Autologous platelet-rich plasma injection in tennis elbow and plantar fasciitis

S.K.Venkatesh Gupta, MS (Ortho) Prof and HOD and Divya Bandari, Post Graduate Department of Orthopaedics, Mamata Medical College/General Hospital, Khammam, Telangana, India

INTRODUCTION

The introduction of platelet-rich plasma (PRP) as a possible adjunct to conservative and operative treatment has motivated significant research into this topic.1 PRP is

 

Financial Disclosure: The authors have no disclosures and report no conflicts of interest.

Correspondence to Divya Bandari, Post Graduation, Mamata Medical College, Khammam, Telangana, India

Tel: þ 917799578082; fax: þ 91 8742 234206;

e-mail: [email protected]m.

1940-7041 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

promoted as an ideal autologous biological blood-derived product that can be exogenously applied to various tissues where it releases high concentrations of platelet-derived growth factors that enhance wound, bone, and tendon healing.2 Platelets present in PRP function as a tissue sealant, initiating wound repair.3 Whereas fibrin matrix acts as a drug delivery system slowly releasing various platelet-derived bioactive factors4 such as vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-b1, insulin-like growth factor (IGF) and platelet derived growth factor (PDGF),5,6 PRP platelets are initially activated by thrombin and collagen, releasing growth factors that attract undifferentiated cells into the newly formed matrix and trigger cell division.7 PRP can inhibit cytokine release from macrophages, improving tissue healing and regeneration by limiting the inflammation,8 can promote new capillary growth,9 and can accelerate epithelialization4 in chronic wounds.

Platelet rich plasma has found its application in various orthopaedic conditions like tendinopathies (i.e., lateral epicondylitis,2,8,10–12 patellar tendinopathy,13–15 Achilles tendinopathy,16,17 shoulder impingement syndrome,18 ro- tator cuff tear,17 osteoarthritis knee,19–21 and avascular necrosis of femoral head).22 We have emphasized two conditions in this article, tennis elbow and plantar fasciitis. Probably one of the most common overuse syndromes is related to excessive wrist extension and is commonly referred to as tennis elbow or lateral epicondylitis. It does not show signs of inflammation but rather angiofibroblas- tic degeneration and collagen disarray. On a histological level, light microscopy reveals both an excess of fibroblasts and blood vessels that are consistent with neo-

angiogenesis.23

Chronic plantar fasciitis is probably the most common cause of foot complaints, making up 11% to 15% of the midfoot and hindfoot symptoms, requiring  professional care among adults.24 The underlying condition that causes plantar fasciitis is a degenerative tissue condition that occurs near the site of origin of the plantar fascia at the medial tuberosity of the calcaneus.25

MATERIALS AND METHODS

The protocol of this study has been approved by the relevant ethical committee related to our institution in which it was performed. All subjects gave full informed consent to participate in this study. During October 2013 to March 2015,100 patients 60 diagnosed with tennis elbow and 40 diagnosed with plantar fasciitis, visiting our center with

failed conservative treatment involving a trial of non- steroidal antiinflammator drugs (NSAIDs) and physiother- apy were treated with PRP and results were evaluated with Visual Analog Score (VAS), Disability of Arm Shoulder and Hand (DASH), and Foot Health Status Questionnaire (FHSQ).

 

Clinical Assessment

Among 100 patients, 60 patients of both sexes and over the age of 18 yr diagnosed as having tennis elbow and 40 diagnosed as having plantar fasciitis were selected based on following:

 

Inclusion Criteria for Tennis Elbow

  1. Pain and tenderness over the lateral aspect of the elbow.
  2. One of the following tests being positive: wrist extension (Cozen’s test), Mill’s maneuver, jar lifting test, wringing test, broom, or stir frying test.

 

Inclusion Criteria for Plantar Fascitis

  1. Pain in the inferior aspect of heel that is usually worse with their first steps in the morning or after a period of inactivity (with maximal tenderness over the anterome- dial aspect of the inferior heel).
  2. Increased pain on passive dorsiflexion of foot.

 

Overall Exclusion Criteria

  1. Patients with history of anemia (hemoglobin < 7.0 g/dL).
  2. Thrombocytopenia (platelets < 150 103 mL).
  3. Pregnancy.
  4. Local malignancy.
  5. Local corticosteroid injections for lateral epicondylitis in previous 1 mo.
  6. Rheumatoid disease and previous surgery or elbow dislocation.
  7. Diabetes mellitus.

In both tennis elbow and plantar fasciitis NSAID’s were avoided for 1 wk before and after the procedure.

 

Method of Data Collection

Data were collected by verbal communication with patients, including their informed consent when the clinical exami- nation was done. Blood investigations like complete blood picture (CBP), clotting time (CT), bleeding time (BT), and random blood sugar (RBS) were done. Written documenta- tion of pain (VAS) and evaluation of limitation of function (DASH and FHSQ) was done before and after the procedure.

 

Preparation of PRP

Blood was drawn from the patient in a syringe (10 mL) preloaded with citrate phosphate dextrose (CPD) and later centrifuged in two spins. The first spin was at 1800 rpm for 15 min to separate erythrocytes and white blood cells from other blood components and a second spin was at 3500 rpm for 10 min for further concentration of platelets. About 2 to 3 mL of platelet rich plasma was pipetted out and injected into the affected site. In our study we found an increase of platelets to three to five times from baseline.

 

 

FIGURE 1. Tennis elbow participants (24 men and 36 women).

 

Procedure

The patient is placed supine and the site is palpated for maximal point of tenderness before giving a local anaes- thetic. Under strict aseptic precautions local anaesthetic (2% xylocaine) followed by PRP is then injected into the affected site with a 18-guage needle, and patient is advised to rest in the outpatient block for approximately 1 hr.

In cases of tennis elbow, the affected hand of the patient is immobilized in elastic crepe bandage and cuff and collar for 48 to 72 hr and the patient is strictly advised not to lift weights or participate in activities that involve wrist extension. In cases of plantar fasciitis, a crepe bandage is applied, and the patient is advised to use micro-cellulose rubber footwear and avoid sports and athletic activities for 48 to 72 hr. After 3 days, the crepe bandage is removed, and the patient is allowed to do daily activities. After the procedure, the patient is prescribed broad spectrum antibiotics (cephalosporins) for 3 days. All NSAIDS are strictly avoided for 7 days after the procedure.

Patients with tennis elbow and plantar fasciitis were evaluated at 1 mo, 2 mo, 3 mo, and 6 mo after injection using the VAS and DASH scores (for tennis elbow) and VAS and FHSQ scores (for plantar fasciitis). One month after injection of PRP, the patients were assessed and if there was no sign of improvement (less than 25% reduction in VAS, DASH AND FHSQ score),10 PRP injection was repeated twice with a gap of 1 mo between each. If no improvement was seen, after a period of 6 mo from the third injection, surgery was considered.

RESULTS

The mean age of the tennis elbow group was 40.5 ± 15.5 yr, and it included 24 men and 36 women and plantar fasciitis group was 42.5 ± 17.5 yr and it included 16 men and 24

women (Figures 1 and 2).

Table 1 compares the mean VAS (Figure 3) and DASH (Figure 4) scores in tennis elbow patients during their first visit and at 1 mo, 2 mo, and 3 mo. Highly significant results

 


FIGURE 2. Plantar fasciitis participants (16 men and 24 women).

 

were observed between the scores at first visit and later
visits, i.e., 4 wk and after 8 wk (P < 0.001).
Table 2 compares the mean VAS (Figure 3) and FHSQ
(Figure 4) scores in plantar fasciitis during the first visit and
at 1 mo, 2 mo, and 3 mo. Highly significant results were
observed between the scores at first visit and later visits, i.e.
4 wk and 8 wk (P < 0.001).
There were four cases of tennis elbow and two cases of
plantar fasciitis that were not successful after 1 mo of
injection. Out of these, two patients with tennis elbow
and one with plantar fasciitis injection had repeated
injections and results were successful. The other three
patients did not agree to have a second injection.

DISCUSSION
The current study strongly suggests that local injection of
PRP is a novel form of treatment that provides significant
relief of pain and improvement in function in both tennis
elbow and plantar fasciitis. Moreover, it is possibly a safer
option for patients than steroid use and surgery. The
proposed mechanism of action of autologous PRP is
improvement of early neotendon properties26 and improvement of tissue healing by enhancing cellular chemotaxis,
proliferation and differentiation, removal of tissue debris,
angiogenesis and laying of extracellular matrix.27
Relative to tennis elbow, our results are similar to those
described by Mishra and Pavelko28 who reported a significant
improvement of symptoms after 8wk in 60% of the patients
treated with PRP. At the end of 6mo, patients treated with PRP
noted 81% improvement in their VAS pain scores (P¼ 0.0001).
Our results also are in agreement with that observed by
Peerbooms et al.10 who reported that 24 of the 49 patients
(49%) in the corticosteroid group and 37 of the 51 patients (73%)
in the PRP group were successful (P< 0.001). Furthermore, in
their study based on improvement on the DASH scores, 25 of the
49 patients (51%) in the corticosteroid group and 37 of the 51
patients (73%) in the PRP group were successful (P¼ 0.005); both
these studies offer encouraging results of an alternative minimally invasive treatment that addresses the pathophysiology of
tennis elbow for which traditional nonsurgical modalities failed.
In our study, we observed highly significant differences
between VAS and DASH scores before and after injection
(P < 0.001); after 4 to 8 wk after injection, 75% patients had
excellent VAS score improvement (> 50% reduction) and
around 62% had reduction of DASH score (> 50%).
Relative to plantar fasciitis, Martinelli et al.29 demonstrated at 12 mo follow-up excellent results in 9 of 14
(64.3%) patients with chronic plantar fasciitis who received
three injections of PRP into the plantar fascia, good results
in two (14.3%), acceptable results in two (14.3%), and a poor
result in one (7.1%) according to the Roles and Maudsley
score. VAS for pain was significantly decreased from 7.1 ± 1.1
before treatment to 1.9 ± 1.5 at the last follow-up (P < 0.01)29
In another study conducted by Barret et al.30 in which PRP
injection was given under ultrasound guidance, complete
pain relief was seen up to 1 yr in 77.8% of patients, and
reduced thickness was observed.
In our study, significant results were observed when VAS and
FHSQ were compared before and after injection (P< 0.003);
82% patients had a decrease in VAS score (> 50%) and around
60% had improvement in FHSQ score (> 50%).
In conclusion, local injection of autologous PRP appeared
to be a promising form of therapy for tennis elbow and
plantar fasciitis. It is both safe (avoiding surgical complications) and effective in relieving pain and improving
function. It is a cost effective procedure for the patients.
The current available data support that repeated steroid
injections are deleterious and may lead to serious consequences, and our study demonstrates a newer, safer, and
better alternative for patients. However sustained efficacy of
this promising and safer therapeutic option should be
further evaluated in long-term follow-up studies that
include a larger number of patients.

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