Elbow Pain – Ulnar Collateral Ligament Sprain

Danielle.Steilen.ProlotherapistDanielle R. Steilen-Matias, MMS, PA-C

In this article Danielle Steilen-Matias, MMS, PA-C discusses various non-surgical treatment options for elbow instability including Prolotherapy and the most research research on Platelet Rich Plasma for tennis elbow.

Tennis elbow is a common condition for a pain specialist to treat.  However, too often pain on the lateral side or the outside side of the elbow carries a blanket misdiagnosis as “tennis elbow” which is an inflammatory condition known as lateral epicondylitis.

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True tennis elbow means there is inflammation and pain in a small dime-sized region on the side of the elbow, at the insertion of the tendon of the forearm extensor tendons. Elbow pain is more commonly due to weakened tendon attachments and annular ligament sprains.

Recently arthroscopic tennis elbow surgery to remove damaged tissue has been studied. Most research centers around the need of the surgery. According to the American Academy of Orthopedic Surgeons website – up to 95% of tennis elbow will resolve without surgery. Another new study questioned a possible over excitement by doctors in recommending arthroscopic tennis elbow,or a tendonitis elbow surgery procedure.

More telling is this research: “The majority of direct medical spending on tennis elbow occurs within the first 6 months of treatment, and relatively little expense occurs between 6 and 12 months after diagnosis unless a patient undergoes surgical intervention.”2  After the surgery, the patient needs more medicine. One would think that is not what someone who wants to return to the tennis court wants to hear – the possibility of extended surgery recovery time.

Annular Ligament Injury

Prolotherapy and Platelet Rich Plasma Therapy can be effective non-surgical alternative treatments for elbow pain because it stimulates repair and regeneration of the elbow joint attachments.

They are different than the more traditional treatments which typically involve cortisone injections, which may give initial pain relief, but further degenerate the ligament and tendon tissue long term.

New research on the warnings of cortisone, including that putting patients at greater risk for need for revision surgery has recently been published.3,4

Other traditional medicine recommendations for treating tennis elbow may include physiotherapy, massage, or bracing. These methods may provide some temporary relief from elbow pain brought on by daily activities. But elbow pain and instability due to weak or damaged ligaments and tendons will not respond permanently to these methods because they are not addressing the underlying instability of the joint.

Platelet Rich Plasma Therapy for Tennis Elbow

Platelet Rich Plasma Therapy treatment for tennis elbow

Platelet Rich Plasma Therapy utilizes growth factors from your own blood, injected into the elbow to stimulate healing.

PRP Research on elbow instability and pain

Doctors in Pakistan have shown the effectiveness of platelets rich plasma versus corticosteroids or the “tennis elbow steroid injection.”

The doctors looked at 102 patients in the study and divided them into two groups of 51(50%) each.

  • In the patients in the cortisone group 53% improvement
  • In the patients in the PRP group 82%

PRP is an effective alternative to corticosteroid in the treatment of lateral epicondylitis (tennis elbow).5

This is in agreement with two papers from late 2015 in which PRP was shown to produce better patient results,6,7 and PRP showing less long-term side effects than the cortisone injections.

  • In new research, doctors from the United Kingdom, writing in the Journal of Hand and Microsurgery reviewed  nine studies to determine effectiveness of Platelet Rich Plasma Therapy treatment for tennis elbow and found that PRP worked – “PRP injections have an important and effective role in the treatment of this debilitating condition.”8 
  • Doctors in Turkey found that in comparing the treatment of chronic elbow tendinosis with platelet-rich plasma (PRP) or Nirschl surgical technique. PRP seems to be better for pain relief and functionality and had more success than the surgery.9

In another new study, patients with chronic tennis elbow received PRP injections in 4-week intervals that were complemented with standardized physical therapy.

  • Sixty-two patients received one (36 patients) or more (26 patients) PRP injections.
  • Statistically, both groups of patients reported significant pain relief and gain in function as well as quality of life 6 months after localized PRP treatment. A single PRP injection may be sufficient.10

The idea behind Platelet Rich Plasma Therapy (PRP) in treating tennis elbow is initiating the inflammatory response. Tendons throughout the body , including those implicated in lateral epicondylitis such as the ECRB (Extensor Carpi Radialis Brevis), heal more slowly than most other types of tissues partly due to a poor blood supply. The inflammatory response brings blood.

In new research, doctors showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection into the ECRB (Extensor Carpi Radialis Brevis). The weight of evidence suggests that corticosteroid injections are neither meaningfully palliative nor disease modifying when used to treat Extensor Carpi Radialis Brevis damage.11

PRP is prepared using a sample of the patient’s own blood. This is why patients may refer to PRP as “tennis elbow blood injections.” This blood is then centrifuged to separate the liquid and solid components of the whole blood. PRP contains 3 to 10 times higher concentrations of platelets in comparison to autologous whole blood .

Platelets have well-established roles in coagulation, inflammation, and immune modulation by mechanism of:

  • platelet-derived growth factor (PDGF),
  • vascular endothelial growth factor (VEGF) – which stimulates new blood vessel formation,
  • transforming growth factor- (TGF-beta-1) –  which modulates cell division and cell survival,
  • insulin-like growth factor (IGF) – regulates growth and repair of the complex IGF system
  • epidermal growth factor (EGF), stimulates cell growth
  • and fibroblast growth factor (FGF). stimulates injury and wound repair

While several major clinical studies have promise in the treatment of difficult to treat tennis elbow. a major limitation in the evaluation of the efficacy of PRP in treatment of lateral epicondylitis and other musculoskeletal diseases is the way with which PRP is prepared and administrated.12 You have to go to  doctor who knows how to use PRP. It is much more than a simple “blood injection”.

 Which tennis elbow injections work best?

Danish researchers writing in the American Journal of Sports Medicine sought to answer a basic question we hear from many patients: Which tennis elbow injections work best? They found:

“[Therapies studied included] glucocorticoid, botulinum toxin, autologous blood [where blood is drawn and then re-injected into the elbow], platelet-rich plasma [where blood is drawn and spun down into a platelet rich solution and then re-injected], and polidocanol [a method to bring more blood to the elbow], glycosaminoglycan [hyaluronic acid is part of this family], Prolotherapy, and hyaluronic acid.”13

After compiling and comparing the research they found that the medical literature suggested that beyond eight weeks:

  • Glucocorticoid injection was no more effective than placebo.
  • Although botulinum toxin showed marginal benefit it caused temporary paresis of finger extension, and all trials were at high risk of bias. (The studies were biased in favor of botulinum toxin.)
  • Prolotherapy and hyaluronic acid were both more efficacious than placebo. But between the two – only Prolotherapy met the criteria for low risk of bias.
  • Polidocanol and glycosaminoglycan showed no effect compared with placebo.

David Rabago, M.D., and researchers from the University of Wisconsin recently published a study in the American Journal of Physical Medicine & Rehabilitation evaluating the use of Prolotherapy for tennis elbow.

Twenty-six adults (32 elbows) suffering from chronic lateral epicondylosis for three months or longer were randomized to:

  • Ultrasound-guided Prolotherapy with dextrose solution,
  • Ultrasound-guided Prolotherapy with dextrose-morrhuate sodium solution (sodium salts and fatty acids of Cod Liver Oil).
  • or watchful waiting (“wait and see”).

The participants receiving Prolotherapy with dextrose and Prolotherapy with dextrose-morrhuate reported improvement at 4, 8, and/or 16 weeks compared with those in the wait-and-see group

The grip strength of the participants receiving Prolotherapy with dextrose exceeded that of the Prolotherapy with dextrose-morrhuate and the wait and see at 8 and 16 weeks. Satisfaction was high; there were no adverse events.

The authors concluded, “Prolotherapy resulted in safe, significant improvement of elbow pain and function compared with baseline status and follow-up data and the wait-and-see control group. This pilot study suggests the need for a definitive trial.”14

In another study, results from treating tennis elbow, among other painful conditions, at a Prolotherapy charity clinic were analyzed and reported. In this study, patients were treated with dextrose Prolotherapy. The cure rate for chronic elbow pain (90% or greater pain relief) at this charity clinic was 92% using dextrose Prolotherapy injections. The difference between this Prolotherapy treatment and a typical steroid injection is that injections were given directly to the tendon and ligaments in a comprehensive fashion.15

Finally in a new study from August 2016, researchers in the British Medical Journal summarized and agreed that:

Botulinum toxin, platelet-rich plasma and autologous blood injection can be recommended for tennis elbow, but corticosteroid is not recommended.

Hyaluronate injection and prolotherapy might be more effective, but their superiority must be confirmed by more research.16

Prolotherapy works on a simple concept: reignite the immune system to heal by causing targeted inflammation (the natural healing process) at the spot of the injury. This is achieved by, in most cases, injecting a simple sugar (dextrose) at the pain generating “trigger points,” in the elbow. Strengthen ligaments and tendons, stabilize the elbow, strengthen the elbow, and end the elbow pain. The pain alleviating aspect of Prolotherapy is also well documented.

1 Matache BA, Berdusco R, Momoli F, Lapner PLC, Pollock JW. A randomized, double-blind sham-controlled trial on the efficacy of arthroscopic tennis elbow release for the management of chronic lateral epicondylitis. BMC Musculoskeletal Disorders. 2016;17:239. doi:10.1186/s12891-016-1093-9. [Pubmed]

2 Sanders TL, Maradit Kremers H, Bryan AJ, Ransom JE, Morrey BF. Health Care Utilization and Direct Medical Costs of Tennis Elbow: A Population-Based Study. Sports Health. 2016 May 23. pii: 1941738116650389. [Pubmed]

3: Branson R, Naidu K, du Toit C, Rotstein AH, Kiss R, McMillan D, Fooks L, Coombes BK, Vicenzino B. Comparison of corticosteroid, autologous blood or sclerosant injections for chronic tennis elbow. J Sci Med Sport. 2016 Oct 29.
pii: S1440-2440(16)30226-2. doi: 10.1016/j.jsams.2016.10.010. [Pubmed]

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

5 Degen RM, Cancienne JM, Camp CL, Altchek DW, Dines JS, Werner BC. Three or more preoperative injections is the most significant risk factor for revision surgery after operative treatment of lateral epicondylitis: an analysis of 3863 patients. J Shoulder Elbow Surg. 2017 Jan 13. pii: S1058-2746(16)30567-5. doi: 10.1016/j.jse.2016.10.022. [Pubmed]

4 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 Jul;9(7):RC05-7. doi: 10.7860/JCDR/2015/14087.6213. Epub 2015 Jul 1. [Pubmed]

5 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. 2015 Sep 11. [Pubmed]

6 Murray DJ, Javed S, Jain N, Kemp S, Watts AC. Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence. J Hand Microsurg. 2015 Dec;7(2):320-325. Epub 2015 Jul 8.

7 Karaduman M, Okkaoglu MC, Sesen H, Taskesen A, Ozdemir M, Altay M. Platelet-rich plasma versus open surgical release in chronic tennis elbow: A retrospective comparative study. J Orthop. 2016 Jan 22;13(1):10-4. doi: 10.1016/j.jor.2015.12.005. eCollection 2016 Mar. [Pubmed]

8 Glanzmann MC, Audigé L. Platelet-rich plasma for chronic lateral epicondylitis: Is one injection sufficient? Arch Orthop Trauma Surg. 2015 Aug 30. [Pubmed]

9. Claessen FM, Heesters BA, Chan JJ, Kachooei AR, Ring D. A Meta-Analysis of the Effect of Corticosteroid Injection for Enthesopathy of the Extensor Carpi Radialis Brevis Origin. J Hand Surg Am. 2016 Aug 18. pii: S0363-5023(16)30379-3. [Pubmed]

10 Kahlenberg CA, Knesek M, Terry MA. New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis. BioMed Research International

11 Krogh TP, Bartels EM, Ellingsen T, 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. 2012 Sep 12. [Pubmed]

12 Rabago D, Lee KS, Ryan M, Chourasia AO, Sesto ME, Zgierska A, Kijowski R, Grettie J, Wilson J, Miller D. Hypertonic Dextrose and Morrhuate Sodium Injections (Prolotherapy) for Lateral Epicondylosis (Tennis Elbow): Results of a Single-blind, Pilot-Level, Randomized Controlled Trial. Am J Phys Med Rehabil. 2013 Jan 3. [Epub ahead of print] [Pubmed]

13 Hauser RA, Hauser MA, Baird NM. Evidence-Based use of dextrose Prolotherapy for musculoskeletal pain: a scientific literature review. Journal of Prolotherapy. 2011;3(4):765-789.

14. Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, Kong FL, Welle K, Jiang ZC, Kabir K. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med. 2016 Aug;50(15):900-8. [Pubmed]

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