Review

A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma

D Rabago¹, T M Best², A E Zgierska³, E Zeisig⁴, M Ryan⁵, D Crane⁶

¹ University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, Wisconsin, USA
² The Ohio State University, Columbus, Ohio, USA
³ University of Wisconsin, Madison, Wisconsin, USA
⁴ University of Umeå, Umeå, Sweden
⁵ University of British Columbia, Vancouver, Canada
⁶ Crane Clinic, Chesterfield, Missouri, USA

David Rabago, MD, University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, 777 S. Mills St, Madison WI, 53715, USA; david.rabago{at}fammed.wisc.edu

Objective: To appraise existing evidence for prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injection therapies for lateral epicondylosis (LE).

Design: Systematic review.

Data sources: Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine. Search strategy: names and descriptors of the therapies and LE.

Study Selection: All human studies assessing the four therapies for LE.

Main results: Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. In follow-up periods ranging from 9 to 108 weeks, studies reported sustained, statistically significant (p<0.05) improvement in visual analogue scale primary outcome pain score measures and disease-specific questionnaires; relative effect sizes ranged from 51% to 94%; Cohen’s d ranged from 0.68 to 6.68. Secondary outcomes also improved, including biomechanical elbow function assessment (polidocanol and prolotherapy), presence of abnormalities and increased vascularity on ultrasound (autologous whole blood and polidocanol). Subjects reported satisfaction with therapies on single-item assessments. All studies were limited by small sample size.

Conclusions: There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.

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