Chronic lateral epicondylosis (CLE) accounts for 4-7 out of every 1, 000 primary care office visits annually. More commonly known as tennis elbow, CLE is often a misnomer because the disease is not necessarily more common in tennis players. In fact the prevalence of CLE in industrial workers is 30% of all cases with symptoms lasting from six months to two years, regardless of therapy.
Tennis elbow is a noninflammatory condition. Characteristically, it entails collagen degeneration, mucoid degeneration, fibroblast proliferation, and neovascularization. Traditional treatment is rest, physical therapy, nonsteroidal anti-inflammatory drugs, and, in the most severe cases, surgery. Corticosteroid injections can be effective in the short-term, but many physicians suggest a “wait and see” approach is more reasonable since tennis elbow is understood to be a self-limited condition.
Doctors from the University of Wisconsin and Griffith University studied the use of prolotherapy (PrT), which is an injection-based therapy to treat chronic musculoskeletal pain and tendinopathy including patients suffering from CLE.
Investigators in the study were: Dr. David Rabago, Dr. Aleksandra Zgierska, Jessica Grettie, Dr. John Wilson, Daniel Miller, Dr. Ken S. Lee, Dr. Rick Kijowski, Dr. Mary E. Sesto from the University of Wisconsin School of Medicine and Public Health; Dr. Amrish O. Chourasia from the University of Wisconsin’s Department of Biomedical Engineering; and Dr. Michael Ryan from Griffith Health Institute in Australia. The study’s title is: “Hypertonic Dextrose and Morrhuate Sodium Injections (Prolotherapy) for Lateral Epicondylosis (Tennis Elbow)” and it was published in the July 2013 issue of the American Journal of Physical Medicine & Rehabilitation.
The study was a three-arm randomized control trial. Group 1 received ultrasound-guided PrT with dextrose solution (PrT-D). Group 2 received ultrasound-guided PrT with dextrose-morrhuate sodium solution (PrT-DM). Group 3 was the “wait and see” group.
All 26 patients (32 elbows) were diagnosed with self-reported lateral elbow pain for three months or longer and had failed one of the three most common treatments for CLE, nonsteroidal anti-inflammatory drugs, physician-initiated physical therapy, or corticosteroid injections before enrolling in the trial.
PrT-D and PrT-DM injections were given at 1, 4, and 8 weeks. With imaging from an ultrasound, up to 2.5 mL of the prepared PrT solution was “peppered” on the bone along the tendon and annular ligament in the sensitive areas. After 16 weeks, the “wait and see” group was offered PrT injection and exited from the study. The other two PrT groups were kept and evaluated again at 32 weeks after entry.
The outcomes test was Patient-Rated Tennis Elbow Evaluation (PRTEE).
Primary endpoint was change in the composite PRTEE score. Secondary endpoint was pain-free grip strength and magnetic resonance imaging severity.
How did PrT do? Patients receiving the PrT-D or PrT-DM showed significantly higher PRTEE scores versus baseline. The amount of PRTEE improvement in both PrT groups was statistically significant 16 weeks, while the “wait and see” group’s scores were not.
Furthermore, PrT-D patients had the greatest grip-strength versus PrT-DM and “wait and see” patients. There was no difference in magnetic resonance imaging severity score. A tertiary outcome was treatment satisfaction rating and most patients reported being “very satisfied” or “satisfied.”
