to the studies the outcomes demonstrate that laser therapy has initial positive effects on decreased pain exceeding that of platelet rich plasma until week two. At this point there becomes a statistical difference from week three through 12 months in which platelet rich plasma treatment in conjunction with physical therapy shows a greater reduction in pain and decreased reccurrence in the long term.
Platelet rich plasma is a newer concept that is believed to work through releasing growth factors and cytokines, which in turn stimulate local stem cells and extra cellular matrix gene expression. This allows for the recruitment of reparative cells from local circulation or bone marrow. At the same time, it helps to inhibit excessive inflammation, apoptosis, and metalloproteinase activity. Through this it is thought that patients will demonstrate a decrease in pain and healing time, while simultaneously having an increase in strength. This treatment, along with physical therapy intervention, may improve healing time, decrease pain and risk of reccurrence, and increase the long-term success of our patients.
Platelet Rich Plasma Treatment is just now up and coming and is taking off in the world of professional athletics. There is still very minimal evidence based research to support this method of treatment as more reliable studies need to be performed. Throughout the profession of Physical Therapy, this could have an impact on the treatment approaches performed on patients with tendonitis or tendinosis, as what used to consist of more decreasing pain and inflammation, may now be more aggressive and shorter in duration if the claims of this research are proven effective.
It is interesting to note that the Laser therapy intervention was effective over short term whereas platelet rich plasma effects where a slower onset, with statistically significant relief over time. It would be interesting to see the effects of platelet rich plasma versus corticosteroids and also a control group in order to determine the overall outcomes and truly determine what is the best treatment approach for these conditions.
Tanya Smith PT, ScD, FAAOMPT
Treatment for lateral epicondylitis can vary, with wide ranging therapeutic options, those which might include platelet rich plasma (PRP) injection, corticosteroid injection, surgery, exercise, modalities and manual therapy. There is no current consensus of treatment options, due to the complexity of this diagnosis. With any multifaceted musculoskeletal disorder, appropriate patient selection should be considered with each case. The IAOM-US recommends a multi-modal treatment approach ie: tranverse friction massage (TFM) to affected tendon, eccentric training of wrist extensors, manipulation if joint limitations exist in supra-adjacent joints or segments of the upper quadrant. These interventions combined with an appropriate patient selection for PRP or corticosteroid injections could improve clinical outcomes. There is evidence to support the use of PRP vs corticosteroid injections for chronic lateral epicondylitis. Gosens et al 2011 reports improved outcomes on DASH and VAS scores on chronic lateral epicondylitis with PRP injection vs corticosteroid injection even with a two year follow-up. Studies performed in the future should look at specific physical therapy interventions with specific dosage, duration and frequency rather than nonspecific physical therapy approach.
Gosens T, Peerbooms JC, Van Laar W, den Oudsten BL. Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-year Follow-up.Am J Sports Med. 2011;39:1200-1208.