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Four Injection Therapies for Tennis Elbow – A Review

Tennis elbow, or lateral epicondylitis, is a tendon disorder that can affect athletes and workers with pain and disability that can last for years. It has traditionally been thought to be caused by inflammation of the tendons. Existing therapies such as rest, exercise, NSAIDs, and cortisone injections don’t always relieve pain or improve function. In the long term, cortisone injections may even make the condition worse, or harder to recover. (Link)

Current evidence suggests that the tendon pathology is actually degenerative change rather than inflammation. Abnormal blood vessels become present in the tendon and collagen fibers become disorganized. Four injection therapies – Prolotherapy, platelet-rich plasma, whole blood, and polidocanol have been used to target the tendon pathology and are showing promise as effective therapies. Researchers at the University of Wisconsin conducted a systemic review of these injection therapies on tennis elbow.

injection therapies

The Study Method

Prospective controlled studies of human clinical trials that involved pre and post assessments were identified. Study designs were assessed for internal validity and each study received a quality score.
For the nine studies that met criteria, the effect size of outcomes was calculated so that studies could be compared.
Four controlled studies and five prospective case series were included. Three evaluated prolotherapy, two evaluated Polidocanol, three evaluated autologous whole blood, and one evaluated PRP for a total of 208 adult subjects who had failed conservative therapy. Ultrasound confirmed subjects had neovascularisation and structural changes in the tendon.

Results

All the injection therapies showed promising results with large effect sizes and no side effects however sample sizes were small so results must be interpreted cautiously.

Prolotherapy subjects reported 90% improvement at 16 weeks.

Polidocanol decreased pain by 55% and increased grip strength at 8 months. Ultrasound showed improved structural defects and vascularity.

Studies using whole blood reported significant improvement in the range of 64% to 88%.

A single injection of PRP resulted in 81% improvement at 27 weeks and 93% at 25.6 months.

Why Do Regenerative Injection Therapies Work?

Injection therapy places the intervention directly at the degenerative site. It is thought to stimulate regenerative cofactors.
Prolotherapy contains hyperosmolar dextrose and this component has been shown to increase platelet-derived growth factor which may act as a signaling factor in tendon repair.
PRP is rich in growth factors and has bioactive signaling factors for tendon repair.

In conclusion, all four injection therapies are treatment options for hard to heal lateral epicondyle tendinopathy (tennis elbow) patients and are safe when performed by a skilled clinician. However, Prolotherapy and PRP treatments are more common and have more research available.

Rabago, D, Best, TM, Zgierska, A, Zeisig, E, Ryan, M. & Crane, D. (2009).

A systemic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. British J of Sports Medicine, 443: 471-481.

Four Injection Therapies for Tennis Elbow – A Review

Pain Management Injection Therapies for Low Back Pain

Pain Management Injection Therapies for Low Back Pain [Internet]. Chou R(1), Hashimoto R(1), Friedly J(1), Fu R(1), Dana T(1), Sullivan S(1), Bougatsos C(1), Jarvik J(1). Rockville (MD): Agency for Healthcare Research and Quality (US); 2015. AHRQ Technology Assessments. Author information: (1)Pacific Northwest …

Prolotherapy

systematic review studying various injection therapies found that prolotherapy and hyaluronic acid injection therapies were more effective than placebo

Stem cell secretome

transdifferentiation is the primary mechanism of effect of stem cell injection therapies. The most commonly used type of stem cells for therapeutic use are

Can Cortisone Injections Make Tennis Elbow Worse?

cortisone injections

Corticosteroid injections were introduced in the 1940s and they soon became popular in the treatment of sports-related injuries because they provide prompt pain relief. When clinical trials were introduced in the 1950s they shed doubt on the long-term effect of cortisone injections. While patients enjoyed the dramatic short-term relief of pain, the injury often relapsed within six months. However, these findings did not dampen enthusiasm for cortisone injections since too many people they seemed a better alternative to rest and physical therapy. However, a major review article published in The Lancet in 2010 intensifies the doubts about the efficacy of cortisone injections.

The Study Method

The Lancet study was a meta-analysis, a scientific way of pooling data from many small studies to increase the study size making the findings more powerful than individual small studies.
Forty-one high-quality randomized controlled clinical trials were pooled, creating a database of 2672 subjects.

Results

Compared to other interventions, cortisone injections reduced tennis elbow pain in the short-term, but this effect was reversed at 6 and 12 months. There was a 63% risk of relapse and lower recovery rate compared to those who did not receive cortisone injections.

In contrast, hyaluronate injections reduced pain in the short term as well as at 6 and 12 months and Prolotherapy provided confirmed relief at 6 months.

People receiving multiple steroid injections are especially at high risk for worsening damage. An average of 4 injections results in a 57% worse outcome when compared to one injection.

The authors conclude that for tennis elbow, cortisone injections seem counterproductive.

Why is this study important?

Cortisone injections have become a standard of practice and are frequently requested by patients because they do provide rapid relief of pain. However, patients, particular athletes, should consider the long-term effects of cortisone injections as they may decrease the tendons regenerative potential.

For many years it was believed that tendon over-use injuries were caused by inflammation. It was logical to use cortisone as a treatment because it is an anti-inflammatory medication. However, numerous studies now show convincingly that chemical markers of inflammation cannot be found in these overuse injuries. We now know that fibers within the tendons fray, which indicates the injury is due to degeneration.
It must be asked, ‘Why do cortisone injections appear to work in the short term?’ The answer is they seem to have an effect on the neural receptors that produce the pain signal. However, they have not been shown to heal structural defects, instead, they may actually impede tissue healing.
While there will always be a desire for a “quick fix,” the author of the Lancet study advises that athletes with tennis elbow think carefully about the wisdom of cortisone shots. New, emerging cellular treatments, such as platelet-rich plasma (PRP), show great promise in healing tendon pain and injury.

Coombs, B., Bisset, L. & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomized controlled trials. The Lancet. 376(9754):1751-1767.

Reynolds, G. (2010). Phys Ed: Do cortisone shots actually make things worse? http://well.blogs.nytimes.com/2010/10/27/do-cortisone-shots-actually-make-things-worse/?_r=0

Meta-Analysis Shows PRP Improves Tennis Elbow

Tennis Elbow Brace Lateral epicondylitis, more commonly known as tennis elbow, is the most frequent reason people see the physician for elbow pain. Tennis elbow is a swelling of the tendons that connect the lower arm to the elbow and is caused by any repetitive, gripping type activities – not just …

Tennis Elbow

Lateral epicondylitis, more commonly known as tennis elbow, is the most frequent reason people see the physician for elbow pain. Tennis elbow is a swelling of the tendons that connect the lower arm to the elbow and is caused by any repetitive, gripping type activities – not just tennis. Corticosteroid (CS) injections offer short-term relief and have been the treatment of choice since the 1950s, but since several studies have shown no long-term benefit from steroid injections clinicians are turning to newer biological therapies. Orthopedic researchers in Bangkok, Thailand conducted a systematic review and meta-analysis to compare the clinical effects of two biological treatment options, autologous blood (more…)

More Evidence for Platelet Rich Plasma Use in Knee Osteoarthritis

Knee Osteoarthritis

Regenerative medical researchers in Barcelona, Spain are investigating new treatments, such as PRP, for osteoarthritis (OA) that address the underlying disease pathology rather than simply treat symptoms. The goal is to improve quality of life and physical function in persons with osteoarthritis. There currently is no curative approach for the millions of people with OA. Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) is commonly prescribed but many people, especially the elderly, have a high risk of side effects with NSAIDs.

Recently autologous plasma rich in growth factors (PRGF), commonly called PRP or Platelet Rich Plasma in the US, rich in proteins, has been considered a promising regenerative approach to stimulate chondrocytes to produce more cartilage (Cartilage is destroyed in OA). PRGF has a high concentration of growth factors. These factors act specifically on the tissue to repair and heal and have been shown to stimulate (more…)

Platelet Rich Plasma Improves Outcomes in Knee Arthritis

A study found in the Clinical Journal of Sports Medicine followed 22 patients with early stage knee osteoarthritis to examine the effect of Platelet Rich Plasma (PRP) on the patients’ pain and function. Patients’ ages were 30 to 70 years with an average age of 54 years, and all of them had experienced knee pain for about 14 months prior to the study. Early stage knee osteoarthritis in each patient was confirmed at the beginning of the study by MRI.

Each of the patients had twenty ml (about 4 teaspoons) of blood drawn and this blood was then spun down to a solution of 6 mls of concentrated platelets (a little more than 1 teaspoon). This concentrated PRP solution was injected into patients’ arthritic knee joints. All patients received one injection. (more…)

Corticosteroid Injections Damage Cartilage in Rabbit Models

Corticosteroid Injections Damage Cartilage

Clinicians began to treat a variety of joint conditions with corticosteroid injections around 1950. Since clinical improvement was noted, physicians began to use the injections more frequently. Scientists at the University of Montreal were prompted to study effects of steroid injections on cartilage because of reports that a significant number of patients experienced accelerated the joint damage. Researchers chose the rabbit model to study because the rabbit knee is similar to the human knee and they could be microscopically examined for tissue changes.

The researchers injected 25 mg of hydrocortisone over 2 to 12 weeks into rabbit knees and studied the effect on three major components of the joint: proteoglycans (joint proteins that provide structure and lubrication), collagen (the main fiber in cartilage, provides strength and shock absorption) and chondrocytes (The main cells found in cartilage – chondrocytes produce collagen and proteoglycans). As a control, one group of rabbits received weekly saline injections for 12 weeks. (more…)

Treatment of Ulnar Collateral Ligament Elbow Injuries with PRP

Elbow Injuries

Overhead throwing athletes are at an increased risk of Ulnar Collateral Ligament (UCL) injuries. The overhead throwing motion places stress over the UCL complex. Over time the ligament can develop micro-injuries that exceed the body’s ability to heal. Micro tears can develop, and at times complete rupture may occur. Surgical reconstruction of the UCL can improve outcomes. However, not all throwing athletes return to prior levels of competition and the time to return to play can be 1 to 2 years. Additional treatment techniques to improve return to play rates are needed for overhead throwing athletes.

At Houston Spine & Sports Medicine, we have been treating Ulnar Collateral Ligament injuries with ultrasound-guided regenerative techniques, such as prolotherapy and PRP, for years. We are excited about the recent article on the use of Platelet-Rich Plasma (PRP) for treatment of UCL tears. Found in the American Journal of Sports Medicine, this article is the first published report on clinical outcomes for UCL injuries that were treated with PRP. (more…)

Platelet Rich Plasma Emerging as Effective Orthopedic Treatment

Effective Orthopedic Treatment

Platelet Rich Plasma (PRP) is an emerging biologic tool in orthopedic and regenerative medicine. The PRP is obtained by drawing out a patient’s blood and spinning it down in a centrifuge, which concentrates the platelets in the blood. The platelets can be concentrated up to 10X the baseline strength, and the plasma also contains cytokines, thrombin, and other growth factors that are indicated in wound healing (1). The PRP is then re-injected into the affected area by the physician according to the treatment plan and goals.

PRP can be used to treat tendons, ligaments, muscle tears, and joint pain (1). According to an article in the Journal of Arthroscopy, platelet-rich plasma may help speed recovery in sports medicine patients and enable them to return to their prior level of activity faster (1). It can take weeks for repair of tissue to occur, but proper nutrition and physical therapy can also aid in this process. (more…)