Comprehensive Prolotherapy and PRP tennis elbow and elbow instability injections
In this article Danielle Steilen-Matias, MMS, PA-C discusses various non-surgical treatment options for elbow instability including Prolotherapy and the most recent research on Platelet Rich Plasma for tennis elbow.
Do you have a question about injections for elbow pain and instability? Get help and information from our Caring Medical staff
If you are reading this article it is very likely that you have a difficult to treat tennis elbow. You maybe searching for more aggressive treatments than the ones you have been prescribed, you may even be exploring surgery. Surgery will be the first treatment option we will explore This first of the difficult to treat tennis elbow treatments
“Tennis elbow” is a common condition, however as a diagnostic reason for elbow pain it is often overused and can cause confusion in treatment.
There are many causes of chronic elbow pain. Extensor tendinopathy (which use to be called “Tennis Elbow,” but was found in many patients who did not play tennis, annular ligament sprain, and biceps muscle strain. Since muscle, ligament, or tendon injury can all cause pain, a proper diagnosis is needed to permanently alleviate the pain.
- Tennis elbow is diagnosed when we observe weakness and pain with wrist extension and tenderness at the elbow where the extensor tendons attach.
- Annular ligament sprain is diagnosed when we palpate this ligament in the elbow and elicit a positive “jump sign.”
Two clinical tests confirm that recalcitrant lateral elbow pain is from ligament laxity causing elbow joint instability
The importance of ligament strength and flexibility in elbow instability cannot be overstated.
In August 2017, University medical researchers in Italy published their findings under the title :”It’s time to change perspective! New diagnostic tools for lateral elbow pain.”
What they are suggesting is what our practice has discussed with our patients since the days of Dr. Hemwall almost 70 years ago, tennis elbow (or elbow pain as it was known back then) is a whole joint disease caused by instability, you must treat the whole elbow. Twenty-five years ago when Ross Hauser, MD, took over the practice, that message never changed.
Here is what the researchers said in the the journal Musculoskeletal surgery.(1)
- The presence of intra-articular findings (problems within the elbow) that may complement the extra-articular pathology (problems from around the elbow) in lateral epicondilytis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated.
- (Our note: This paper is acknowledging that elbow instability does play a role in the cause of “tennis elbow”.)
This paper is acknowledging that elbow instability does play a role in the cause of “tennis elbow”
So the Italian team devised two new tests aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance.
- Ten patients suffering of atraumatic lateral elbow pain unresponsive to conservative treatment were considered in this study.
- Two clinical tests were developed and administrated prior to arthroscopy:
- Supination and Antero-Lateral pain Test (SALT);
- Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER).
- SALT moves the elbow around trying to get the “jump” or pain response
- PEPPER palpates the elbow – presses down on spots looking for the jump response
In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity (ligament laxity of weakness) or intra-articular abnormal findings had a positive response to at least one of the two tests.
SALT proved to have a high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis. PEPPER test was sensible, specific and accurate in the detection of radial head chondropathy (bones problems).
Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition.
Caring Medical and Rehabilitation Services research on instability
The problem of joint instability and in this case elbow instability is a problem of the elbow ligaments. In 2014 we published our article “Structural Basis of Joint Instability as Cause for Chronic Musculoskeletal Pain and Its Successful Treatment with Regenerative Injection Therapy (Prolotherapy)”(2) In that article our research team wrote:
“Ligaments are specialized dense bands of tough, fibrous collagenous connective tissue bundles that attach one bone to another. Ligaments function to hold bones in approximation, assist joint proprioception (keeping the joint where it should be and not hyperextended) and provide mechanical support and stability.”
The keyword is stability. The excitement exhibited by the above research about instability is something that Prolotherapists have discussed for decades. Weak ligaments lead to joint instability and tendinopathy, strong ligaments lead to pain-free joint stability and healed tendons.
Despite the identification of elbow instability as being caused by ligament doctors still recommending arthroscopic tennis elbow for the most difficult cases.
Recently, a lot of research has centered on arthroscopic tennis elbow surgery. This attention to surgery is odd as according to the American Academy of Orthopedic Surgeons website – up to 95% of tennis elbow will resolve without surgery.
This odd circumstance may be explained by a study lead by the University of Ottawa which questioned a possible overexcitement by doctors in recommending arthroscopic tennis elbow or an elbow tendonitis surgery procedure. In a study that they hope to publish before the end of 2018, the research team will compare arthroscopic surgery for tennis elbow vs a sham or fake surgery.
Here is what the researchers wrote at the US National Institutes of Health Clinical Trial website:
“Chronic tennis elbow can be treated surgically, with arthroscopy gaining popularity in recent years as it presents a less invasive option, allows for direct visualization of the elbow joint for other pathology and has a faster return-to-work time compared to other surgical procedures. Despite its promise there have been no high quality studies evaluating the efficacy of arthroscopic tennis elbow release, bringing the actual efficacy of this procedure into question. We propose a randomized, double-blind controlled trial comparing arthroscopic release with arthroscopic debridement for the management of chronic tennis elbow in an effort to definitively answer this question and provide better recommendations for the use of this procedure.”(3)
Tennis Elbow Treatments
Prolotherapy for Tennis Elbow
David Rabago, M.D., and researchers from the University of Wisconsin recently published a study in the American Journal of Physical Medicine & Rehabilitation evaluating the use of Prolotherapy for tennis elbow.
Twenty-six adults (32 elbows) suffering from chronic lateral epicondylosis for three months or longer were randomized to:
- Ultrasound-guided Prolotherapy with dextrose solution,
- Ultrasound-guided Prolotherapy with dextrose-morrhuate sodium solution (sodium salts and fatty acids of Cod Liver Oil).
- or watchful waiting (“wait and see”).
The participants receiving Prolotherapy with dextrose and Prolotherapy with dextrose-morrhuate reported improvement at 4, 8, and/or 16 weeks compared with those in the wait-and-see group
The grip strength of the participants receiving Prolotherapy with dextrose exceeded that of the Prolotherapy with dextrose-morrhuate and the wait and see at 8 and 16 weeks. Satisfaction was high; there were no adverse events.
The authors concluded, “Prolotherapy resulted in safe, significant improvement of elbow pain and function compared with baseline status and follow-up data and the wait-and-see control group. This pilot study suggests the need for a definitive trial.”(4)
Caring Medical and Rehabilitation Services research
In Caring Medical and Rehabilitation Services (CMRS), our research results for treating tennis elbow at a Prolotherapy charity clinic were analyzed and reported. In this study, patients were treated with dextrose Prolotherapy.
- The results of this retrospective, uncontrolled, observational study show that prolotherapy helps decrease pain and stiffness and improve the quality of life in patients with unresolved elbow
pain. The Hackett-Hemwall dextrose prolotherapy gave 64% percent of patients greater than 75% pain relief with 94% of them having 50% or more of their pain relieved. One hundred percent of the patients stated their pain and their life was better after prolotherapy.
These results were reported as part of our larger study “Evidence-Based use of dextrose Prolotherapy for musculoskeletal pain: a scientific literature review.” Published in the Journal of Prolotherapy 2011.(5)
In the medical journal Clinical medicine insights. Arthritis and musculoskeletal disorders, we updated our research by publishing: A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain.(6)
- In the Clinical journal of sports medicine, doctors from the Department of Family Medicine, University of Wisconsin-Madison found that their Prolotherapy treatment group showed significant improvement in pain levels compared with patients given saline injection with the same number of needle punctures and volume (91% versus 33%). In addition, extension strength and grip strength was markedly improved in the treatment group as well.(7)
- Korean doctors published research that studied 84 patients with lateral epicondylitis who were treated with dextrose prolotherapy. Dextrose prolotherapy decreased VAS (Visual analog pain score) from 6.79 to 2.95, which reached statistical significance.(8)
- Another study from Korena university researchers achieved a significant reduction in pain with VAS from baseline patients with lateral epicondylosis as well with treatment of the lateral epicondyle with 15% dextrose. Evidence of tendon healing was observed via ultrasound imaging.(9)
Prolotherapy works on a simple concept: reignite the immune system to heal by causing targeted inflammation (the natural healing process) at the spot of the injury. This is achieved by, in most cases, injecting a simple sugar (dextrose) at the pain generating “trigger points,” in the elbow. Strengthen ligaments and tendons, stabilize the elbow, strengthen the elbow, and end the elbow pain. The pain alleviating aspect of Prolotherapy is also well documented.
Platelet Rich Plasma Therapy and Cortisone for Tennis Elbow
Platelet Rich Plasma Therapy utilizes growth factors from your own blood, injected into the elbow to stimulate healing.
The idea behind Platelet Rich Plasma Therapy (PRP) in treating tennis elbow is initiating the inflammatory response. Tendons throughout the body , including those implicated in lateral epicondylitis such as the ECRB (Extensor Carpi Radialis Brevis), heal more slowly than most other types of tissues partly due to a poor blood supply. The inflammatory response brings blood.
Cortisone research – disappointing for Tennis Elbow
In research from doctors at Massachusetts General Hospital-Harvard Medical School, research showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection into the ECRB (Extensor Carpi Radialis Brevis). The weight of evidence suggests that corticosteroid injections are neither meaningfully palliative nor disease modifying when used to treat Extensor Carpi Radialis Brevis damage.(10)
In a study published in Journal of science and medicine in sports, doctors looked at Autologous blood injection, a treatment where a patient’s own blood is injected into the site of injury to get the blood platelets at the wound in comparison to cortisone.
Autologous blood injection differs from Platelet Rich Plasma. In PRP the blood platelets are separated out in an attempt to give a more effective treatment by making the plasma “platelet rich.” Autologous blood injection is considered by many a less effective form of PRP. The doctors also compared polidocanol, an injection treatment that is often given to irritate the immune system to repair varicose veins. Polidocanol belongs to the field of Sclerotherapy, “irritation medicine.” Prolotherapy is also part of the field of “irritation medicine,” and at one time Prolotherapy was called Sclerotherapy.
So it can be said in this study we have a less effective means of PRP and Prolotherapy being compared to cortisone injections.
Here are the results:
- Complete recovery or much improvement was greater for corticosteroid injection than autologous blood and polidocanol at 4 weeks
- In contrast, at 26 weeks corticosteroid patients were significantly worse than polidocanol.
- Recurrence of pain and symptoms after corticosteroid injection was significantly higher than autologous blood or polidocanol
- Corticosteroid injection produced greater reduction in tendon thickness and vascularity than autologous blood at 4 weeks only.
- Compared to autologous blood, polidocanol reduced tendon thickness at 4 and 12 weeks.
- Conclusion: Injections of corticosteroid cannot be recommended over polidocanol or autologous blood.(11)
Like autologous blood injection, PRP is prepared using a sample of the patient’s own blood. This is why patients may refer to PRP as “tennis elbow blood injections.” This blood is then centrifuged to separate the liquid and solid components of the whole blood. PRP contains 3 to 10 times higher concentrations of platelets in comparison to autologous whole blood.
While several major clinical studies have promise in the treatment of difficult to treat tennis elbow, a major limitation in the evaluation of the efficacy of PRP in treatment of lateral epicondylitis and other musculoskeletal diseases is the way with which PRP is prepared and administrated.(12) You have to go to doctor who knows how to use PRP. It is much more than a simple “blood injection”.
In a direct comparison of autologous blood injections, platelet rich plasma injections and cortisone, doctors wrote in the Journal of orthopaedics and traumatology:
Based on the evidence presented, it can be concluded that when comparing three active treatments:
- PRP injection was the best treatment for reducing pain after 2 months whereas autologous blood was the best treatment for improving disabilities scores.
- However, autologous blood injection had the highest risk of adverse effects (injection site pain and skin reaction).(13)
In the Journal of clinical and diagnostic research doctors wrote simply:
- The results (of our study) revealed that the long term efficacy of PRP treatment is better. Therefore, we concluded PRP as a superior treatment option to cortisone in cases of tennis elbow.(14)
Doctors in Pakistan have shown the effectiveness of platelets rich plasma versus corticosteroids or the “tennis elbow steroid injection.”
The doctors looked at 102 patients in the study and divided them into two groups of 51(50%) each.
- In the patients in the cortisone group 53% improvement
- In the patients in the PRP group 82%
Their conclusion: PRP is an effective alternative to corticosteroid in the treatment of lateral epicondylitis (tennis elbow).(15)
Below is a brief review of the seemingly overwhelming evidence that PRP is a superior treatment.
- Doctors from the United Kingdom, writing in the Journal of Hand and Microsurgery reviewed nine studies to determine effectiveness of Platelet Rich Plasma Therapy treatment for tennis elbow and found that PRP worked – “PRP injections have an important and effective role in the treatment of this debilitating condition.”(16)
- Doctors in Turkey found that in comparing the treatment of chronic elbow tendinosis with platelet-rich plasma (PRP) or Nirschl surgical technique (tendon release). PRP seems to be better for pain relief and functionality and had more success than the surgery.(17)
In March 2017, doctors in China published more positive results for platelet rich plasma vs steroid for lateral epicondylitis. Their research showed:
- Treatment of patients with lateral epicondylitis by steroid could slightly relieve pain and significantly improve function of elbow in the short-term (2 to 4 weeks, 6 to 8 weeks).
- PRP appears to be more effective in relieving pain and improving function in the intermediate-term (12 weeks) and long-term (half year and one year).
- Considering the long-term effectiveness of PRP, we recommend PRP as the preferred option for lateral epicondylitis.(18)
Danish researchers writing in the American Journal of Sports Medicine presented a summary of which tennis elbow injections work best? They found:
“[Therapies studied included] glucocorticoid, botulinum toxin, autologous blood, platelet-rich plasma, polidocanol, glycosaminoglycan [hyaluronic acid is part of this family], Prolotherapy, and hyaluronic acid.
After compiling and comparing the research they found that the medical literature suggested that beyond eight weeks:
- Glucocorticoid injection was no more effective than placebo.
- Although botulinum toxin showed marginal benefit it caused temporary paresis of finger extension, and all trials were at high risk of bias. (The studies were biased in favor of botulinum toxin.)
- Prolotherapy and hyaluronic acid were both more efficacious than placebo. But between the two – only Prolotherapy met the criteria for low risk of bias.
- Polidocanol and glycosaminoglycan showed no effect compared with placebo.(19)
Do you have a question about injections for elbow pain and instability? Get help and information from our Caring Medical staff
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