A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma
- 1University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, Wisconsin, USA
- 2The Ohio State University, Columbus, Ohio, USA
- 3University of Wisconsin, Madison, Wisconsin, USA
- 4University of Umeå, Umeå, Sweden
- 5University of British Columbia, Vancouver, Canada
- 6Crane 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;
- Accepted 10 November 2008
- Published Online First 21 November 2008
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.
Competing interests: DC Massachusetts is a consultant and lecturer for Harvest Technologies of Plymouth, MA, USA, a manufacturer of centrifuge and ancillary equipment for platelet-rich plasma injection therapy. Harvest itself had no direct or indirect role in the production of this manuscript. No other co-author reports any conflict of interest.