Does PRP for Tennis Elbow Really Work?

Tennis elbow or lateral epicondylitis is among the most common causes of elbow pain. It does not solely occur in tennis players but in anyone active in sport or work. Treatment for tennis elbow includes activity modification, exercise therapy, shockwave therapy, and injections. Recently, PRP injection for tennis elbow has become more popular. So, does platelet-rich plasma for tennis elbow work, and how do we do it?

Diagnosis

Tennis elbow is usually diagnosed based on history and examination. Sometimes, tests such as an ultrasound or an MRI can help rule out other causes of elbow pain.

Pain commonly occurs outside the elbow, often during sports-related activity. Usually, there is tenderness close to the lateral epicondyle. Also, upward wrist movement is painful.

It is essential to rule out other causes of elbow pain, such as elbow joint arthritis, radial nerve entrapment at the elbow, elbow instability, or neck pain.

Simple treatments for tennis elbow

In most cases, we try simple treatments such as activity modification, oral ibuprofen, a tennis elbow brace, and exercises to strengthen the forearm and shoulder.

Recently, GTN patches have shown promise in relieving tendon pain, such as tennis elbow.

We consider more invasive treatments for challenging cases, such as shockwaves or injections. Previously, cortisone shots were used for tennis elbow. However, recent evidence shows that people who have a cortisone shot do worse than those who do nothing. So, if cortisone is harmful, what about PRP?

What is PRP?

Platelet-rich plasma therapy, also known as Plasma therapy, has recently become popular. Platelets have a high concentration of growth factors that encourage tendon damage healing.

How do we perform a PRP Injection for Tennis Elbow?

PRP therapy for tennis elbow comes from your blood. First, 15-30 ml of blood is taken from your forearm or elbow. Then, the blood is spun in a centrifuge to separate the cells from the plasma, containing a high platelet concentration. Finally, we inject the plasma into the damaged tissue. Generally, iPRP injections are performed with ultrasound guidance so that the plasma can be directed into the focal area of tendon damage.

Although many centres do this injection differently, we think one or two injections work best, depending on the type of PRP used.

What is the Evidence for PRP for Tennis Elbow?

There is now increasing evidence that PRP injections for tennis elbow are effective.

PRP is more effective than cortisone. Dr Masci has written a review of the evidence for injection in tendons. A review study comparing PRP with cortisone in tennis elbow found that PRP has a better, longer-term effect. However, a recent Cochrane review found that PRP was not better than placebo or other injections. So, the evidence is still mixed, with some supporting PRP and others not.

Also, the type of PRP may be necessary. For example, a recent review found that high white cell count PRP is better than low white cell count PRP for tennis elbow. We often use Arthrex ACP Max as our preferred PRP with a high white cell and high platelet concentration.

How many PRP injections are needed for tennis elbow?

It depends on the type of PRP used.

We recommend 2-3 injections, spaced about a week apart, for a low-platelet-concentration PRP injection. However, only one shot is required for the super-concentrated high-dose PRP injection.

How long should you rest after a PRP for Tennis Elbow?

A common side effect of PRP for tennis elbow is tenderness at the injection site. Soreness. This reaction is normal and nothing to worry about. We suggest applying ice packs regularly and taking paracetamol for a few days. Also, you should rest the elbow for about a week after each PRP injection. Often, the tendon feels sore for up to four weeks before it starts to improve.

An example of a PRP injection recovery time for tennis elbow:

Day 0-2: Rest the elbow for two days. Apply regular ice and take simple analgesia for pain.

Day 3-7: Re-engage with lower body activities, including gym, cycling and running.

Day 8-14: Restart exercises targeting tennis elbow. Review by a physiotherapist after ten days.

Day 14 -28: Progress tendon loading exercises and re-engage with lighter upper body weights.

Day 28 onwards: Resume heavier upper-body weights and progress directed by your therapist.

Are PRP Injections in the Elbow Painful?

Generally, yes, both during and after the injection.

As local anaesthetics interact and destroy PRP, we should use as little anaesthetic as possible. Therefore, PRP injections in the elbow are more painful than other injections, such as cortisone injections.

Also, PRP therapy can make your tendon feel worse, particularly in the first few weeks. Therefore, we suggest icing the elbow 48 hours after the injection. Overall, this acute pain settles within a few weeks.

Unfortunately, some people do not respond well to a PRP injection for tennis elbow and need other treatment.

Can I drive after a PRP injection for the Elbow?

Given this injeciton causes a significant post-injection flare, we suggest you avoid driving for at least 12 hours after an injeciton.

PRP vs surgery: Which is preferred for Tendons?

Although the evidence ifor PRP s still not fantastic we know surgery is no better. For example, in a recent study on the effectiveness of stendon surgery, it was not better than physiotherapy and was associated with more adverse events. Moreover, in tennis elbow specifically, surgery was not found to be more effective than simple treatments.

You should avoid surgery unless you’ve tried all other conservative treatments, including PRP therapy.

Apart from PRP for tennis elbow, are there other injection options?

Yes. Another injection option for tennis elbow is percutaneous needle tenotomy. Using a small needle, we repeatedly needle the focal area of the tendon swelling using ultrasound guidance. Unlike PRP, we can use a numbing solution or local anaesthetic to make the procedure more comfortable. Repeated needling of the tendon stimulates a healing response. Like PRP therapy for tennis elbow, needle tenotomy often makes the elbow feel worse before it feels better. It usually takes up to 4 weeks before you notice an effect.

Recent studies suggest that needle tenotomy is effective for tennis elbow and might be a good option before more expensive PRP therapy. Therefore, many doctors think needle tenotomy should be the preferred injection option for tennis elbow.

What about a tennis elbow tendon tear?

Tennis elbow tear, also called the Extensor Carpi Radialis tendon tear, is relatively common in longstanding tennis elbow. Generally, these tears are small and located on the undersurface of the tendon near the radial collateral ligament. Unless the tear is full-thickness and retracted (rare), the treatment is the same as tendonitis. There is no evidence that tennis elbow tears need different treatments from regular tennis elbow tendonitis.

You should still follow the same treatment guidelines as for regular tendonitis: simple treatments first, then GTN patches and shockwave therapy. We usually offer PRP injections if conservative management fails.

Surgery is indicated only for full-thickness tennis elbow tears that are significantly retracted.

Final word from Sportdoctorlondon about Platelet-rich plasma for tennis elbow

Overall, platelet therapy for tennis elbow is safe. However, as a general rule, you should only consider using platelet-rich plasma for tennis elbow after failing other simpler treatments. Most people with tennis elbow will improve without the need for an injection. However, if you need an injection, our preferred option is a single shot of concentrated PRP with high white cell count.