prp for lateral epicondylitis

PRP for Lateral Epicondylitis

Matthew Bloom, OMS IV

Have you had your morning cup of coffee yet?

300mg/day

Lateral Epicondylitis

Platelet-Rich Plasma

Current research on tx of lateral epicondylitis with PRP vs CSI

Overview

Also referred to as: Elbow tendinosis Elbow tendonitis Elbow tendinopathy Epicondylalgia Tennis elbow


Epidemiology 1–3% in general population

Risk Factors Smoking Obesity Age (45–54) Repetitive movement (>2 hours daily) Forceful activity (>20 kg)


Clinical Anatomy Lateral humeral epicondyle serves as the bony

common origin of the wrist extensor muscles Injury to the extensor carpi radialis brevis

muscle (ECRB) (felt at tip of lateral epicondyle) Differentiate an effusion in this region, which

represents intraarticular pathology or swelling posteriorly due to olecranon bursitis, from the lateral epicondylitis, which is extraarticular in nature


Pathophysiology Chronic tendinosis rather than an acute inflammatory

process Presence of disorganized tissue and neovasculature with

very few inflammatory cells Studies using grayscale ultrasonography and color Doppler

followed by anesthetic injection suggest that vasculoneural growth in the common extensor origin, most commonly the ERCB, is the likely source of pain

Targeting this degenerative tendinosis and neovascularization is the focus of emerging treatments (PRP?)


Mechanism of Injury Repetitive or explosive athletic movements

involving eccentric motion, in which the muscle-tendon unit is lengthened while contracting

Clinical Presentation Lateral elbow pain with varying severity


Nirschl characterizes seven stages of tendinopathy: Phase I – Mild pain after exercise activity, resolves within 24

hours Phase II – Pain after exercise activity, exceeds 48 hours, resolves

with warm-up Phase III – Pain with exercise activity that does not alter activity Phase IV – Pain with exercise activity that alters activity Phase V – Pain caused by heavy activities of daily living Phase VI – Intermittent pain at rest that does not disturb sleep;

Pain caused by light activities of daily living Phase VII – Constant rest pain (dull aching) and pain that

disturbs sleep


Clinical Examination Localized tenderness over the lateral

epicondyle and proximal wrist extensor muscle mass

Pain with resisted wrist extension with the elbow in full extension

Pain with passive terminal wrist flexion with the elbow in full extension


Lateral EpicondylitisCozen’s Test

JAMA February 6, 2013 – Vol. 309, No. 5 “Effect of Corticosteroid Injection, Physiotherapy,

or Both on Clinical Outcomes in Patients with Unilateral Lateral Epicondylalgia: A Randomized Controlled Trial” Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino

B Division of Physiotherapy, School of Health and

Rehabilitation Sciences, University of Queensland, St Lucia, Australia

JAMA Article Review

Objective: To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia

Design: A 2 × 2 factorial, randomized, injection-blinded, placebo-controlled trial

Setting: Conducted at a single university research center and 16 primary care settings in Brisbane, Australia

JAMA Article Review

Patients N = 165 Enrolled between July 2008 and May 2010 1-year follow-up in May 2011 Age 18 years or older Eligibility was determined by telephone

interview Physical examination was conducted by one

researcher and confirmed by a second

JAMA Article Review

Inclusion Criteria Unilateral lateral epicondylalgia > 6 weeks Pain over the lateral epicondyle with pain severity

> 30 mm on a 100-mm visual analog scale (VAS) Pain provoked by at least 2 of the following:

Gripping Palpation Resisted wrist or middle finger extension Stretching of forearm extensor muscles

JAMA Article Review

Exclusion Criteria Receipt of injection (6 months) Receipt of a course of physiotherapy (3 months) Concomitant neck or other arm pain (6 months) Symptoms suggesting radicular, neurologic, or

systemic arthritic conditions Pregnant or breastfeeding Contraindication to injection

JAMA Article Review

Randomization Stratified according to pain severity greater or

less than 57.5 mm on a 100-mm VAS

Blinding Researcher who assessed outcomes was

blinded to both injection and physiotherapy assignment

Patients were blinded to injection but not physiotherapy

JAMA Article Review

Interventions Corticosteroid injection (n = 43)

10 mg/mL of triamcinolone acetonide in a 1 mL injection plus 1 mL of 1% lignocaine

Placebo injection (n = 41) 0.5 mL of 0.9% isotonic saline

Corticosteroid injection plus physiotherapy (n = 40)

Placebo injection plus physiotherapy (n = 41)

JAMA Article Review

Interventions Injections were applied to the site of maximum

palpable tenderness at the common extensor origin

Physiotherapy consisted of 8 30-minute sessions over 8 weeks

Patients were advised to avoid any activity that caused or provoked pain and to refrain from strenuous activity for 2 weeks

JAMA Article Review

Interventions After 2 weeks, a gradual return to normal

activity was encouraged to minimize potential for recurrence

Patients were allowed to use an analgesic or anti-inflammatory medication, heat or cold pack, or braces as needed

Patients were discouraged from seeking treatments other than those specifically assigned

JAMA Article Review

Hypotheses At 1 year, clinical outcomes would be worse in

patients receiving CSI vs. placebo At 1 year, clinical outcomes would be better in

patients receiving physiotherapy vs. no physiotherapy

Outcome Measures Patients estimated their global rating of change at 4,

8, 12, 26, and 52 weeks on a 6-point Likert scale ranging from “complete recovery” to “much worse”

JAMA Article Review

Primary Outcomes CSI demonstrated lower complete recovery or

much improvement at 1 year compared with placebo (83% vs. 96%) p = .01

CSI demonstrated greater recurrence at 1 year compared with placebo (54% vs. 12%) p < .001

JAMA Article Review

Recovery/Im-provement

Recurrence0%

20%

40%

60%

80%

100%

CSIPlacebo

JAMA Article Review

Primary Outcomes No interaction between injection (CSI vs.

placebo) and physiotherapy (yes vs. no) (p = .99)

No difference in physiotherapy vs. no physiotherapy at 1 year for complete recovery or much improvement (91% vs. 88%, p = .56)

No difference in physiotherapy vs. no physiotherapy at 1 year for recurrence (29% vs. 38%, p = .25)

JAMA Article Review

Secondary Outcomes At 4 weeks, significant improvement occurred

across the board for CSI compared to placebo injection and physiotherapy (yes vs. no)

At 26 weeks, improvement began to decline for CSI compared to placebo and showed no difference for physiotherapy (yes vs. no)

p < .001

JAMA Article Review

Conclusions CSI showed improvement at 4 weeks compared to

placebo, but a subsequent decline in effectiveness at 6 months, with worse outcome at 1 year

Physiotherapy showed no benefit when combined with CSI at 4 weeks and no long-term benefit overall, however, it was shown to be useful in the short-term when utilized alone

Corticosteroids are potent in suppressing inflammation, but histological evidence does not support an inflammatory response in this condition

JAMA Article Review

JAMA Article Review

Discussion Time!

Strengths vs. Weaknesses?

Overview PRP is a regenerative therapy useful in addressing

many musculoskeletal injuries PRP is being increasingly used for tx of chronic non-

healing tendon injuries PRP contains growth factors (GFs) that stimulate

neovascularization to increase the blood supply and available nutrients for damaged tissue to regenerate

Neovascularization also brings new cells and removes debris from damaged tissue


Growth factors Alpha granules are storage units within platelets that

contain inactive prepackaged growth factors including: Transforming Growth Factor Beta (TGFβ) Vascular Endothelial Growth Factor (VEGF) Platelet-Derived Growth Factor (PDGF) Epithelial Growth Factor (EGF) Fibroblast Growth Factor (FGF)

Together these factors help to stimulate cell replication, angiogenesis, epithelialization, granulation tissue formation, extracellular matrix formation, and regulation of bone cell metabolism


Production PRP is a plasma suspension that contains all

components of whole blood in varying amounts Contains at least 200,000 platelets/μL, but

generally 3-5× this Centrifugation of venous whole blood

containing an anticoagulant results in a plasma supernatant with a gradient of cellular concentration


Production Erythrocytes are the densest and will remain at

the bottom A buffy coat of white blood cells follows Platelets are at the highest concentration in

the plasma layer just above the buffy coat and decrease in concentration toward the top


Pathophysiology With repetitive overuse, collagen fibers in

tendons form micro-tears Injured tendons heal by scarring, which

adversely effects function and increases risk of re-injury

In addition, tendons heal at a slow rate secondary to poor vascularization


Pathophysiology Traditional therapies do not alter the tendon’s

poor healing capabilities, but rather involve long-term palliative care

Some studies suggest CSIs have adverse side effects including atrophy and worsening structural changes to tendons

However, GFs in platelets are known to promote tissue regeneration…


AJSM July 3, 2013 online “Platelet-Rich Plasma Significantly Improves Clinical

Outcomes in Patients With Chronic Tennis Elbow” Allan K. Mishra, MD, Nebojsa V. Skrepnik, MD, PhD, Scott

G. Edwards, MD, Grant L. Jones, MD, Steven Sampson, DO, Doug A. Vermillion, MD, Matthew L. Ramsey, MD, David C. Karli, MD, MBA, Arthur C. Rettig, MD

Allan K. Mishra, MD, Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center

AJSM Article Review

Conflicts of Interest One or more of the authors has declared the following potential conflict of

interest or source of funding: This study was sponsored by Biomet Biologics. A.K.M. receives royalties for patents from Biomet and ThermoGenesis and owns stock in BioParadox and ThermoGenesis. N.V.S. has received payment for speaking and as a consultant from Auxilium and receives research support from Biomet, DePuy, Ferring Pharmaceuticals, Biomemetic, Pfizer, Smith & Nephew, Zimmer, and Wyeth. S.G.E. is a paid consultant and receives research support from Medartis, owns stock or stock options in Mylad, and receives research support from Biomet. G.L.J. is an unpaid consultant for Arthrotek and receives research support from Biomet and Genzyme. S.S. has made presentations for Sonosite. D.A.V. has made presentations for Genzyme and receives research support from Biomet. M.L.R. receives royalties from and is a paid consultant for Integra (Ascension) and Zimmer and has made presentations for Arthrex. D.C.K. is an employee of and receives royalties from Greyledge Technologies. A.C.R. receives research support from Biomet.

AJSM Article Review

Objective: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group

Design: Double-blinded, prospective, multicenter, randomized, controlled trial from 2006 – 2011

AJSM Article Review

Patients N = 230 Failed at least 1 conventional therapy Considerable variability in types and amounts

of treatment

AJSM Article Review

Inclusion Criteria Pain by palpation at the lateral epicondyle Baseline elbow pain ≥ 50 mm on a 100-mm VAS

during resisted wrist extension H/o elbow pain > 3 months Pain unresponsive to 1 of 3 conventional tx options:

CSI PT/OT NSAIDs

AJSM Article Review

Exclusion Criteria Pregnancy Age < 18 years H/o anemia, bleeding disorder, or blood disorder H/o CTS on the affected side within 1 year of

randomization Cervical radiculopathy Systemic disorders such as DM, RA, or

hypothyroidism

AJSM Article Review

Exclusion Criteria Prior surgery for elbow tendinosis Active elbow tendinosis within 4 weeks of

randomization Low H/H Abnormal platelet count (outside 150,000 – 400,000) H/o arthritis or fx of affected elbow CSI within 6 weeks, PT/OT within 4 weeks, or NSAIDs

within 1 week of randomization

AJSM Article Review

Procedure 2 – 3 mL of PRP injected into the ECRB tendon and

surrounding area using a peppering technique A single penetration into the skin and 5

penetrations of the tendon Control group was injected with 2 – 3 mL of

bupivacaine with same peppering technique Entire 10-mL syringe was covered in black tape and

patients’ arms were draped to maintain blinding

AJSM Article Review

AJSM Article Review

Outcome Measures Successful tx defined as > 25% reduction of the VAS pain

score with resisted wrist extension as compared to baseline 4, 8, 12, and 24 week follow-ups

Results Greater improvement in pain scores compared to control

group at every follow-up Statistically significant at 8 (p = .01) and 24 weeks (p

= .027)

AJSM Article Review

4 Weeks 8 Weeks* 12 Weeks 24 Weeks*0

1020304050607080

PRPControl

AJSM Article Review

Conclusions PRP was shown to produce clinically

meaningful improvements in pain scores and elbow tenderness compared with an active control group with no significant complications

“Practice-changing evidence” supporting the use of PRP for patients who have failed standard non-operative therapies

AJSM Article Review

Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol 2006; 164:1065

Smidt N, Lewis M, VAN DER Windt DA, et al. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol 2006; 33:205

Haahr JP, Andersen JH. Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Rheumatology (Oxford) 2003; 42:1216

Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med 1992; 11:851 Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain

in patients with Tennis elbow. Knee Surg Sports Traumatol Arthrosc 2006; 14:659

References

Evans WJ, Meredith CN, Cannon JG, et al. Metabolic changes following eccentric exercise in trained and untrained men. J Appl Physiol 1986; 61:1864

Newham DJ, Jones DA, Clarkson PM. Repeated high-force eccentric exercise: effects on muscle pain and damage. J Appl Physiol 1987; 63:1381

Tsuang YH, Lam SL, Wu LC, et al. Isokinetic eccentric exercise can induce skeletal muscle injury within the physiologic excursion of muscle-tendon unit: a rabbit model. J Orthop Surg Res 2007; 2:13

Croisier JL, Foidart-Dessalle M, Tinant F, et al. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med 2007; 41:269

Boswell SG, Cole BJ, Sundman EA, Karas V, Fortier LA. Platelet-rich plasma: a milieu of bioactive factors. Arthroscopy 2012 Mar; 28(3):429-39

Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med 2008 Dec; 1(3-4):165-74

References

Any Questions?

prp for lateral epicondylitis

Documents