What is the role of Platelet-rich Plasma (PRP) injections in treating lateral epicondylitis?

PRP Injections for Lateral Epicondylitis

PRP injections are an effective treatment option for chronic lateral epicondylitis that has failed conservative management, offering superior long-term outcomes compared to corticosteroids and potentially avoiding the need for surgery. 1, 2, 3

When to Consider PRP

PRP should be offered to patients with lateral epicondylitis after at least 6 months of failed conservative treatment including physiotherapy, NSAIDs, and activity modification 1, 4. This represents a critical decision point where PRP can serve as an alternative to surgical intervention 3.

Evidence Supporting PRP Use

Pain and Functional Outcomes

• PRP demonstrates significantly better outcomes than continued physiotherapy alone, with Patient Related Tennis Elbow Evaluation (PRTEE) scores showing marked improvement at 6 months (43.2 vs 62.8, p<0.001) and sustained benefits through 24 months 1
• PRP provides superior long-term efficacy compared to corticosteroid injections, though both show initial improvement 2
• Approximately 88% of patients experience meaningful improvement in pain and function following PRP injection 5

Surgical Avoidance

• PRP significantly reduces the need for surgical intervention (0% vs 20% in physiotherapy-only group, p=0.027) at mean 38-month follow-up 1
• PRP offers comparable outcomes to lateral epicondylar surgery in short- and mid-term follow-up, making it an appropriate surgical alternative 3

Treatment Protocol

Injection Regimen

A single PRP injection is typically sufficient for most patients with chronic lateral epicondylitis 4. The evidence shows:

• Single injection produces significant improvement in PREE scores (54.0 to 23.0) and qDASH scores (50.3 to 20.7) at 6 months 4
• Multiple injections (2-3 given at 4-week intervals) do not provide statistically significant additional benefit over single injection 4
• If inadequate response occurs, consider repeating injection rather than proceeding directly to surgery 5

Adjunctive Treatment

Combine PRP injection with standardized physical therapy for optimal outcomes 4. This multimodal approach addresses both tissue healing and biomechanical factors.

Important Caveats

Guideline Context Limitations

The available guidelines primarily address rotator cuff pathology rather than lateral epicondylitis specifically. The American Academy of Orthopaedic Surgeons (AAOS) states that "limited evidence does not support the routine use of PRP for the treatment of rotator cuff tendinopathy or partial tears" 6, but this recommendation does not apply to lateral epicondylitis, which has distinct pathophysiology and a stronger evidence base for PRP efficacy.

Historical Guideline Perspective

Older guidelines from 2005 note that corticosteroid injections for lateral epicondylitis are more effective than NSAIDs acutely but do not change long-term outcomes 6. This historical context makes PRP's demonstrated long-term superiority over corticosteroids particularly meaningful 2.

Safety Profile

• PRP carries minimal risk of adverse events 4
• Most common side effect is transient prolonged pain at injection site 1
• No systemic complications reported in the reviewed studies 1, 4, 2, 5

Clinical Algorithm

1. Initial conservative management (0-6 months): NSAIDs, physiotherapy, activity modification 6
2. Consider corticosteroid injection if acute symptom relief needed, understanding limited long-term benefit 6
3. Offer PRP injection after 6 months of failed conservative treatment 1, 4
4. Single PRP injection with concurrent physiotherapy 4
5. Reassess at 6 months: 88% should show improvement 5
6. If inadequate response: Consider repeat PRP injection before surgery 5
7. Surgery reserved for the minority who fail PRP treatment 1, 3