Published: 2021-02-23

Comparison of efficacy of needling and a combination of needling and platelet rich plasma in relieving pain and improving function in patients of tennis elbow: a prospective, randomized, double blinded, placebo controlled clinical trial

Vikram Sharma, Vivek Chandak


Background: Lateral epicondylitis is a common musculoskeletal disorder for which an effective treatment strategy remains unknown. Aim of the study was to examine whether a single injection of platelet-rich plasma (PRP) with needling is more effective than needling with placebo in reducing pain in adults with lateral epicondylitis. Study design used was randomized controlled trial.    

Methods: A total of 66 patients with chronic lateral epicondylitis were randomized (1:1) to receive either a blinded injection of PRP (group A) or saline (placebo) group B. The primary end point was a change in pain using the VAS and patient-rated tennis elbow evaluation (PRTEE) questionnaire. The secondary outcome being improvement in function (PRTEE scores).

Results: The VAS score and PRTEE score improved significantly in both the groups at all 3 follow-up examinations. Group A had significantly better results than the group B.

Conclusions: PRP injection are safe and effective management strategy for lateral epicondylitis


Tennis elbow, Lateral humeral epicondylitis, Tendinopathy, Growth factors, Platelet-rich plasma, Needling

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Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of autologous platelet concentrate in lateral epicondylitis in a double- blind randomized controlled trial. Am J Sports Med. 2010;38(2):255-32.

Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemi-cal, and electron microscopy studies. J Bone Joint Surg Am. 1999;81(2):259-78.

Verhaar JA. Tennis elbow. Anatomical, epidemiological and therapeutic aspects. Int Orthop. 1994;18(5):263-7.

Chard MD, Hazleman BL. Tennis elbow-a reappraisal. Br J Rheumatol. 1989;28(3):186-90.

Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6A):832-9.

Ljung BO, Alfredson H, Forsgren S. Neurokinin 1-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epi- condyles of the humerus: studies on tennis elbow and medial epicondylalgia. J Orthop Res. 2004;22(2):321-7.

Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports Traumatol Arthrosc. 2006;14(7):659-63.

Major HP. Lawn-tennis elbow [letter]. Br Med J. 1883;2:557.

Coppinger JA, Cagney G, Toomey S. Characterization of the proteins released from activated platelets leads to localization of novel platelet proteins in human atherosclerotic lesions. Blood. 2004;103(6):2096-104.

Mishra A, Randelli P, Barr C, Talamonti T, Ragone V, Cabitza P. Platelet-rich plasma and the upper extremity. Hand Clin. 2012;28(4):481-91.

Mishra A, Woodall J Jr, Vieira A. Treatment of tendon and muscle using platelet-rich plasma. Clin Sports Med. 2009;28(1):113-25.

Kajikawa Y, Morihara T, Sakamoto H. Platelet rich plasma enhances the initial mobilization of circulation-derived cells for ten- don healing. J Cell Physiol. 2008;215(3):837-45.

Virchenko O, Aspenberg P. How can one platelet injection after tendon injury lead to a stronger tendon after 4 weeks? Interplay between early regeneration and mechanical stimulation. Acta Orthop. 2006;77(5):806-12.

Visser LC, Arnoczky SP, Caballero O, Kern A, Ratcliffe A, Gardner KL. Growth factor-rich plasma increases tendon cell proliferation and matrix synthesis on a synthetic scaffold: an in vitro study. Tissue Eng Part A. 2010;16(3):1021-9.

Wang X, Qiu Y, Triffitt J, Carr A, Xia Z, Sabokbar A. Proliferation and differentiation of human tenocytes in response to platelet rich plasma: an in vitro and in vivo study. J Orthop Res. 2012;30(6):982-90.

Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006;33(11):1774-8.

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(6):1200-8.

Peerbooms JC, Sluimer J, Bruijn DL, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double- blind randomized controlled trial: platelet-rich plasma versus cortico- steroid injection with a 1-year follow-up. Am J Sports Med. 2010;38(2):255-62.

McShane JM, Shah VN, Nazarian LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary? J Ultrasound Med. 2008;27(8):1137-44.

Hill JJ, Trapp RG, Colliver JA. Survey on the use of corticosteroid injections by orthopedists. Contemp Orthop. 1989;18:39-45.

Mac Dermid JC. Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation. J Hand Ther. 2001;14:105-14.

Zhang J, Keenan C, Wang JH. The effects of dexamethasone on human patellar tendon stem cells: implications for dexamethasone treatment of tendon injury. J Orthop Res. 2013;31(1):105-10.

Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jen- sen P, Ellingsen T. Treatment of lateral epicondylitis with platelet- rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625-35.

Mi B, Liu G, Zhou W, Lv H, Liu Y, Wu Q et al. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. Phys Sportsmed. 2017;45(2):97-104.

Gautam VK, Verma S, Batra S, Bhatnagar N, Arora S. Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis: clinical and ultrasonographic evaluation. J Orthop Surg (Hong Kong). 2015;23(1):1-5.

Yadav R, Kothari SY, Borah D. Comparison of local injection of platelet rich plasma and corticosteroids in the treatment of lateral epicondylitis of humerus. J Clin Diagn Res. 2015;9(7):RC05-7.

Dhillon PBM, Aggarwal S, Marwaha N, Prakash M. Leukocyte- poor platelet-rich plasma versus bupivacaine for recalcitrant lateral epicondylar tendinopathy. J Orthop Surg (Hong Kong). 2015;23(1):6-10.

Creaney L. Platelet-rich plasma and the biological complexity of tissue regeneration. Br J Sports Med. 2011;45(8):611.

Raeissadat SA, Rayegani SM, Hassanabadi H, Rahimi R, Sedighipour L, Rostami K. Is platelet-rich plasma superior to whole blood in the management of chronic tennis elbow: one-year randomized clinical trial. BMC Sports Sci Med Rehabil. 2014;6(1).

Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta- analysis. J Orthop Traumatol. 2016;17(2):101-12.

Chou LC, Liou TH, Kuan YC, Huang YH, Chen HC. Autologous blood injection for treatment of lateral epicondylosis: a meta- analysis of randomized controlled trials. Phys Ther Sport. 2016;18:68-73.

Lo MY, Safran MR. Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res. 2007;463:98-106.

Cohen MS, Romeo AA. Open and arthroscopic management of lateral epicondylitis in the athlete. Hand Clin. 2009;25:331-8.

Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil. 2012.

Lebiedziński R, Synder M, Buchcic P, Polguj M, Grzegorzewski A, Sibinski M. A randomized study of autologous conditioned plasma and steroid injections in the treatment of lateral epicondylitis. Int Orthop. 2015;39(11):2199-203.

Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013;41(6):1435-46.

Palacio EP, Schiavetti RR, Kanematsu M, Ikeda TM, Mizobuchi RR, Galbiatti JA. Effects of platelet-rich plasma on lateral epicondylitis of the elbow: prospective randomized controlled trial. Rev Bras Ortop. 2016;51(1):90-5.

Mi B, Liu G, Zhou W, Lv H, Liu Y, Wu Q et al. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. Phys Sports med. 2017;45(2):97-104.

Khaliq A, Khan I, Inam M, Saeed M, Khan H, Iqbal MJ. Effectiveness of platelets rich plasma versus corticosteroids in lat- eral epicondylitis. J Pak Med Assoc. 2015;65(11, 3):S100-4.

Mishra A, Harmon K, Woodall J Jr, Vieira A. Sports medicine applications of platelet rich plasma. Curr Pharm Biotechnol. 2012;13(7):1185-95.

Mishra A, Harmon K, Woodall J Jr, Vieira A. Sports medicine applications of platelet rich plasma. Curr Pharm Biotechnol. 2012;13(7):1185-95.

Lim W, Park SH, Kim B, Kang SW, Lee JW, Moon YL. Relationship of cytokine levels and clinical effect on platelet- rich plasma-treated lateral epicondylitis. J Orthop Res. 2018;36(3):913-20.

Gaspar MP, Motto MA, Lewis S, Jacoby SM, Culp RW, Lee Osterman A, et al. Platelet-rich plasma injection with percutaneous needling for recalcitrant lateral epicondylitis: comparison of tenotomy and fenestration techniques. Orthop J Sports Med. 2017;5(12):232596711774207.

Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463-71.