Tennis Elbow, Strong Evidence AGAINST Platelet-Rich Plasma

Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. de Vos RJ, Windt J, Weir A. Br J Sports Med. 2014 Jun;48(12):952-6.

Abstract
BACKGROUND:
Chronic lateral epicondylar tendinopathy is frequent in athletes, and platelet-rich plasma (PRP) is being used increasingly in its treatment.

OBJECTIVE:
To systematically review the literature on the efficacy of PRP injections for chronic lateral epicondylar tendinopathy.

METHODS:
The databases of PubMed, EMBASE, CINAHL, Medline OvidSP, Scopus, Google Scholar, Web of Science and Cochrane Library were searched in October 2013. Inclusion criteria were a clinical diagnosis of chronic lateral epicondylar tendinopathy, a randomised controlled trial, an intervention with a PRP injection and the outcome measures described in terms of pain and/or function. One author screened the search results and two authors independently assessed the study quality using the Physiotherapy Evidence Database (PEDro) score. A study was considered to be of high quality if its PEDro score was ≥6. A best evidence synthesis was used to identify the level of evidence.

RESULTS:
Six studies were included, of which four were considered to be of high quality. Three high-quality studies (75%) and two low-quality studies showed no significant benefit at the final follow-up measurement or predefined primary outcome score when compared with a control group. One high-quality study (25%) showed a beneficial effect of a PRP injection when compared with a corticosteroid injection (corticosteroid injections are harmful in tendinopathy). Based on the best evidence synthesis, there is strong evidence that PRP injections are not efficacious in chronic lateral epicondylar tendinopathy.

CONCLUSIONS:
There is strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy.

My comments:

I don’t have a lot to add to this one. The researchers did a great job,  they knew their material and knew that in the one out of four high-quality studies where platelet-rich plasma did show a benefit, it was because it was compared to corticosteroids that are outright harmful for tennis elbow, and pretty much harmful for tendons in general. I’m not sure I care for the term “chronic lateral epicondylar tendinopathy,” as it’s right up there with “lateral epicondylopathy” in awkwardness, and has even more syllables. So, I’m find with the term, “tennis elbow.”

I would expect the results of this study to generalize to other forms of tendinitis/tendinopathy, because every other treatment I have read about that is or isn’t effective, generalizes to other forms of tendinopathy. Because the authors cited another review which stated that if research showed platelet-rich plasma was supposed to work for anything, “refractory lateral epicondylosis” (yet another new term for tennis elbow) was their strongest case [FREE FULL TEXT]. Plus, new treatments that don’t likely work at all tend to generalize their ineffectiveness to other body parts, and the juggernaut of medical review articles Cochrane seems pretty down on platelet-rich plasma for all musculoskeletal soft tissue injuries.

The idea of withdrawing one’s blood, concentrating the platelets and injecting them back into the tendon just sounds sketchy to me. First of all, the concentration isn’t that much, just 2.2 to 5.5 times in the studies reviewed, so platelets are already there to some extent. Secondly, once you shot the tendon up with platelets I would expect them to float away fairly quick in general circulation, well before they had a chance to attract the various growth factors for which the are purported to do. Yeah, sayer’s will say that tendons have poor circulation so the platelets might not wash away, and they might be right. So again, how are those platelets supposed to attract those growth factors?  My guess, is that those growth factors are all in the blood.

However, there are a few positive sides. Platelet-rich plasma is generally marketed to physicians and shows that medical doctors fall for the same type of over-hyped bogus treatments that physical therapists do, so that makes me feel better. Platelet-rich plasma doesn’t generally leave you worse off than you started, other than your wallet being lighter, which you can’t say for cortisone. Actually, I take that back. Having your tendon peppered by a needle is not pleasant at all, but I expect the theatrics induce a fair placebo effect.

OK, so here is a genuine bright side. The right exercises do a GREAT JOB at relieving tennis elbow, which is easily treated at your gym or at home FOR FREE, if you have dumbbells. The basics, and in depth details, of my program are fully illustrated in my blog on “shooter’s elbow.” Shooter’s elbow is just another colloquial name for tennis elbow in people that shoot rather than play tennis. The principles and rehabilitation are exactly the same.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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