PM R 7 (2015) 654-661
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Point/Counterpoint
Guest Discussants: Joseph Ihm, MD, Kenneth Mautner, MD, Joseph Blazuk, MD Feature Editor: Jaspal Ricky Singh, MD
Platelet-Rich Plasma Versus an Eccentric Exercise Program for Recalcitrant Lateral Elbow Tendinopathy CASE SCENARIO A 48-year-old male, left handedominant air conditioning repairman has a 3-month history of persistent pain in his left elbow. He does not report any traumatic precipitating incident. He is now having difficulty performing his work duties, especially gripping and lifting. In addition, he has had to stop playing recreational tennis and golf. His initial treatment was physical therapy, including therapeutic ultrasound, friction massage, and use of a counterforce strap. After 8 sessions and minimal improvement in his pain, he was referred to a sports medicine specialist. The pain averages 5 out of 10 on a visual analog scale (VAS) and is usually a deep ache, but at times it is sharp. Examination showed no obvious inflammation of common extensor origin. Tenderness was present over the lateral epicondyle, and gripping reproduced the pain. The Cozen test (resisted wrist extension with an extended and pronated elbow) and resisted middle finger extension were positive for pain. The patient was diagnosed with chronic lateral elbow tendinopathy. Given his lack of improvement with physical therapy, the patient is requesting a more aggressive approach. Dr Joseph Ihm will argue that an eccentric exercise strengthening program should be implemented to provide long-term relief. Drs Kenneth Mautner and Joseph Blazuk will argue that an injection of platelet-rich plasma (PRP) is warranted in this patient to optimize and restore his long-term function. Joseph Ihm, MD, Responds This case involves a common patient scenario seen by musculoskeletal physiatrists. Patients with lateral elbow tendinopathy often receive physical therapy that does not include an optimal exercise program to address the local tendinosis, an assessment of how the kinetic chain affects the patient’s upper quadrant, or an assessment of occupational issues that may be contributing to the pain. The physical therapy program described in this case is mostly passive, although the patient may have undergone some form of strengthening. As a result, the first thing to do is discuss the details of the physical therapy program that he just completed. In general, if a patient has not had therapy with specific directions to perform eccentric exercises focusing on the wrist extensors, then this type of exercise should be pursued as the next line of treatment. As part of the therapy program, the patient’s kinetic chain should be addressed because he is involved in 2 sports that could provoke
lateral elbow pain if deficiencies in strength or limitations in range of motion are present in the upper limbs, trunk, hips, or lower limbs. If needed, diagnostic ultrasound could be performed, which would determine if a partial tear is present or if there is a clinically significant calcification within the proximal common extensor tendons, either of which may alter recommendations for treatment. Considering these issues, the practitioner is left with a decision to make. Should the physician encourage the patient to undergo additional physical therapy emphasizing eccentric exercises before proceeding with more aggressive treatment, or should the patient be offered more aggressive treatment (eg, an injection of platelet-rich plasma [PRP]) at this time? Although a PRP injection is potentially a worthwhile option, it may not provide significant long-term relief compared with other injections [1] (eg, percutaneous tenotomy injection of autologous blood), and an eccentric
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strengthening program is often pursued after the injection anyway. What follows is a discussion of the literature to date regarding the use of eccentric exercises to treat lateral elbow tendinopathy in persons without a partial tear or calcific tendinitis, followed by a specific treatment plan for this patient. Eccentric exercises for the wrist extensors are commonly used as a first-line treatment for lateral elbow tendinopathy. Several studies have evaluated the effectiveness of this type of exercise program on pain and function related to lateral elbow tendinopathy, with many studies showing a positive effect. A recent review by Cullinane et al [2] showed that an eccentric exercise program, either in isolation or as an adjunct to other therapies, resulted in decreased pain and improved function and grip strength compared with baseline measures. This review evaluated articles using the Modified Cochrane Musculoskeletal Injuries Group score sheet to assess methodological quality and identified the articles as being of low, medium, or high quality based on their score. Twelve articles met the authors’ criteria for inclusion, and 3 of the articles were high quality. All 3 high-quality studies showed a positive effect of eccentric strengthening exercises on pain and/or function. Each of these studies will be discussed individually in the following paragraphs. Croisier et al [3] studied a group of patients who had symptoms an average of 8 months and had undergone treatment that did not involve strengthening exercises prior to inclusion in the study. The control group received passive treatment, whereas the active group received both passive treatment plus an eccentric strengthening exercise program for the forearm supinators and wrist extensors. Patients performed the exercises 3 times per week for 9 weeks. By 7 weeks, the eccentric strengthening group experienced improvement in pain compared with the control group. At the end of treatment at 9 weeks, the average pain in the eccentric strengthening group had gone from 6.9 to 1.2; in the control group the average pain had gone from 6.7 to 4.3. Ultrasound evaluation performed before and after treatment by a radiologist who was blinded to patient allocation demonstrated that the treatment group had more subjects in whom the tendon normalized (48%) compared with the control group (28%), which was a statistically significant finding. Stasinopoulos et al [4] compared a home exercise program (HEP) with a supervised exercise program (SEP) in patients who had pain for an average of 5 months. All the patients in this study were manual workers. The exercises assigned were the same for both groups and involved performing eccentric exercises for the wrist extensors 5 days per week for 12 weeks. Patients were instructed to continue with the exercise even if they experienced mild pain but
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were told to stop the exercise if the pain became disabling. The difference in treatment between groups was that the SEP group was supervised by a physical therapist during every exercise session, whereas the HEP group was supervised by a physical therapist once a week. Improvement in pain in both groups occurred by 12 weeks and was maintained at 24 weeks. The pain in the HEP group had decreased from 8.75 to 3.27 at 12 weeks, compared with the SEP group, for whom the pain had decreased from 8.70 to 1.68. Shortcomings of this study include the potential cost of therapy in the supervised group. So ¨derberg et al [5] assessed the effect of a 6-week eccentric wrist extensor exercise program and a forearm band on pain-free hand grip and wrist extensor strength compared with a group that only used the forearm band. The group that underwent treatment with the eccentric exercise program had significantly higher pain-free hand grip and wrist extensor strength at the end of 6 weeks, but not at 3 weeks. However, there was no difference in global perceived pain at 6 weeks. Limitations of this study include having only a 6-week follow-up. Of the 9 other studies in the review by Cullinane et al [2], 2 were low quality and 7 were medium quality. Overall, the majority of findings from these studies consistently support the inclusion of a wrist extensor eccentric exercise program as part of multimodal therapy program for improving outcomes in patients with lateral elbow tendinopathy. The major weakness of these studies is that their quality limits their use in determining optimal treatment. Because none of the 12 studies had control groups who did not participate in any form of treatment, it is not known what affect the natural healing process had on recovery. However, evidence suggests that some patients with lateral elbow tendinopathy do recover within 12 months without treatment. Smidt et al [6] studied 3 groups, with 1 group receiving a corticosteroid injection, 1 group receiving physiotherapy, and 1 group receiving minimal advice from their family doctor without an HEP. Subjects in the physiotherapy group received passive treatments and a strengthening program, although the specifics of the strengthening exercise program were not provided. Patients in each group had 11 weeks of pain. At 1 year, the percentage of patients reporting success with treatment was 69% for injections, 91% for physiotherapy, and 83% for a wait-and-see approach. Physiotherapy had better results than a wait-and-see approach, but differences were not significant. The most common adverse effect in all 3 groups was radiating pain in the forearm or upper arm, which occurred more often in the injection and physiotherapy groups compared with the waitand-see group. Raman et al [7] performed a systematic review evaluating the effect of different types of resistance
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exercise on lateral elbow tendinopathy. The authors determined that there is moderate evidence to suggest the use of isotonic eccentric exercise as a treatment program for lateral elbow tendinopathy and weak evidence for the use of isokinetic and isometric exercise. They recommended a protocol of eccentric exercises performed for 3 sets of 10-15 repetitions daily for approximately 6-12 weeks. A review of the literature on eccentric wrist extensor exercises for lateral elbow tendinopathy indicates that there is good evidence that this type of exercise program is effective for treating pain and function, even for persons involved in manual labor. However, given the results of Smidt et al [6], if a patient wanted to avoid active treatment, there is a good chance that pain would improve spontaneously after several months. Another aspect of treatment of the patient in the presented case should be an analysis of his kinetic chain, because he is involved in both tennis and golf, which can excessively load the wrist extensor mechanism. In tennis, assessing stroke mechanics and ensuring that players have proper equipment, including optimal racket grip size and string tension, are important factors in minimizing or eliminating pain from lateral elbow tendinopathy [8]. Identifying weaknesses or limitations in the trunk and lower limb musculature could be beneficial given the contributions of these body regions in the generation of force during racquet sports play [9]. In golfers, detailed biomechanical analysis of the swing determined that the thoracic and lumbar spine and hip joints generate 69%-72% of the total body work during the swing [10]. Therefore, if weaknesses or limitations occur in body regions that are involved in generating power while playing tennis or golf, an abnormal workload will be absorbed by other areas (including the elbow). In addition to addressing kinetic chain issues related to sports play, the patient’s activities at work should be discussed in detail to determine if changes in the work environment could be beneficial. After considering the literature on eccentric exercises for lateral elbow tendinopathy, what should be the recommended treatment for this patient at this time? If he wanted to wait and live with the pain, he would likely have an improvement in pain during the next several months. If he wanted to pursue an active treatment that would likely improve his pain within the next several weeks, he should pursue an eccentric exercise program for the wrist extensors that is performed 1-2 times per day for 3 sets of 15 repetitions for 6-12 weeks. With this treatment plan, there is also a reasonable chance that the tendon architecture will normalize, and this improvement in tendon
appearance is more likely to occur than if no treatment is pursued. In addition to performing eccentric exercises, passive treatments could still be performed, including cross-friction massage, wrist extensor stretching, or use of a forearm brace. Although an injection with PRP is an option, PRP may not improve pain any faster than an eccentric exercise program, and most protocols have patients receive physical therapy with a strengthening program after the injection; thus, this patient should have a trial of optimal physical therapy prior to any injection. Given that he plays golf and tennis, a sports-specific evaluation of his kinetic chain should be performed, and he could consider having his mechanics during sports play reviewed to ensure they are not causing or contributing to his symptoms. The positioning and use of his upper limbs should be optimized while at work, if feasible, to minimize the effect of these activities on his pain. With an adequate trial of a wrist extensor eccentric strengthening program, assessment and treatment of kinetic chain deficiencies and limitations, and optimization of his work habits, he will likely have successful improvement of his pain from lateral elbow tendinopathy without the need for an injection of any kind.
References 1. Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis. Am J Sports Med 2012;41:1435-1446. 2. Cullinane FL, Boocock MG, Trevelyan FG. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 2014;28:3-19. 3. Croisier J-L, Foidart-Dessalle M, Tinant F, et al. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med 2007;41:269-275. 4. Stasinopoulos D, Stasinopoulos I, Pantelis M, et al. Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med 2010;44:579-583. 5. So ¨derberg JL, Grooten WJ, Ang BO. Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: A randomized-controlled trial. Scand J Med Sci Sports 2012;22: 797-803. 6. Smidt N, van der Windt DAWM, Assendelft WJJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet 2002;359: 657-662. 7. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosisdA systematic review. J Hand Ther 2012;25:5-25. 8. De Smedt T, de Jong A, Van Leemupt W, et al. Lateral epicondylitis in tennis: Update on aetiology, biomechanics and treatment. Br J Sports Med 2007;41:816-819. 9. Elliott B. Biomechanics and tennis. Br J Sports Med 2006;40: 392-396. 10. Nesbit SM, Serrano M. Work and power analysis of the golf swing. J Sports Sci Med 2005;4:520-533.
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Kenneth Mautner, MD, and Joseph Blazuk, MD, Respond Tennis elbow (also known as lateral epicondylitis/ epicondylosis, lateral elbow tendinopathy, and common extensor tendon tendinopathy) is a problem frequently encountered in sports medicine clinics. The disease course can be prolonged, although fortunately, this condition is typically self-limited. Smidt et al [1] demonstrated that by taking a waitand-see approach with no specific treatment, 83% of patients improved at 52 weeks. It is interesting to consider that we routinely prescribe physical therapy, with its associated time and monetary costs, to a group of patients in whom, according to this particular study, 83% may benefit just as well without dedicated therapy. Eccentric exercise certainly has proven results in treating various tendinopathies, including Achilles [2], patellar tendon [3], and common extensor tendon [4]. However, subsets of patients with chronic tendon pain, with extremes ranging from 11% [5] to 44% [6], fail to improve despite undergoing properly performed eccentric therapy. From a practical consideration, in the case presented, our patient is likely disenchanted with physical therapy, considering that its failure to resolve his pain is indeed the reason he presents to our office. Furthermore, a literature review by Woodley et al [7] calls into question whether eccentric therapy is any more effective than other control interventions. The review concludes that there is “a dearth of high quality research in support of the clinical effectiveness of eccentric exercise over other treatments in the management of tendinopathies.” Haahr and Andersen [8] also looked at tennis elbow from an occupational health perspective and found that employment in manual jobs, high physical strain at work, and dominant-sided symptoms bode poorly for improvement with either no specific intervention or conventional conservative care. Given this pretext, we would first ensure an accurate diagnosis with a complete lateral elbow ultrasound examination. If that examination showed significant changes such as extensor carpi radialis brevis tendon thickening, areas of hypoechogenicity, partial tearing, enthesophytes, and/or significant neovascularization, we would then discuss 3 treatment options. We could, as previously described, take a wait-and-see approach. We know that many tendinopathies will improve over time without intervention. In our experience, however, significant associated pathologic findings on ultrasound combined with poor prognostic risk factors harbinger a less favorable disease course despite only 3 months of symptoms. Second, we could send the patient for a more formal
physical therapy program, including cross-frictional massage, heat, stretching, and a dedicated eccentric protocol. Third, we could treat his common extensor tendon with a percutaneous tenotomy with or without a PRP injection. The studies that have examined the efficacy of treating chronic pathologic conditions of the tendon with PRP have yielded mixed results. In studies that portray PRP as ineffective, we need to question the PRP composition to ascertain if it explains the failure of the treatment (eg, specific volume injected, platelet concentration, leukocyte counts, red blood cell counts, and activation). We should also note whether ultrasound was used to ensure accurate placement/needling of the pathologic region. In studies that suggest PRP’s efficacy, several important considerations arise. We must assess the adequacy of the study’s time frame and ask if changes in pain and function are due to the needle itself, the actual injectate (again, many formulations of PRP are used), the postprocedure treatment program, or a comparison to a harmful (cortisone) control group that may artificially inflate results. In many cases, multiple factors contribute to improvement. In 2006, Mishra and Pavelko [9] followed up on a group of patients with lateral epicondylosis through standard physical therapy protocols. Twenty of these patients had refractory pain for an average of 15 months and were considering surgery. A control group was given 1 bupivacaine injection, and the treatment group received 1 PRP injection. At final follow-up (ranging from 12-38 months), 93% of the treatment group was pain free, while 60% of the control group withdrew and sought other treatment. No complications occurred in the PRP group. That 2006 study was a pilot study and as such is subject to criticism because of its small sample size. A 2014 study of 230 patients by Mishra et al [10] again compared a local anesthetic injectate control with needling of the tendon with a needling procedure with a PRP injection. The study found statistically significant improvement through 24 weeks in the PRP group with respect to Patient-Rated Tennis Elbow Evaluation scores, VAS scores, and treatment success as prospectively defined. The 2 Mishra studies suggest that the act of needling does not explain the efficacy of PRP. Similarly, the concentration and composition of PRP injectate influence outcomes, as Thanasas et al [11] demonstrated in a 2011 study. Thanasas et al [11] compared injection of PRP to injection of autologous blood in the treatment of chronic lateral epicondylitis and found
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that injection of PRP is more efficacious than injection of autologous whole blood with respect to VAS scores. PRP skeptics are quick to point out that the choice of injectate in the control comparison group may exert significant sway over outcomes. Peerbooms et al [12] published a widely criticized pro-PRP study in 2010 that reported that PRP was more efficacious than cortisone in treating patients with lateral epicondylosis. The toxicity of corticosteroid to tendon health is well established. We do not contest that the control choice may have been less than ideal. However, at the time of the 2010 publication, a cortisone injection for tennis elbow was standard of care in many orthopedic and some physiatric practices. In this controlled, double- blinded, and randomized study by Peerboom et al [11], it was found that cortisone worked better for the first 8 weeks compared with PRP, but by week 12, there was a crossover effect, with the cortisone effects wearing off and the PRP effects starting to show more benefit. These effects were sustained at 2-year follow-up. Lastly, one should consider that in the study by Coombes et al [13] in which placebo injection with or without physical therapy was compared with cortisone injection with or without physical therapy for treatment of lateral epicondylitis, physical therapy did not result in any significant differences in outcomes. Also, a multicenter, retrospective review of PRP injections for various chronic tendinopathies found that eccentric exercises performed after PRP injection offered no additional benefit [14]. These considerations cast further doubt that sending our patient back to physical therapy will yield different results. In summary, the patient in this case has several known risk factors for continued pain and dysfunction despite therapy. The review by Woodley et al [7] has found a dearth of high-quality research in support of the clinical effectiveness of eccentric exercise compared with conventional therapy. Our patient has already failed to respond to conventional therapy. Unfortunately, to the best of our knowledge, no studies have been performed to directly compare PRP with physical therapy for treatment of lateral epicondylosis. It is our opinion that a one-time PRP procedure is a reasonable and likely cost-effective alternative to a time-intensive physical therapy
protocol without clear advantages found in the literature. References 1. Smidt N, van der Windt DA, Assendelft WJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomized controlled trial. Lancet 2002;359: 657-662. 2. Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathyda randomized trial with 1-year follow-up. Scand J Med Sci Sports 2004;14:286-295. 3. Young MA, Cook JL, Purdam CR, et al. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med 2005;39:102-105. 4. 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;41:269-275. 5. Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003;11:327-333. 6. Sayana MK, Maffulli N. Eccentric calf muscle training in nonathletic patients with Achilles tendinopathy. J Sci Med Sport 2007;10:52-58. 7. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med 2007;41: 188-198. 8. 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 of the usual approach in general practice. Rheumatology 2003;42:1216-1225. 9. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006;34: 1774-1778. 10. Mishra AK, Skrepnik NV, Edwards SG, et al. Platelet-rich plasma significantly improves clinical outcomes in patients with chronic tennis elbow: A double-blind, prospective, multicenter, controlled trial of 230 patients. Am J Sports Med 2014;42:463-471. 11. Thanasas C, Papadimitriou G, Charalambidis C, et al. Platelet-rich versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: A randomized controlled clinical trial. Am J Sports Med 2011;39:2130-2134. 12. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: Platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med 2010;38:255-262. 13. Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. JAMA 2013;309:461-469. 14. Mautner K, Colberg RE, Malanga G, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: A multicenter, retrospective review. PM R 2013;5: 169-175.
Joseph Ihm, MD, Rebuts I agree with Drs Mautner and Blazuks’ point that this patient may be less than excited about doing additional physical therapy. In cases like his, I try to explain in detail how long he should be in therapy and
the goals of the therapy, including how to perform the exercises and how the program can normalize the appearance of the tendon. Given the evidence from the 3 high-quality studies on eccentric exercise in the
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treatment of lateral elbow tendinopathy [1], I would ask him to do the therapy for 6 sessionsdone session per week for 6 weeks. If he has minimal or no improvement with this plan, then he could be offered an injection. I would also agree that if I used the 2007 review article by Woodley et al [2] regarding eccentric exercise in the treatment of lateral elbow tendinopathy, I would not have great evidence to convince this patient to pursue additional physical therapy. However, this article does not include the 3 high-quality studies cited by Cullinane et al in their 2014 review, which are the 3 articles discussed in my initial response, so using the article by Woodley et al [2] does not provide the practitioner or patient with the best evidence available regarding treatment of lateral elbow tendinopathy using an eccentric exercise program. Although exercise has been shown to be beneficial in treating lateral elbow tendinopathy, Drs Mautner and Blazuk argue that treating this patient with an injection of PRP would be a reasonable next step. An intervention such as an injection is an option; however, injecting PRP may not be more effective than other injections, can require more than one injection, and can cost the patient several hundred dollars or more [3] because insurance companies likely will not cover the cost. A systematic review and network meta-analysis by Krogh et al [4] of all injection therapies for lateral elbow tendinopathy showed that PRP is effective compared with placebo, but the effect size of treatment using PRP was smaller than that for autologous blood. Also, whereas 2 studies evaluating the effectiveness of PRP in the treatment of lateral elbow tendinopathy met the criteria to be included in this meta-analysis, only 1 of these studies was found to have a low risk of bias. A recent systematic review evaluating injection of PRP in the treatment of lateral elbow tendinopathy showed that 3 out of 4 high-quality studies included for review did not show an improvement compared with a control group [5]. Although more research may show that PRP is effective for lateral elbow tendinopathy, the current evidence does not suggest that PRP is the best injection for this condition. Drs Mautner and Blazuk cite 4 studies that discuss the use of PRP in the treatment of lateral elbow tendinopathy. One study has a small sample size, which limits its utility. Another study compared corticosteroid to PRP, and I do not believe that use of a corticosteroid injection is warranted in this case, so I will address only the other two studies. A 2014 study by Mishra et al [6] study showed superior outcomes with an injection of PRP compared with bupivacaine. In this study, no difference was observed between the groups at 4, 8, or 12 weeks. Significant improvements between groups occurred only at the final follow-up at 24 weeks. Because Haasters et al [7] showed that bupivacaine is toxic to tendon
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cells, that toxicity could have negatively affected the outcome of the subjects injected with bupivacaine in the study by Mishra et al [6]. In the study by Mishra et al [6], treatment with bupivacaine resulted in a success rate of 68.3% compared with 83.9% in the group treated with PRP. The article by de Vos et al [5] deemed this study to be of low quality by way of its PEDro score, which again may limit its utility. The article by Thanasas et al [8] showed statistically significant improvement in the VAS pain score compared with autologous blood only at 6 weeks but not at 3 or 6 months. Both groups had greater than 50% improvement in pain at 3 and 6 months. This study showed short-term superiority over autologous blood but not long-term superiority. The last study cited, by Coombes et al [9], used an exercise program involving concentric and eccentric exercises, so this study does not exactly provide evidence against use of an eccentric program in the treatment of lateral elbow tendinopathy. In the end, although an injection may be an option, this patient should predictably respond well to additional physical therapy that incorporates an eccentric wrist extensor exercise program. Even if an injection is an option, PRP is not necessarily the best choice, and this patient could be offered percutaneous tenotomy injection of autologous blood.
References 1. Cullinane FL, Boocock MG, Trevelyan FG. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 2014;28:3-19. 2. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med 2007;41: 188-198. 3. Emory Healthcare. Platelet-rich plasma (PRP) therapy: What is the cost of PRP treatment? Available at http://www.emoryhealthcare. org/sports-medicine/procedures/prp-therapy.html. Accessed May 7, 2015. 4. Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis. Am J Sports Med 2012;41:1435-1446. 5. de Vos RJ, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: A systematic review. Br J Sports Med 2014;48:952-956. 6. Mishra AK, Skrepnik NV, Edwards SG, 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;42:463-471. 7. Haasters F, Polzer H, Prall WC, et al. Bupivacaine, ropivacaine, and morphine: Comparison of toxicity on human hamstring-derived stem/progenitor cells. Knee Surg Sports Traumatol Arthrosc 2011; 19:2138-2144. 8. Thanasas C, Papadimitriou G, Charalambidis C, et al. Platelet-rich versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: A randomized controlled clinical trial. Am J Sports Med 2011;39:2130-2134. 9. Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. JAMA 2013;309:461-469.
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Kenneth Mautner, MD, and Joseph Blazuk, MD, Rebut Our colleague, Dr Ihm, brings up several good points on which we agree. The patient’s kinetic chain, as well as his racquet, technique, work environment, and ergonomics, all warrant scrutiny. No treatment offered will provide lasting benefit if it does not address the underlying cause of his condition. Furthermore, the treatment plan needs to be patient centered by taking into consideration the patient’s expectations of treatment, outcomes, and time frames for those outcomes. “Life circumstances” justifiably do play a role in determining proper treatment. As mentioned in the case description, our patient is requesting a more aggressive approach than the therapy he has already tried. Dr Ihm comments that a PRP injection may not provide significant long-term relief compared with other injections (eg, percutaneous tenotomy injection of autologous blood). We believe the literature we reviewed in our initial position does not reflect this stance. Indeed, a strong factor for the consideration of PRP is that, when it does provide relief, the relief tends to be long lasting in the setting of a condition that is known to recur frequently. To that point, the initial study by Mishra and Pavelko [1] followed up on persons with recalcitrant lateral epicondylopathies for a range of 12-38 months after a single PRP injection, and 93% of subjects were pain free at final follow-up. As previously mentioned, Haahr and Andersen [2] demonstrated that working as a manual laborer portended poor success of conservative care for tennis elbow. Dr Ihm referenced a study by Stasinopoulos (a physiotherapist) et al [3] that did show that manual laborers undergoing supervised physical therapy with a focus on eccentric exercise had greater reductions in pain scores. However, this group had 60 physical therapy visits. In our post-PRP instructions, we do recommend an eccentric strengthening program as patients progress through their rehabilitation. Frequently our patients will work with a physical therapist a handful of times to develop an individualized rehabilitation program they can then implement on their own. We believe this is sufficient and certainly more practical than 60 therapy sessions. We have previously addressed the review by Woodley et al [4] on eccentric exercise for the treatment of chronic tendinopathy. This review did not support the notion that eccentric exercise was more effective than other forms of therapy. Dr Ihm brings up the review by Cullinane et al [5] that suggests the
opposite. It should be emphasized that in the review by Cullinane et al, only 3 of 12 studies were determined to be of high quality and a third of the studies included did not involve randomized controlled trials. Furthermore, 11 of the 12 studies incorporated eccentric exercise in addition to other therapy treatments, and significant variation existed in the exercise protocol. The only study that looked at eccentric exercise in isolation showed no significant improvements in pain when compared with a multimodal treatment program. Also, the review by Raman et al [6] did find “moderate research evidence” to support isotonic eccentric exercise for improving pain, strength, and function over time. However, findings appeared inconclusive as to the additional benefits of eccentric exercise when added to an existing multimodal treatment program and compared with other forms of treatment. These findings seem to corroborate Woodley’s review. In summary, given the equivocal evidence that an eccentric program will offer more benefit than the conventional physical therapy the patient has already pursued, we believe that a noninterventional approach is an arduous pathway that will not result in clinically relevant gains. In that process you may have cost your patient time and money, and perhaps most importantly, you may have eroded his trust in your ability to resolve his problem.
References 1. Mishra AK, Skrepnik NV, Edwards SG, 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;42:463-471. 2. 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 of the usual approach in general practice. Rheumatology 2003;42: 1216-1225. 3. Stasinopoulos D, Stasinopoulos I, Pantelis M, et al. Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med 2010;44:579-583. 4. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med 2007;41:188-198. 5. Cullinane FL, Boocock MG, Trevelyan FG. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 2014;28:3-19. 6. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosisdA systematic review. J Hand Ther 2012;25:5-25.
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Disclosure J.I. Rehabilitation Institute of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL Disclosure: nothing to disclose
J.B. Department of Physical Medicine and Rehabilitation, Emory University, Atlanta, GA Disclosure: nothing to disclose
K.M. Departments of Physical Medicine and Rehabilitation, and Orthopaedics, Emory University School of Medicine, Atlanta, GA Disclosures outside this publication: payment for lectures including service on speakers bureaus, Sonosite (money to author); stock/stock options, Tenex (money to author)
J.R.S. Weill Cornell Spine Center, Physical Medicine and Rehabilitation. Address correspondence to: J.R.S., 525 E 68th Street, Baker 16th Floor, New York, NY 10065; e-mail: [email protected] Disclosure outside this publication: consultancy, Kimberly Clark (money to author)
Web Poll Question For the case scenario presented in this Point/Counterpoint, which approach would you take? a. eccentric exercise strengthening program b. platelet-rich plasma To cast your vote, visit www.pmrjournal.org
Results of March’s Web Poll For the case scenario presented in Determining the Need for Pain Medications for a Patient With a Disorder of Consciousness, which approach would you take? 86% a more conservative use of these medications 14% aggressive use of opioid pain medications and suggestions regarding how to prescribe them
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Point/Counterpoint
Guest Discussants: Joseph Ihm, MD, Kenneth Mautner, MD, Joseph Blazuk, MD Feature Editor: Jaspal Ricky Singh, MD
Platelet-Rich Plasma Versus an Eccentric Exercise Program for Recalcitrant Lateral Elbow Tendinopathy CASE SCENARIO A 48-year-old male, left handedominant air conditioning repairman has a 3-month history of persistent pain in his left elbow. He does not report any traumatic precipitating incident. He is now having difficulty performing his work duties, especially gripping and lifting. In addition, he has had to stop playing recreational tennis and golf. His initial treatment was physical therapy, including therapeutic ultrasound, friction massage, and use of a counterforce strap. After 8 sessions and minimal improvement in his pain, he was referred to a sports medicine specialist. The pain averages 5 out of 10 on a visual analog scale (VAS) and is usually a deep ache, but at times it is sharp. Examination showed no obvious inflammation of common extensor origin. Tenderness was present over the lateral epicondyle, and gripping reproduced the pain. The Cozen test (resisted wrist extension with an extended and pronated elbow) and resisted middle finger extension were positive for pain. The patient was diagnosed with chronic lateral elbow tendinopathy. Given his lack of improvement with physical therapy, the patient is requesting a more aggressive approach. Dr Joseph Ihm will argue that an eccentric exercise strengthening program should be implemented to provide long-term relief. Drs Kenneth Mautner and Joseph Blazuk will argue that an injection of platelet-rich plasma (PRP) is warranted in this patient to optimize and restore his long-term function. Joseph Ihm, MD, Responds This case involves a common patient scenario seen by musculoskeletal physiatrists. Patients with lateral elbow tendinopathy often receive physical therapy that does not include an optimal exercise program to address the local tendinosis, an assessment of how the kinetic chain affects the patient’s upper quadrant, or an assessment of occupational issues that may be contributing to the pain. The physical therapy program described in this case is mostly passive, although the patient may have undergone some form of strengthening. As a result, the first thing to do is discuss the details of the physical therapy program that he just completed. In general, if a patient has not had therapy with specific directions to perform eccentric exercises focusing on the wrist extensors, then this type of exercise should be pursued as the next line of treatment. As part of the therapy program, the patient’s kinetic chain should be addressed because he is involved in 2 sports that could provoke
lateral elbow pain if deficiencies in strength or limitations in range of motion are present in the upper limbs, trunk, hips, or lower limbs. If needed, diagnostic ultrasound could be performed, which would determine if a partial tear is present or if there is a clinically significant calcification within the proximal common extensor tendons, either of which may alter recommendations for treatment. Considering these issues, the practitioner is left with a decision to make. Should the physician encourage the patient to undergo additional physical therapy emphasizing eccentric exercises before proceeding with more aggressive treatment, or should the patient be offered more aggressive treatment (eg, an injection of platelet-rich plasma [PRP]) at this time? Although a PRP injection is potentially a worthwhile option, it may not provide significant long-term relief compared with other injections [1] (eg, percutaneous tenotomy injection of autologous blood), and an eccentric
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strengthening program is often pursued after the injection anyway. What follows is a discussion of the literature to date regarding the use of eccentric exercises to treat lateral elbow tendinopathy in persons without a partial tear or calcific tendinitis, followed by a specific treatment plan for this patient. Eccentric exercises for the wrist extensors are commonly used as a first-line treatment for lateral elbow tendinopathy. Several studies have evaluated the effectiveness of this type of exercise program on pain and function related to lateral elbow tendinopathy, with many studies showing a positive effect. A recent review by Cullinane et al [2] showed that an eccentric exercise program, either in isolation or as an adjunct to other therapies, resulted in decreased pain and improved function and grip strength compared with baseline measures. This review evaluated articles using the Modified Cochrane Musculoskeletal Injuries Group score sheet to assess methodological quality and identified the articles as being of low, medium, or high quality based on their score. Twelve articles met the authors’ criteria for inclusion, and 3 of the articles were high quality. All 3 high-quality studies showed a positive effect of eccentric strengthening exercises on pain and/or function. Each of these studies will be discussed individually in the following paragraphs. Croisier et al [3] studied a group of patients who had symptoms an average of 8 months and had undergone treatment that did not involve strengthening exercises prior to inclusion in the study. The control group received passive treatment, whereas the active group received both passive treatment plus an eccentric strengthening exercise program for the forearm supinators and wrist extensors. Patients performed the exercises 3 times per week for 9 weeks. By 7 weeks, the eccentric strengthening group experienced improvement in pain compared with the control group. At the end of treatment at 9 weeks, the average pain in the eccentric strengthening group had gone from 6.9 to 1.2; in the control group the average pain had gone from 6.7 to 4.3. Ultrasound evaluation performed before and after treatment by a radiologist who was blinded to patient allocation demonstrated that the treatment group had more subjects in whom the tendon normalized (48%) compared with the control group (28%), which was a statistically significant finding. Stasinopoulos et al [4] compared a home exercise program (HEP) with a supervised exercise program (SEP) in patients who had pain for an average of 5 months. All the patients in this study were manual workers. The exercises assigned were the same for both groups and involved performing eccentric exercises for the wrist extensors 5 days per week for 12 weeks. Patients were instructed to continue with the exercise even if they experienced mild pain but
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were told to stop the exercise if the pain became disabling. The difference in treatment between groups was that the SEP group was supervised by a physical therapist during every exercise session, whereas the HEP group was supervised by a physical therapist once a week. Improvement in pain in both groups occurred by 12 weeks and was maintained at 24 weeks. The pain in the HEP group had decreased from 8.75 to 3.27 at 12 weeks, compared with the SEP group, for whom the pain had decreased from 8.70 to 1.68. Shortcomings of this study include the potential cost of therapy in the supervised group. So ¨derberg et al [5] assessed the effect of a 6-week eccentric wrist extensor exercise program and a forearm band on pain-free hand grip and wrist extensor strength compared with a group that only used the forearm band. The group that underwent treatment with the eccentric exercise program had significantly higher pain-free hand grip and wrist extensor strength at the end of 6 weeks, but not at 3 weeks. However, there was no difference in global perceived pain at 6 weeks. Limitations of this study include having only a 6-week follow-up. Of the 9 other studies in the review by Cullinane et al [2], 2 were low quality and 7 were medium quality. Overall, the majority of findings from these studies consistently support the inclusion of a wrist extensor eccentric exercise program as part of multimodal therapy program for improving outcomes in patients with lateral elbow tendinopathy. The major weakness of these studies is that their quality limits their use in determining optimal treatment. Because none of the 12 studies had control groups who did not participate in any form of treatment, it is not known what affect the natural healing process had on recovery. However, evidence suggests that some patients with lateral elbow tendinopathy do recover within 12 months without treatment. Smidt et al [6] studied 3 groups, with 1 group receiving a corticosteroid injection, 1 group receiving physiotherapy, and 1 group receiving minimal advice from their family doctor without an HEP. Subjects in the physiotherapy group received passive treatments and a strengthening program, although the specifics of the strengthening exercise program were not provided. Patients in each group had 11 weeks of pain. At 1 year, the percentage of patients reporting success with treatment was 69% for injections, 91% for physiotherapy, and 83% for a wait-and-see approach. Physiotherapy had better results than a wait-and-see approach, but differences were not significant. The most common adverse effect in all 3 groups was radiating pain in the forearm or upper arm, which occurred more often in the injection and physiotherapy groups compared with the waitand-see group. Raman et al [7] performed a systematic review evaluating the effect of different types of resistance
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exercise on lateral elbow tendinopathy. The authors determined that there is moderate evidence to suggest the use of isotonic eccentric exercise as a treatment program for lateral elbow tendinopathy and weak evidence for the use of isokinetic and isometric exercise. They recommended a protocol of eccentric exercises performed for 3 sets of 10-15 repetitions daily for approximately 6-12 weeks. A review of the literature on eccentric wrist extensor exercises for lateral elbow tendinopathy indicates that there is good evidence that this type of exercise program is effective for treating pain and function, even for persons involved in manual labor. However, given the results of Smidt et al [6], if a patient wanted to avoid active treatment, there is a good chance that pain would improve spontaneously after several months. Another aspect of treatment of the patient in the presented case should be an analysis of his kinetic chain, because he is involved in both tennis and golf, which can excessively load the wrist extensor mechanism. In tennis, assessing stroke mechanics and ensuring that players have proper equipment, including optimal racket grip size and string tension, are important factors in minimizing or eliminating pain from lateral elbow tendinopathy [8]. Identifying weaknesses or limitations in the trunk and lower limb musculature could be beneficial given the contributions of these body regions in the generation of force during racquet sports play [9]. In golfers, detailed biomechanical analysis of the swing determined that the thoracic and lumbar spine and hip joints generate 69%-72% of the total body work during the swing [10]. Therefore, if weaknesses or limitations occur in body regions that are involved in generating power while playing tennis or golf, an abnormal workload will be absorbed by other areas (including the elbow). In addition to addressing kinetic chain issues related to sports play, the patient’s activities at work should be discussed in detail to determine if changes in the work environment could be beneficial. After considering the literature on eccentric exercises for lateral elbow tendinopathy, what should be the recommended treatment for this patient at this time? If he wanted to wait and live with the pain, he would likely have an improvement in pain during the next several months. If he wanted to pursue an active treatment that would likely improve his pain within the next several weeks, he should pursue an eccentric exercise program for the wrist extensors that is performed 1-2 times per day for 3 sets of 15 repetitions for 6-12 weeks. With this treatment plan, there is also a reasonable chance that the tendon architecture will normalize, and this improvement in tendon
appearance is more likely to occur than if no treatment is pursued. In addition to performing eccentric exercises, passive treatments could still be performed, including cross-friction massage, wrist extensor stretching, or use of a forearm brace. Although an injection with PRP is an option, PRP may not improve pain any faster than an eccentric exercise program, and most protocols have patients receive physical therapy with a strengthening program after the injection; thus, this patient should have a trial of optimal physical therapy prior to any injection. Given that he plays golf and tennis, a sports-specific evaluation of his kinetic chain should be performed, and he could consider having his mechanics during sports play reviewed to ensure they are not causing or contributing to his symptoms. The positioning and use of his upper limbs should be optimized while at work, if feasible, to minimize the effect of these activities on his pain. With an adequate trial of a wrist extensor eccentric strengthening program, assessment and treatment of kinetic chain deficiencies and limitations, and optimization of his work habits, he will likely have successful improvement of his pain from lateral elbow tendinopathy without the need for an injection of any kind.
References 1. Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis. Am J Sports Med 2012;41:1435-1446. 2. Cullinane FL, Boocock MG, Trevelyan FG. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 2014;28:3-19. 3. Croisier J-L, Foidart-Dessalle M, Tinant F, et al. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med 2007;41:269-275. 4. Stasinopoulos D, Stasinopoulos I, Pantelis M, et al. Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med 2010;44:579-583. 5. So ¨derberg JL, Grooten WJ, Ang BO. Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: A randomized-controlled trial. Scand J Med Sci Sports 2012;22: 797-803. 6. Smidt N, van der Windt DAWM, Assendelft WJJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet 2002;359: 657-662. 7. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosisdA systematic review. J Hand Ther 2012;25:5-25. 8. De Smedt T, de Jong A, Van Leemupt W, et al. Lateral epicondylitis in tennis: Update on aetiology, biomechanics and treatment. Br J Sports Med 2007;41:816-819. 9. Elliott B. Biomechanics and tennis. Br J Sports Med 2006;40: 392-396. 10. Nesbit SM, Serrano M. Work and power analysis of the golf swing. J Sports Sci Med 2005;4:520-533.
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Kenneth Mautner, MD, and Joseph Blazuk, MD, Respond Tennis elbow (also known as lateral epicondylitis/ epicondylosis, lateral elbow tendinopathy, and common extensor tendon tendinopathy) is a problem frequently encountered in sports medicine clinics. The disease course can be prolonged, although fortunately, this condition is typically self-limited. Smidt et al [1] demonstrated that by taking a waitand-see approach with no specific treatment, 83% of patients improved at 52 weeks. It is interesting to consider that we routinely prescribe physical therapy, with its associated time and monetary costs, to a group of patients in whom, according to this particular study, 83% may benefit just as well without dedicated therapy. Eccentric exercise certainly has proven results in treating various tendinopathies, including Achilles [2], patellar tendon [3], and common extensor tendon [4]. However, subsets of patients with chronic tendon pain, with extremes ranging from 11% [5] to 44% [6], fail to improve despite undergoing properly performed eccentric therapy. From a practical consideration, in the case presented, our patient is likely disenchanted with physical therapy, considering that its failure to resolve his pain is indeed the reason he presents to our office. Furthermore, a literature review by Woodley et al [7] calls into question whether eccentric therapy is any more effective than other control interventions. The review concludes that there is “a dearth of high quality research in support of the clinical effectiveness of eccentric exercise over other treatments in the management of tendinopathies.” Haahr and Andersen [8] also looked at tennis elbow from an occupational health perspective and found that employment in manual jobs, high physical strain at work, and dominant-sided symptoms bode poorly for improvement with either no specific intervention or conventional conservative care. Given this pretext, we would first ensure an accurate diagnosis with a complete lateral elbow ultrasound examination. If that examination showed significant changes such as extensor carpi radialis brevis tendon thickening, areas of hypoechogenicity, partial tearing, enthesophytes, and/or significant neovascularization, we would then discuss 3 treatment options. We could, as previously described, take a wait-and-see approach. We know that many tendinopathies will improve over time without intervention. In our experience, however, significant associated pathologic findings on ultrasound combined with poor prognostic risk factors harbinger a less favorable disease course despite only 3 months of symptoms. Second, we could send the patient for a more formal
physical therapy program, including cross-frictional massage, heat, stretching, and a dedicated eccentric protocol. Third, we could treat his common extensor tendon with a percutaneous tenotomy with or without a PRP injection. The studies that have examined the efficacy of treating chronic pathologic conditions of the tendon with PRP have yielded mixed results. In studies that portray PRP as ineffective, we need to question the PRP composition to ascertain if it explains the failure of the treatment (eg, specific volume injected, platelet concentration, leukocyte counts, red blood cell counts, and activation). We should also note whether ultrasound was used to ensure accurate placement/needling of the pathologic region. In studies that suggest PRP’s efficacy, several important considerations arise. We must assess the adequacy of the study’s time frame and ask if changes in pain and function are due to the needle itself, the actual injectate (again, many formulations of PRP are used), the postprocedure treatment program, or a comparison to a harmful (cortisone) control group that may artificially inflate results. In many cases, multiple factors contribute to improvement. In 2006, Mishra and Pavelko [9] followed up on a group of patients with lateral epicondylosis through standard physical therapy protocols. Twenty of these patients had refractory pain for an average of 15 months and were considering surgery. A control group was given 1 bupivacaine injection, and the treatment group received 1 PRP injection. At final follow-up (ranging from 12-38 months), 93% of the treatment group was pain free, while 60% of the control group withdrew and sought other treatment. No complications occurred in the PRP group. That 2006 study was a pilot study and as such is subject to criticism because of its small sample size. A 2014 study of 230 patients by Mishra et al [10] again compared a local anesthetic injectate control with needling of the tendon with a needling procedure with a PRP injection. The study found statistically significant improvement through 24 weeks in the PRP group with respect to Patient-Rated Tennis Elbow Evaluation scores, VAS scores, and treatment success as prospectively defined. The 2 Mishra studies suggest that the act of needling does not explain the efficacy of PRP. Similarly, the concentration and composition of PRP injectate influence outcomes, as Thanasas et al [11] demonstrated in a 2011 study. Thanasas et al [11] compared injection of PRP to injection of autologous blood in the treatment of chronic lateral epicondylitis and found
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that injection of PRP is more efficacious than injection of autologous whole blood with respect to VAS scores. PRP skeptics are quick to point out that the choice of injectate in the control comparison group may exert significant sway over outcomes. Peerbooms et al [12] published a widely criticized pro-PRP study in 2010 that reported that PRP was more efficacious than cortisone in treating patients with lateral epicondylosis. The toxicity of corticosteroid to tendon health is well established. We do not contest that the control choice may have been less than ideal. However, at the time of the 2010 publication, a cortisone injection for tennis elbow was standard of care in many orthopedic and some physiatric practices. In this controlled, double- blinded, and randomized study by Peerboom et al [11], it was found that cortisone worked better for the first 8 weeks compared with PRP, but by week 12, there was a crossover effect, with the cortisone effects wearing off and the PRP effects starting to show more benefit. These effects were sustained at 2-year follow-up. Lastly, one should consider that in the study by Coombes et al [13] in which placebo injection with or without physical therapy was compared with cortisone injection with or without physical therapy for treatment of lateral epicondylitis, physical therapy did not result in any significant differences in outcomes. Also, a multicenter, retrospective review of PRP injections for various chronic tendinopathies found that eccentric exercises performed after PRP injection offered no additional benefit [14]. These considerations cast further doubt that sending our patient back to physical therapy will yield different results. In summary, the patient in this case has several known risk factors for continued pain and dysfunction despite therapy. The review by Woodley et al [7] has found a dearth of high-quality research in support of the clinical effectiveness of eccentric exercise compared with conventional therapy. Our patient has already failed to respond to conventional therapy. Unfortunately, to the best of our knowledge, no studies have been performed to directly compare PRP with physical therapy for treatment of lateral epicondylosis. It is our opinion that a one-time PRP procedure is a reasonable and likely cost-effective alternative to a time-intensive physical therapy
protocol without clear advantages found in the literature. References 1. Smidt N, van der Windt DA, Assendelft WJ, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomized controlled trial. Lancet 2002;359: 657-662. 2. Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathyda randomized trial with 1-year follow-up. Scand J Med Sci Sports 2004;14:286-295. 3. Young MA, Cook JL, Purdam CR, et al. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med 2005;39:102-105. 4. 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;41:269-275. 5. Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003;11:327-333. 6. Sayana MK, Maffulli N. Eccentric calf muscle training in nonathletic patients with Achilles tendinopathy. J Sci Med Sport 2007;10:52-58. 7. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med 2007;41: 188-198. 8. 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 of the usual approach in general practice. Rheumatology 2003;42:1216-1225. 9. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006;34: 1774-1778. 10. Mishra AK, Skrepnik NV, Edwards SG, et al. Platelet-rich plasma significantly improves clinical outcomes in patients with chronic tennis elbow: A double-blind, prospective, multicenter, controlled trial of 230 patients. Am J Sports Med 2014;42:463-471. 11. Thanasas C, Papadimitriou G, Charalambidis C, et al. Platelet-rich versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: A randomized controlled clinical trial. Am J Sports Med 2011;39:2130-2134. 12. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: Platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med 2010;38:255-262. 13. Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. JAMA 2013;309:461-469. 14. Mautner K, Colberg RE, Malanga G, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: A multicenter, retrospective review. PM R 2013;5: 169-175.
Joseph Ihm, MD, Rebuts I agree with Drs Mautner and Blazuks’ point that this patient may be less than excited about doing additional physical therapy. In cases like his, I try to explain in detail how long he should be in therapy and
the goals of the therapy, including how to perform the exercises and how the program can normalize the appearance of the tendon. Given the evidence from the 3 high-quality studies on eccentric exercise in the
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treatment of lateral elbow tendinopathy [1], I would ask him to do the therapy for 6 sessionsdone session per week for 6 weeks. If he has minimal or no improvement with this plan, then he could be offered an injection. I would also agree that if I used the 2007 review article by Woodley et al [2] regarding eccentric exercise in the treatment of lateral elbow tendinopathy, I would not have great evidence to convince this patient to pursue additional physical therapy. However, this article does not include the 3 high-quality studies cited by Cullinane et al in their 2014 review, which are the 3 articles discussed in my initial response, so using the article by Woodley et al [2] does not provide the practitioner or patient with the best evidence available regarding treatment of lateral elbow tendinopathy using an eccentric exercise program. Although exercise has been shown to be beneficial in treating lateral elbow tendinopathy, Drs Mautner and Blazuk argue that treating this patient with an injection of PRP would be a reasonable next step. An intervention such as an injection is an option; however, injecting PRP may not be more effective than other injections, can require more than one injection, and can cost the patient several hundred dollars or more [3] because insurance companies likely will not cover the cost. A systematic review and network meta-analysis by Krogh et al [4] of all injection therapies for lateral elbow tendinopathy showed that PRP is effective compared with placebo, but the effect size of treatment using PRP was smaller than that for autologous blood. Also, whereas 2 studies evaluating the effectiveness of PRP in the treatment of lateral elbow tendinopathy met the criteria to be included in this meta-analysis, only 1 of these studies was found to have a low risk of bias. A recent systematic review evaluating injection of PRP in the treatment of lateral elbow tendinopathy showed that 3 out of 4 high-quality studies included for review did not show an improvement compared with a control group [5]. Although more research may show that PRP is effective for lateral elbow tendinopathy, the current evidence does not suggest that PRP is the best injection for this condition. Drs Mautner and Blazuk cite 4 studies that discuss the use of PRP in the treatment of lateral elbow tendinopathy. One study has a small sample size, which limits its utility. Another study compared corticosteroid to PRP, and I do not believe that use of a corticosteroid injection is warranted in this case, so I will address only the other two studies. A 2014 study by Mishra et al [6] study showed superior outcomes with an injection of PRP compared with bupivacaine. In this study, no difference was observed between the groups at 4, 8, or 12 weeks. Significant improvements between groups occurred only at the final follow-up at 24 weeks. Because Haasters et al [7] showed that bupivacaine is toxic to tendon
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cells, that toxicity could have negatively affected the outcome of the subjects injected with bupivacaine in the study by Mishra et al [6]. In the study by Mishra et al [6], treatment with bupivacaine resulted in a success rate of 68.3% compared with 83.9% in the group treated with PRP. The article by de Vos et al [5] deemed this study to be of low quality by way of its PEDro score, which again may limit its utility. The article by Thanasas et al [8] showed statistically significant improvement in the VAS pain score compared with autologous blood only at 6 weeks but not at 3 or 6 months. Both groups had greater than 50% improvement in pain at 3 and 6 months. This study showed short-term superiority over autologous blood but not long-term superiority. The last study cited, by Coombes et al [9], used an exercise program involving concentric and eccentric exercises, so this study does not exactly provide evidence against use of an eccentric program in the treatment of lateral elbow tendinopathy. In the end, although an injection may be an option, this patient should predictably respond well to additional physical therapy that incorporates an eccentric wrist extensor exercise program. Even if an injection is an option, PRP is not necessarily the best choice, and this patient could be offered percutaneous tenotomy injection of autologous blood.
References 1. Cullinane FL, Boocock MG, Trevelyan FG. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 2014;28:3-19. 2. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med 2007;41: 188-198. 3. Emory Healthcare. Platelet-rich plasma (PRP) therapy: What is the cost of PRP treatment? Available at http://www.emoryhealthcare. org/sports-medicine/procedures/prp-therapy.html. Accessed May 7, 2015. 4. Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis. Am J Sports Med 2012;41:1435-1446. 5. de Vos RJ, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: A systematic review. Br J Sports Med 2014;48:952-956. 6. Mishra AK, Skrepnik NV, Edwards SG, 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;42:463-471. 7. Haasters F, Polzer H, Prall WC, et al. Bupivacaine, ropivacaine, and morphine: Comparison of toxicity on human hamstring-derived stem/progenitor cells. Knee Surg Sports Traumatol Arthrosc 2011; 19:2138-2144. 8. Thanasas C, Papadimitriou G, Charalambidis C, et al. Platelet-rich versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: A randomized controlled clinical trial. Am J Sports Med 2011;39:2130-2134. 9. Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. JAMA 2013;309:461-469.
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Recalcitrant Lateral Elbow Tendinopathy Treatment
Kenneth Mautner, MD, and Joseph Blazuk, MD, Rebut Our colleague, Dr Ihm, brings up several good points on which we agree. The patient’s kinetic chain, as well as his racquet, technique, work environment, and ergonomics, all warrant scrutiny. No treatment offered will provide lasting benefit if it does not address the underlying cause of his condition. Furthermore, the treatment plan needs to be patient centered by taking into consideration the patient’s expectations of treatment, outcomes, and time frames for those outcomes. “Life circumstances” justifiably do play a role in determining proper treatment. As mentioned in the case description, our patient is requesting a more aggressive approach than the therapy he has already tried. Dr Ihm comments that a PRP injection may not provide significant long-term relief compared with other injections (eg, percutaneous tenotomy injection of autologous blood). We believe the literature we reviewed in our initial position does not reflect this stance. Indeed, a strong factor for the consideration of PRP is that, when it does provide relief, the relief tends to be long lasting in the setting of a condition that is known to recur frequently. To that point, the initial study by Mishra and Pavelko [1] followed up on persons with recalcitrant lateral epicondylopathies for a range of 12-38 months after a single PRP injection, and 93% of subjects were pain free at final follow-up. As previously mentioned, Haahr and Andersen [2] demonstrated that working as a manual laborer portended poor success of conservative care for tennis elbow. Dr Ihm referenced a study by Stasinopoulos (a physiotherapist) et al [3] that did show that manual laborers undergoing supervised physical therapy with a focus on eccentric exercise had greater reductions in pain scores. However, this group had 60 physical therapy visits. In our post-PRP instructions, we do recommend an eccentric strengthening program as patients progress through their rehabilitation. Frequently our patients will work with a physical therapist a handful of times to develop an individualized rehabilitation program they can then implement on their own. We believe this is sufficient and certainly more practical than 60 therapy sessions. We have previously addressed the review by Woodley et al [4] on eccentric exercise for the treatment of chronic tendinopathy. This review did not support the notion that eccentric exercise was more effective than other forms of therapy. Dr Ihm brings up the review by Cullinane et al [5] that suggests the
opposite. It should be emphasized that in the review by Cullinane et al, only 3 of 12 studies were determined to be of high quality and a third of the studies included did not involve randomized controlled trials. Furthermore, 11 of the 12 studies incorporated eccentric exercise in addition to other therapy treatments, and significant variation existed in the exercise protocol. The only study that looked at eccentric exercise in isolation showed no significant improvements in pain when compared with a multimodal treatment program. Also, the review by Raman et al [6] did find “moderate research evidence” to support isotonic eccentric exercise for improving pain, strength, and function over time. However, findings appeared inconclusive as to the additional benefits of eccentric exercise when added to an existing multimodal treatment program and compared with other forms of treatment. These findings seem to corroborate Woodley’s review. In summary, given the equivocal evidence that an eccentric program will offer more benefit than the conventional physical therapy the patient has already pursued, we believe that a noninterventional approach is an arduous pathway that will not result in clinically relevant gains. In that process you may have cost your patient time and money, and perhaps most importantly, you may have eroded his trust in your ability to resolve his problem.
References 1. Mishra AK, Skrepnik NV, Edwards SG, 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;42:463-471. 2. 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 of the usual approach in general practice. Rheumatology 2003;42: 1216-1225. 3. Stasinopoulos D, Stasinopoulos I, Pantelis M, et al. Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med 2010;44:579-583. 4. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med 2007;41:188-198. 5. Cullinane FL, Boocock MG, Trevelyan FG. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 2014;28:3-19. 6. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosisdA systematic review. J Hand Ther 2012;25:5-25.
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Disclosure J.I. Rehabilitation Institute of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL Disclosure: nothing to disclose
J.B. Department of Physical Medicine and Rehabilitation, Emory University, Atlanta, GA Disclosure: nothing to disclose
K.M. Departments of Physical Medicine and Rehabilitation, and Orthopaedics, Emory University School of Medicine, Atlanta, GA Disclosures outside this publication: payment for lectures including service on speakers bureaus, Sonosite (money to author); stock/stock options, Tenex (money to author)
J.R.S. Weill Cornell Spine Center, Physical Medicine and Rehabilitation. Address correspondence to: J.R.S., 525 E 68th Street, Baker 16th Floor, New York, NY 10065; e-mail: [email protected] Disclosure outside this publication: consultancy, Kimberly Clark (money to author)
Web Poll Question For the case scenario presented in this Point/Counterpoint, which approach would you take? a. eccentric exercise strengthening program b. platelet-rich plasma To cast your vote, visit www.pmrjournal.org
Results of March’s Web Poll For the case scenario presented in Determining the Need for Pain Medications for a Patient With a Disorder of Consciousness, which approach would you take? 86% a more conservative use of these medications 14% aggressive use of opioid pain medications and suggestions regarding how to prescribe them
