Elbow tendinitis is typically an overuse injury, stemming from repetitive motions that strain the tendons connecting your forearm muscles to your elbow. The primary symptom is a persistent ache in your elbow joint.

While people often use the term “elbow tendinitis” generally, there are two main types, distinguished by where the pain occurs. The most common is lateral epicondylitis, better known as tennis elbow. This condition causes pain on the bony bump on the outside of your elbow. The other type is medial epicondylitis, or golfer’s elbow. As the name suggests, this condition causes pain on the inside of your elbow. This pain isn’t always confined to the joint; it can often radiate down into your forearm and even reach your wrist, making many daily movements difficult and uncomfortable.

Platelet Rich Plasma therapy extracts platelets from your blood and then re-injects the Platelet-Rich Plasma into the injured elbow. The research below from leading medical universities and research centers from around the world helps confirm our own observations of these treatments.

A September 2023 paper (1) wrote: “Platelet-rich plasma (PRP) is probably the most widely used orthobiologic treatment modality for the conservative management of tendon, muscle and cartilage injuries. Its effectiveness depends on the underlying pathology and the affected body region. The best evidence exists for the treatment of patellar tendinitis (“jumper’s knee”) and epicondylitis humeri radialis (“tennis elbow”).”

PRP research

darrow elbow1
darrow elbow1

As discussed throughout this article, PRP treatment for tennis elbow is looked upon even by doctors who use it as a a controversial treatment for elbow pain. A November 2021 study (2) demonstrates this with the results of a survey that was sent to European doctors who use PRP. What they found was the controversy was not so much over if PRP worked, but how it could work better. This survey showed that

“Consensus of agreement (among the doctors who use the treatment) was only reached for 17/40 (42.5%) statements. For statements on PRP formulation, consensus of agreement was reached in 2/6 statements (33%). Only limited consensus on the contraindications, delivery strategy and delivery technique was achieved.”

In this article I am demonstrating research that suggests when PRP would work, when it would not work. Many times that the treatment does not work is not in the treatment itself, but in the application. How was the treatment given, how was the solution prepared.

A May  2023 paper (3) followed up by suggesting: “the use of orthobiologics, such as platelet-rich plasma (PRP), has been proposed to promote tendon regeneration and is supposed to be a valuable treatment option. However, scientific data are conflicting and the short- and long-time results are controversial.”

PRP injections vs. Cortisone

There are many research papers that compare cortisone or steroid injection and PRP treatments.

The results of a comparative June 2023 study (4) found PRP injections to have more long-lasting benefits than cortisone in cases of Lateral Elbow Tendinopathy. In this study of 64 patients, 29 were men and 35 were women, average age was 40 years with a range from 22 to 60 years two groups were created; a group that would receive an ultrasound guided PRP injection and a group that would receive an ultrasound guided cortisone injection.

The researchers used three scoring surveys to gauge the treatment progress.

The DASH (Disabilities of the Arm, Shoulder and Hand) is a scored questionnaire with results measured in numbers. If a patient reports a 0 score – that means they have no disabilities. The maximum severe disability score is 100.

The Patient-Rated Tennis Elbow Evaluation (PRTEE)  score which is a measure that helps patients rate tennis elbow pain and disability levels from 0 to 10.

VAS Score (VAS) which asks patients to rate overall pain (0 = no pain; 10 = unbearable pain).
Here were the side by side comparisons:

  • VAS score PRP patients 1.25 (out of 10) better than 3.68 in the steroid group
  • DASH score PRP patients 4.00 better than 7.43 in the steroid group.
  • PRTEE score PRP patients 3.96 better than 7.53 in the steroid group.

Treatment was successful in 31 patients in the PRP group (96%), out of which 2 patients showed a recurrence due to an increase in VAS score after 6 months.

Treatment was considered improved in 12 patients in the steroid group, of which 4 showed recurrence in 6 months.

The study suggests that both PRP and steroid injections significantly improved the functional outcomes in terms of VAS score, DASH score, and PRTEE score.

“The response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis.”

In December 2018 a multi-national team of doctors wrote in the journal Current reviews in musculoskeletal medicine (5) compared PRP treatments to cortisone for tennis elbow. They wrote that:

“The response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis. PRP injection does not seem to have the potential complications associated with a steroid injection such as skin atrophy, discoloration, and secondary tendon tears.” They also noted that in comparison with extracorporeal shockwave, dry needling, or surgical treatments, (PRP injections in tennis elbow seems to be the best-studied intervention.”

  • University researchers in India suggest Platelet-rich plasma (PRP) offers a better option for the treatment of lateral epicondylitis. In a comparison of PRP and cortisone injections, the doctors say  PRP is a superior treatment option in the long-term. (6)
  • A second study published in the Indian journal of orthopaedics compared single injection of platelet-rich plasma for tennis elbow as compared with single injections of triamcinolone (corticosteroid) and placebo (normal saline) over a short term period.
    • Both the PRP and triamcinolone groups had better pain relief at 3 and 6 months as compared to normal saline group, but at 6 months followup, the PRP group had statistically significant better pain relief than triamcinolone group.
    • In the triamcinolone group, 13 patients had injection site hypopigmentation (loss of skin color) and 3 patients had subdermal (skin and subdermal fat layer) atrophy. (7)
  • In the journal The Physician and sports medicine, doctors found steroid could slightly relieve pain and significantly improve function of elbow in the short-term (2 to 4 weeks, 6 to 8 weeks). PRP appears to be more effective in relieving pain and improving function in the intermediate-term (12 weeks) and long-term (half year and one year). Considering the long-term effectiveness of PRP, the researchers recommend PRP as the preferred option for tennis elbow.(8)
  • Doctors from teaching universities in Thailand examined injections of cortisone, autologous blood injection (simple blood injection) and PRP.  What they found was the blood injection and the PRP injection provided superior results to cortisone for pain reduction and functional improvement. The autologous blood injection had a higher rate of site complication that was significant enough to note.(9)
  • A November 2019 study compared the effectiveness of Platelet Rich Plasma injections versus autologous blood injection (blood without making it Platelet Rich), and cortisone. The findings were “PRP was associated with more improvement in pain intensity and 29 function in the long-term than the comparators.”(10)

In a September 2023 comparison study (11), researchers suggested Exercise therapy was beneficial in decreasing pain regardless of dosage or type. Conflicting results were seen with ultrasound, laser, and shockwave therapy. Corticosteroid injections provided the most short-term pain relief, and platelet-rich plasma and autologous blood injections were most effective in the long term.

Long term-benefit of PRP vs Cortisone

  • Dutch researchers writing in the American Journal of Sports Therapies documented the positive effects of PRP on tennis elbow. Treatment of patients with PRP reduced elbow pain and increased function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years.”(12)
  • British doctors agree – research in the British Journal of Sports Medicine says cortisone should never be used and that injections therapies including PRP can be effective and excellent long-term treatments for elbow pain.(13)

A June 2021 study (14)  also examined the current evidence for the effectiveness of platelet rich plasma (PRP) injections versus corticosteroid injections as treatment interventions for tennis elbow. In this systematic review the researchers examined previously published papers evaluating PRP vs. corticosteroid injections as treatment methods for tennis elbow. Two independent researchers searched and screened for articles that were systematic reviews that directly compared PRP to corticosteroid injections injections for tennis elbow. The results were: Corticosteroid injections were more efficacious for short-term pain relief, and PRP injections were more efficacious for long-term pain relief and improved function. PRP injections appear to be a more effective long-term treatment option than corticosteroid injections for those with tennis elbows who did not respond to conservative management.

A September 2023 study (15) found cortisone injections had more impact in the first month of treatment, but PRP should superioir pain and disability outcomes at both 3 and 6 months follow ups. The study authors added that: “However, these findings must all be viewed with caution as the high risk of bias and moderate to low quality of the included studies may not justify a recommendation of one treatment over another.”

A March 2022 study (16) testing the effectiveness of PRP injections for tennis elbow. This study suggested: “Injection of PRP were, found to be effective in treating tendinopathy and arthritis. . . this “study was conducted to access the functional outcome of PRP injection in tennis elbow patients.” Results “In total, 80 individuals participated in (this) study, of which the average age of the participants was 45-54 There is statistical significance in the difference of means of pain score obtained using both VAS (visual pain score) and MAYO (function ability)  score at 12 weeks and 24 weeks.  . .  In tennis elbow patients, PRP injection shows an effective reduction in pain according to VAS and MAYO score and especially, younger age patients have shown more benefit in terms of pain reduction with PRP treatment.”

Long term-benefit of PRP vs Physical Therapy

In some of the more research reported in the surgical journal – Journal of Hand and Microsurgery (17) doctors reviewed and presented their evidence on the effectiveness of PRP injections. They found PRP injections have an important and effective role in the treatment of elbow instability. Here is what they wrote:

  • The majority of sufferers recover within 1 year with conservative management which includes physical therapy. The most effective treatment for chronic lateral epicondylitis, however, is argued amongst experts.
  • In the opinion of this study, after review of the literature, PRP injections have an important and effective role in the treatment of debilitating tennis elbow pathology, in cases where physical therapy has been unsuccessful.
  • Previously, cases that persisted despite physical therapy have been treated with corticosteroid injections. Steroid injections are reported to give short-term pain relief, however the proven recurrence rates and complications (including dermal depigmentation, subcutaneous atrophy, and a theoretical risk of increased tendon rupture) should limit their use.
  • PRP has been shown to provide a continuing long-term benefit in cases of chronic lateral epicondylosis, in the recent literature. It is superior to autologous blood injection injections and placebo/dry needling procedures.

A May 2023 paper (18) compared the effectiveness of platelet-rich plasma injections and ultrasonic tenotomy and debridement for lateral elbow tendinopathy. They found “Ultrasonic tenotomy and debridement and PRP both led to significant improvement in patient pain within the 12-week follow-up period. There was no significant difference in efficacy between the two procedures.”

A December 2022 study (19) suggested that Platelet-rich plasma (PRP) injections may alleviate symptoms of chronic medial or lateral epicondylitis. In this study, doctors retrospectively analyzed a total of 55 patients with chronic medial or lateral epicondylitis who had undergone at least 6 months of any conservative treatment before the PRP treatments.

The patients were divided into two groups: the PRP group (25 patients), who received a single injection of autologous PRP to the medial or lateral epicondyle, and the physical therapy group (30 patients), who continued with physical therapy and pain medication.

The primary outcome measures were pain and functional outcomes measured in terms of the following: Patient Related Tennis Elbow Evaluation (PRTEE), Visual Analogue Scale (VAS), and Disabilities of the Arm, Shoulder, and Hand (DASH), which were detected at pre-intervention, 6-, 12-, 24-, and 36-month follow-up.

Secondary outcomes included complications and the need for any surgery at follow-up.

Results: Primary outcome measurements showed significantly better results favoring the PRP group. The PRP group required significantly fewer surgical procedures at follow-up (about one year after treatment), and one case of prolonged pain after injection was detected.

Conclusions: “Patients who underwent PRP injections for epicondylitis resulted in better pain and functional outcomes compared to physiotherapy, and this improvement lasted at least 24 months. They required fewer surgical procedures and achieved faster recovery than the physical therapy group. We recommend PRP for chronic epicondylitis of the elbow before considering surgery when other treatments have failed.”

Ultrasound or palpitation to find the injection site?

A November 2022 paper (20) compared the effectiveness of palpation-guided and ultrasound (US)-guided platelet-rich plasma (PRP) injections in patients with chronic lateral epicondylitis. In this study, 60 patients diagnosed with chronic lateral epicondylitis were  randomly assigned to either the palpation-guided or the US-guided injection group before they received PRP injection. All patients were assessed using the Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH) scale, and grip strength at baseline and at one, three, and six months after injection.

The researchers found that statistically similar results between two groups. The VAS and DASH scores improved significantly after the injection at each control, as well as grip strength in both groups

A team of researchers in the United Kingdom wrote in the Journal of orthopaedics (21).

  • “Our study adds to the evidence that PRP injection for intractable lateral epicondylitis of the elbow is an acceptable and useful treatment with improvement in symptoms in 56 out of 64 patients (87.5%). It adds to the literature in that we have tried to ascertain the effect of PRP on reducing the need for a complex, risk laden, surgical intervention. . .we consider PRP injection, for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms and have shown it has reduced the need for surgical intervention in this difficult cohort of patients.”

Chronic elbow instability causing tennis elbows in people with physically demanding jobs and frequency of cortisone injections.

A study published in January 2021 (22) can offer evidence that strengthening and tightening the ligaments and tendons of the elbow can help with elbow pain. This is what the study said:

“Instability can coexist and may be associated with refractory lateral epicondylitis. The risk factors of instability associated with refractory lateral epicondylitis are heavy labor and multiple steroid injections.”

This is what I see in my patients. A person comes in with a history of elbow pain. They go to a few doctors, get the traditional treatments and do not get pain alleviation. Mostly in part because they continue at a job that is considered “heavy labor.” So they go onto get a few cortisone injections to help them at their jobs. The cortisone injections over time has lead to a wearing down or thinning of the ligaments and tendons of the elbow causing instability. Your bones are floating around in a hypermobile, unstable state and are compressing and impinging on nerves and other soft tissue. This instability is what PRP and stem cell therapy can address. By stabilizing the elbow, the tennis elbow pain can now be managed.

A February 2024 paper (23)  compared ultrasound guided dry needling  and ultrasound guided platelet rich plasma (PRP) for common tears of the common extensor tendon.

  • 40 patients diagnosed with lateral epicondylitis were randomly assigned to the two study groups (dry needling and PRP).
  • Results: There was significant improvement in the visual analogue scale pain score (0 – 10 self reported pan) in PRP group compared to the dry needling group at 9 months. However, this difference was not evident at 3 and 6 months follow-up. (PRP was more long-term). Average improvement in common extensor tendon thickness in PRP group  was slightly better than dry needling. There was no difference in tear (if present) healing between both groups at 3 months. However at 6 months follow up, PRP demonstrated significant healing in tear compared to dry needling.
  • Conclusion: “Two injections of Ultrasound guided PRP are more beneficial non operative treatment compared to ultrasound guided dry needling, in lateral epicondylitis.”

MRI validation of tendon recovery following PRP treatments

We are often asked if we suggest an MRI for patients following treatments. Usually the answer is no. If the treatment works then the evidence is in the patients pain and function improving. An August 2022 paper (24) did do after PRP treatment MRI. The MRI results of patients at 6 follow-up visits over a 2-year period after platelet-rich plasma injection in patients with lateral epicondylitis were assessed.

  • Thirty patients who underwent PRP treatment for lateral epicondylitis and sequential MRI evaluation were prospectively enrolled.
  • Significant improvements in the MRI scores occurred by 3 months and continued over a period of 24 months.
  • Continuous tendon recovery assessed by MRI was found during a 2-year period after PRP treatment. Improvements in the MRI scores followed and continued longer than improvements assessed by the clinical scores.

Other articles

Tennis elbow surgery research

References

1 Weishorn J, Spielmann J, Kern R, Mayer J, Friedmann-Bette B, Renkawitz T, Bangert Y. New treatment methods in competitive sports: What can we learn from the medical care of top athletes?. Orthopadie (Heidelberg, Germany). 2023 Sep 22.
2 Evans JP, Maffulli N, Smith C, Watts A, Valderas J, Goodwin V. Even experts cannot agree on the optimal use of platelet-rich plasma in lateral elbow tendinopathy: an international Delphi study. Journal of Orthopaedics and Traumatology. 2021 Dec;22(1):1-0.
3 Schmidt-Horlohé K. Therapie der lateralen und medialen Epikondylopathie. Die Orthopädie. 2023 Apr 13:1-8.
4 Kamble P, Prabhu RM, Jogani A, Mohanty SS, Panchal S, Dakhode S. Is Ultrasound (US)-Guided Platelet-Rich Plasma Injection More Efficacious as a Treatment Modality for Lateral Elbow Tendinopathy Than US-Guided Steroid Injection?: A Prospective Triple-Blinded Study with Midterm Follow-up. Clinics in Orthopedic Surgery. 2023 Jun;15(3):454.
5 Kwapisz A, Prabhakar S, Compagnoni R, Sibilska A, Randelli P. Platelet-Rich Plasma for Elbow Pathologies: a Descriptive Review of Current Literature. Current reviews in musculoskeletal medicine. 2018 Sep 25:1-9.
6 Yadav R, Kothari SY, Borah D.  Comparison of Local Injection of Platelet Rich Plasma and Corticosteroids in the Treatment of Lateral Epicondylitis of Humerus. J Clin Diagn Res. 2015 Jul;9(7):RC05-7. doi: 10.7860/JCDR/2015/14087.6213.
7 Seetharamaiah VB, Gantaguru A, Basavarajanna S. A comparative study to evaluate the efficacy of platelet-rich plasma and triamcinolone to treat tennis elbow. Indian journal of orthopaedics. 2017 May;51(3):304.
8 Mi B, Liu G, Zhou W, Lv H, Liu Y, Wu Q, Liu J. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. The Physician and Sportsmedicine. 2017 Apr 3;45(2):97-104.
9 Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2015 Sep 11.
10 Tang S, Wang X, Wu P, Wu P, Yang J, Du Z, Liu S, Wei F. Platelet-rich plasma versus autologous blood versus corticosteroid injections in the treatment of lateral epicondylitis: a systematic review, pairwise and network meta-analysis of randomized controlled trials. PM R. 2019 Nov 17. doi: 10.1002/pmrj.12287. [Epub ahead of print]
11 Kinney WR, Anderson BR. Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review. Journal of chiropractic medicine. 2023 Sep;22(3):204-11.
12 Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011 Jun;39(6):1200-8. Epub 2011 Mar 21.
13 Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, Kong FL, Welle K, Jiang ZC, Kabir K. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med. 2015 Sep 21. pii: bjsports-2014-094387. doi: 10.1136/bjsports-2014-094387.
14 Kemp JA, Olson MA, Tao MA, Burcal CJ. Platelet-Rich Plasma versus Corticosteroid Injection for the Treatment of Lateral Epicondylitis: A Systematic Review of Systematic Reviews. International Journal of Sports Physical Therapy. 2021;16(3):597.
15 Hohmann E, Tetsworth K, Glatt V. Corticosteroid injections for the treatment of lateral epicondylitis are superior to platelet rich plasma at 1 month but platelet rich plasma is more effective at 6 months: An updated systematic review and meta-analysis of level 1 and 2 studies. Journal of Shoulder and Elbow Surgery. 2023 May 27.
16 Paramanantham M, Seenappa H, Venkataraman S, Shanthappa AH. Functional Outcome of Platelet-Rich Plasma (PRP) Intra-lesional Injection for Tennis Elbow–A Prospective Cohort Study. Cureus. 2022 Mar 8;14(3).
17 Murray DJ, Javed S, Jain N, Kemp S, Watts AC. Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence. J Hand Microsurg. 2015 Dec;7(2):320-5. doi: 10.1007/s12593-015-0193-3. Epub 2015 Jul 8.
18 Rupe MW, Fleury IG, Glass N, Kruse R. Efficacy of Ultrasonic Tenotomy and Debridement and Platelet-Rich Plasma Injections for Lateral Elbow Tendinopathy. Journal of Hand Surgery Global Online. 2023 May 18.
19 Annaniemi JA, Pere J, Giordano S. Platelet-Rich Plasma Injections Decrease the Need for Any Surgical Procedure for Chronic Epicondylitis versus Conservative Treatment—A Comparative Study with Long-Term Follow-Up. Journal of Clinical Medicine. 2022 Dec 23;12(1):102.
20 Sağlam G, Alişar DÇ. Ultrasound-guided versus palpation-guided platelet-rich plasma injection for the treatment of chronic lateral epicondylitis: A prospective, randomized study. Archives of Rheumatology. 2023 Mar;38(1):67.
21 Hastie G, Soufi M, Wilson J, Roy B. Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention. Journal of orthopaedics. 2018 Mar 1;15(1):239-41.
22 Kholinne E, Liu H, Kim H, Kwak JM, Koh KH, Jeon IH. Systematic Review of Elbow Instability in Association With Refractory Lateral Epicondylitis: Myth or Fact?. The American Journal of Sports Medicine.:0363546520980133.
233 Sharma GK, Patil A, Kaur P, Rajesh S, Drakonaki E, Botchu R. Comparison of efficacy of ultrasound-guided platelet rich plasma injection versus dry needling in lateral epicondylitis—a randomised controlled trial. Journal of Ultrasound. 2024 Feb 23:1-7.
24 Suzuki T, Hayakawa K, Nakane T, Fujita N. Repeated magnetic resonance imaging at six follow-up visits over a 2-year period after platelet-rich plasma injection in patients with lateral epicondylitis. Journal of Shoulder and Elbow Surgery. 2022 Mar 2.