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The Egyptian Journal of Radiology and Nuclear Medicine 48 (2017) 403–413

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Original Article

Role of Ultrasound Guided Platelet-Rich Plasma (PRP) Injectionin Treatment of Lateral Epicondylitis

http://dx.doi.org/10.1016/j.ejrnm.2017.03.0020378-603X/� 2017 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Peer review under responsibility of The Egyptian Society of Radiology and NuclearMedicine.⇑ Corresponding author.

E-mail address: [email protected] (E.M. Khattab).

Enass M. Khattab ⇑, Mohamad H. AbowardaDepartment of Radiodiagnosis, Faculty of Medicine, Zagazig University, Egypt

a r t i c l e i n f o a b s t r a c t

Article history:Received 15 November 2016Accepted 4 March 2017Available online 27 March 2017

Keywords:UltrasoundInjection of PRPLateral epicondylitis

Background: Lateral epicondylitis is referred to a degenerative disorder that affects the common extensortendon (CET) where it attaches to the lateral epicondyle of the humerus. Nowadays, one of minimallyinvasive interventions is platelet-rich plasma (PRP) injection that had been explored in some controlledclinical studies to show its effectiveness in treating lateral epicondylitis through inducing inflammationrather than suppressing it.Objectives: The aim of our study was to investigate the effectiveness of ultrasound guided platelet-richplasma (PRP) injection in treating chronic lateral epicondylitis in addition to identifying the potentialsonographic morphological changes in the common extensor tendon (CET) after PRP injection.Results: Statistical analysis showed high significant improvement in all ultrasound findings of commonextensor tendon (CET) including echotexture, thickness, cross section, partial tear and calcification inmajority of patients.Conclusion: We concluded that US-guided platelet-rich plasma (PRP) injection for treatment of lateralepicondylitis was a safe, minimally invasive and effective procedure in improving the sonographic andpathological changes of common extensor tendon (CET).� 2017 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier. Thisis an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/

4.0/).

1. Introduction However, medications like non-steroidal anti-inflammatory

Lateral epicondylitis is referred as a degenerative disorder thataffects the common extensor tendon (CET) where it attaches to thelateral epicondyle of the humerus [1].

Waseem et al. [2] explained that this condition is not an inflam-matory process with no inflammatory cells (e.g. macrophages, lym-phocytes or neutrophils) could be detected in the affected tissue.But, it is a form of tendinosis that affects the common extensor ten-don with a fibroblastic and vascular response called angio-fibroblastic degeneration of CET. Moreover, tennis elbow (TE) isconsidered a misnomer since tennis player account for only about5% of all patients suffering from this condition. That make ‘‘lateralepicondylosis” or ‘‘lateral elbow tendinosis” is themost appropriateterm that express that condition. Despite of this lateral epicondyli-tis is more recognized and widely used in the scientific community.

The annual prevalence of lateral epicondylitis is about 1–3% ofpopulation that induces morbidity secondary to pain and functiondisability that prevents an active life style [3].

drugs (NSAIDS), physical therapy, shock wave therapy, botulismtoxin injection and corticosteroids injection were used to treat lat-eral epicondylitis many studies showed that they did not alter poorhealing of the CET and had long term course of treatment. In addi-tion, adverse side effects of long-run use of NSAIDs like bleedingulcers and renal failure and those of corticosteroids like tendonatrophy and permanent structural changes, make these types oftreatments controversial [4].

Nowadays, minimally invasive interventions that stimulatehealing response and counteracting the degenerative structuralchanges in lateral epicondylitis have been investigated. One of theseemerging technologies is platelet-rich plasma (PRP) injection [5].

Platelet-rich plasma is a volume of the plasma fraction of autol-ogous blood having a platelet concentration of 5 times more thanbase line (5 � 200,000 platelets/ul). Platelets in PRP contain growthfactors and build up reparative processes. The action of PRPtherapy in chronic tendinopathies is varied and hypothesized toinclude angiogenesis, increase in growth factor expression and cellproliferation, increase the effect of repair cells and tensile strength.Lateral epicondylitis may be characterized by complex changes inthe tendon in addition to an inflammatory process. Therefore,

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404 E.M. Khattab, M.H. Abowarda / The Egyptian Journal of Radiology and Nuclear Medicine 48 (2017) 403–413

PRP owing to its high content of various growth factors may bemore effective as a healing agent [5].

Diagnostic ultrasound and MRI before PRP injection will help toconfirm clinical diagnosis and establish baseline findings.Ultrasound guidance of the injection will ensure precise targetingof tissue needle placement and real-time visualization of needleduring injection with documentation of changes in tendon mor-phology & structure after PRP injection [6].

US is an excellent option for diagnostic imaging evaluation oflateral epicondylitis, with a reported sensitivity of approximately80% and specificity of approximately 50%. Tendinosis appears astendon enlargement and heterogeneity. Tendon tears are depictedas hypoechoic regions with adjacent tendon discontinuity. Sur-rounding fluid and calcification also may be seen [7].

The normal MR imaging appearance of the CET is that of a ver-tically oriented structure that originates from the lateral epi-condyle. The tendon should show uniform low signal intensity,regardless of the imaging sequence used. Tendon morphology isbest assessed on coronal and axial images. The MR imaging find-ings of lateral epicondylitis on both T1- and T2-weighted imagesinclude intermediate signal intensity within the substance of thetendon with or without tendon thickening. Partial thickness tearsare seen as a region with the signal intensity of fluid extendingpartway across the tendon [8].

The aim of the present study is to investigate the effectivenessof ultrasound guided (PRP) injection in treating chronic lateral epi-condylitis in addition to identify the potential sonographic mor-phological changes in the CET after PRP injection with respect tothe baseline sonographic findings.

2. Patients and methods

2.1. Technical design

2.1.1. Site of the study, sample size and methods of collection ofpatients

Forty-two patients (31 females and 11 males), were included inthe study with age range from 30 to 50 years old (median of age

Table 1Symptoms before and 6 months after treatment.

Symptoms Before treatment (N = 42) 6 mon(N = 4

No. % No.

Impaired gripNo 0 0% 16Yes 42 100% 26

Restricted daily activitiesNo 0 0% 9Yes 42 100% 33

PainNo 0 0% 16Yes 42 100% 26

PRTEE pain subscaleMean ± SD 29.97 ± 10.35 19.92Median (range) 29.50 (12–47) 18 (6–

PRTEE function subscaleMean ± SD 30.38 ± 11.02 20.30Median (range) 30 (11–48) 19.50

PRTEE total scoreMean ± SD 60.35 ± 21.36 40.23Median (range) 59.50 (23–95) 37.50

p < 0.05 is significant.Sig.: significance.

a Wilcoxon signed ranks test.§ McNemar test.

38 years old).The mean time of symptoms was19.95 months(range 3–36 months). Patients were diagnosed, treated and fol-lowed up in the ultrasound unit in the Radiology Department bysonographic assessments at baseline diagnosis, during injectionof PRP, three and six months post procedure.

2.1.2. Subjects included in the study

� Inclusion criteria:1. All patients were suspected to have chronic lateral epi-

condylitis as determined on clinical examination (based onsymptoms, site of tenderness and pain elicited with resistedactive extension of the wrist in pronation and elbow inextension) and confirmed with base line ultrasonographicexamination and MRI examinations.

2. History of at least two periods of elbow pain lasting>10 days; symptoms lasting at least 3 months or longer.

� Exclusion criteria:1. Patients with normal base line ultrasonographic imaging.2. Presence of full tendon tear.3. Patients received local steroid injection within 3 months of

randomization;4. Patients received oral non-steroidal anti-inflammatory or

corticosteroids within 15 days before inclusion in the study.5. Patients unable to comply with scheduled visits.6. History of trauma.7. Medical history of rheumatic disorder.

� All patients were subjected to:1. Full history taking.2. Clinical evaluation of all patients at baseline, they were

asked to rate their levels of pain and function disability from0 to 10 according to a validated questionnaire called PRTEEQuestionnaire (Patient Rated Tennis Elbow Evaluation). Itconsists of two subscales, PAIN subscale (0 = no pain,10 = worst imaginable) and FUNCTION subscale (0 = no diffi-culty, 10 = unable to do). In addition to the individual sub-scale scores, a total score was computed on a scale of 100(0 = no disability) where pain and functional problems areweighted equally [9]

ths after treatment2)

Test p-value (Sig.)

%

38.1% 19.765§ <0.001 (HS)61.9%

21.4% 10.080§ <0.001 (HS)78.6%

38.1% 19.765§ <0.001 (HS)61.9%

± 11.61 �5.306a <0.001 (HS)48)

± 11.31 �5.297a <0.001 (HS)(4–48)

± 22.79 �5.382a <0.001 (HS)(10–96)

E.M. Khattab, M.H. Abowarda / The Egyptian Journal of Radiology and Nuclear Medicine 48 (2017) 403–413 405

3. The pre-procedure gray scale images were classified at base-line according to echotexture grading scale system of a studyprotocol reported by Martin et al. [10] which divided lateralepicondylitis echotexture into grade 1(a), 1(b), 1(c), 2 and 3.Grade 1(a): hypoechoic lesion less than one third of CETGrade 1(b): hypoechoic lesion between one third and twothirds of the tendon. Grade 1(c): hypoechoic lesion more thantwo thirds of CET Grade 2: presence of partial tear. Grade 3:presence of complete tear. As a protocol of the study, weconsidered grade 1a and 1b as mild cases, grade 1c and 2 asmoderate cases and grade 3 as severe cases.

4. Radiological evaluation at baseline by ultrasonographicexamination of the affected elbow was confirmed by MRIexamination before PRP injection.

5. MRI was performed to all patient at baseline and six monthspost procedure to confirm the sonographic findings. The pre-procedure MRI findings were including presence of tendon

Table 3US findings before and 6 months after treatment.

U/S findings Before treatment (N = 42) 6 mon(N = 4

No. % No.

TextureFocal 24 57.1% 38Diffuse 18 42.9% 4

Grade1a 0 0% 161b 8 19% 211c 18 42.9% 42 16 38.1% 1

Thickness of tendon (mm)Mean ± SD 7.87 ± 1.07 7.26 ±Median (range) 7.94 (5.27–9.70) 7.24 (

Cross sectional (mm2)Mean ± SD 80.34 ± 15.59 69.85Median (range) 81.37 (53.6–115.2) 68.51

Tendon tearNo tear 26 61.9% 41Partial tear 16 38.1% 1

CalcificationAbsent 30 71.4% 36Present 12 28.6% 6

Degree of tendinosisMild 8 19% 36Moderate 18 42.9% 5Severe 16 38.1% 1

p < 0.05 is significant.Sig.: significance.

* Paired t-test.a Wilcoxon signed ranks test.

§ McNemar test.� Chi-square test.

Table 2Signs before and 6 months after treatment.

Signs Before treatment (N = 42) 6 months(N = 42)

No. % No.

Tenderness over lateral epicondyleAbsent 0 0% 23Present 42 100% 19

Resisted wrist extension testAbsent 0 0% 16Present 42 100% 26

p < 0.05 is significant.Sig.: significance.§ McNemar test.

thickening, abnormal signal intensity or a fluid filled gap inT2WI and STIR sequences. According to these findings weclassify the lateral epicondylitis into three grades (mild: ten-don thickening with abnormal intermediate signal intensityat T2 weighted images, moderate: tendon thickening withabnormal high signal intensity involving less than two thirdsof tendon thickness, severe: tendon thickening with abnor-mal high signal intensity involving more than two thirds oftendon thickness) [11].

6. A single injection of platelet-rich plasma (PRP) guided byultrasonography after written consent was performed toall the patients.

2.1.3. Preparation of PRPBlood was extracted from the patient in a 10 ml syringe, pre-

loaded with citrate phosphate dextrose (CPD) and then centrifugedfor 15 min at 3500 rpm to separate and concentrate the platelets

ths after treatment2)

Test p-value (Sig.)

%

90.5% 12.070§ 0.001 (S)9.5%

38.1% 43.972� <0.001 (HS)50%9.5%2.4%

1.10 �18.126* <0.001 (HS)4.80–9.63)

± 17.21 �5.283a <0.001 (HS)(43.95–122)

97.6% 16.594§ <0.001 (HS)2.4%

85.7% 17.500§ 0.031 (NS14.3%

85.7% 38.401� <0.001 (HS)11.9%2.4%

after treatment Test p-value (Sig.)

%

54.8% 31.672§ <0.001 (HS)45.2%

38.1% 19.765§ <0.001 (HS)61.9%

Fig. 1. Diagram showing clinical re-evaluation findings during follow up sessions.

Fig. 2. Changes in tendon thickness, cross section area, calcification and number of partial tear during ultrasound follow up sessions.

Table 4MRI findings before and 6 months after treatment.

MRI findings Before treatment (N = 42) 6 months after treatment(N = 42)

Test p-value (Sig.)

No. % No. %

Tendon thickeningAbsent 0 0% 5 11.9% 5.316§ <0.001 (HS)Present 42 100% 37 88.1%

T2WI and STIR signal intensityIntermediate 26 61.9% 41 97.6% 1.665§ <0.001 (HS)High 16 38.1% 1 2.4%

Degree of tendinosisMild 8 19% 37 88.1% 40.833� <0.001 (HS)Moderate 18 42.9% 4 9.5%Severe 16 38.1% 1 2.4%

p < 0.05 is significant.Sig.: significance.§ McNemar test.� Chi-square test.



from other blood components. Then 2 mL of platelet-rich plasma(with absolute platelet count of 1 million platelets/mm3 as con-firmed by manual counting) was injected into the affected site.

2.1.4. Procedure of injectionThe patient is placed supine with affected upper limb in neu-

tral position, the site is palpated for maximum point of tender-ness before giving a local anaesthetic. Under complete aseptic

Fig. 3. Changes in the degree of tendinosis

Case 1. Mild degree of lateral epicondylitis. A male patient 38 years old age with long hscore was (29) that improved to (10) six months post-injection of PRP. H = Humerus, REpicondyle, Cap = Capitellum. A. Pre injection: A1: Longitudinal US scan: of left lateral elthan 2/3 of the tendon, and osteophyte formation (purple arrow) suggesting grade 1b(65.87 mm2), red arrow showed cross section of the hypo-echoic area (28 mm2) consisteaxial T2WI of left elbow: showed intermediate signal intensity at the site of CET (red arroof the tendon, yellow arrows showed (22-gauge, 1.5 in. needle), red arrow showed theinjection: C1, C2 and C3: MRI coronal T2WI, STIR, and axial T2WI of left elbow six month

precautions local anaesthetic injection (2% xylocaine) was donefollowed by PRP injection into the affected site with 18-guageneedle, the patient is advised to rest for approximately 1 h afterthe procedure.

7. Patients were informed about the post procedure protocol.They were rescheduled for a follow up appointment three andsix months after PRP injection.

during ultrasound follow up sessions.

istory of left lateral elbow pain for more than 10 months. Total pre-injection PRTEE= Radius, U = Ulna, CET = Common Extensor Tendon, RH = Radial Head, LE = Lateralbow region showed thickening of CET (6.64 mm), heterogeneity (red arrow) of lesslateral epicondylitis. A2: Transverse US scan: showing cross section of the tendonnt with grade (1b) lateral epicondylitis. A3, A4 and A5: MRI coronal T2WI, STIR, andw). B. During injection: US of CET during needle placement into the abnormal areasheterogeneous hypoechoic area & purple arrow showing the osteophyte. C. Post

s post injection showed decrease of signal intensity at the site of CET (green arrow).

Case 1 (continued)


8. Final radiological and clinical follow up of the affected elbowwere performed six months after PRP injection with compar-ison between both pre and post procedure clinical and radiolog-ical findings.

2.2. Post-procedure protocol

Patients were educated for short-term and long-termexpectations:

1. PRP injection promotes local inflammation, so we told themthat pain should be expected, and can be treated with ice andnarcotic prescription such as Acetaminophen.

2. Anti-inflammatory drugs (NSAIDs) should be avoided for atleast two weeks.

3. Physical therapy should be avoided at least two weeks after theprocedure.

4. Gradual return to activity over 6–8 weeks.

2.3. Follow-up program

All patients were evaluated at baseline clinically and radiologi-cally (US & MRI). The following visit was after three months,patients were re-evaluated clinically and sonographically and find-ings were recorded.

Final follow up was done after six months with post procedureclinical and radiological re-evaluation and recording the findings.

1. Clinical reevaluation by:– Answering PRTEE Pain Subscale Questionnaire.


– Answering PRTEE Function Subscale Questionnaire.– Computing the total PRTEE Total Score where pain and func-

tion equally weighted.2. Radiological re-evaluation by:

– Ultrasound.– MRI.

2.4. Statistical analysis

All data were collected, tabulated and statistically analyzedusing SPSS 19.0 for windows (SPSS Inc., Chicago, IL, USA) &

Case 2. Moderate degree of lateral epicondylitis. A female patient 35 years old age withPRTEE score was (56) that improved to (22) six months post-injection of PRP. A. Pre-injec(red arrow) of more than 2/3 of the tendon, osteophyte formation (purple arrow) &corticCET showing cross section of the tendon (108 mm2), and cross section of the hypo-echoicand A5: MRI coronal T2WI, STIR and axial T2WI: showed intermediate signal replacing tDuring PRP injection: US of CET during needle placement into the abnormal area. C: Posthickness of CET into (6.4 mm) with reduction of the hypoechoic heterogeneous area (decrease both cross section of the tendon into (89 mm2) and cross section of the hypoecmonths post-injection: showed marked decrease in the signal intensity into intermedia

MedCalc 13 for windows (MedCalc Software bvba, Ostend,Belgium).

Quantitative data were expressed as the mean ± SD & median(range), and qualitative data were expressed as absolute frequen-cies ‘‘number”& relative frequencies (percentage).

Continuous data were checked for normality by using ShapiroWalk test. Paired t-test was used to compare two dependentgroups of normally distributed data while Wilcoxon signed rankstest was used for non-normally distributed data.

Percent of paired categorical variables were compared usingChi-square test or McNemar test when appropriate. All tests weretwo sided.

long history of left lateral elbow pain for more than 12 months. Total pre-injectiontion: A1: Longitudinal US scan: showed thickening of CET (7.64 mm), heterogeneityal irregularity of the lateral epicondyle surface. A2: Transverse US scan: of the samearea (78 mm2), findings were consistent with grade (1c) lateral epicondylitis. A3, A4he whole thickness of CET extending from the cortical surface of LE (red arrow). B:t injection: C1: Longitudinal US scan six months post injection: showed decreasedgreen arrow) into less than 1/3 of total thickness. C2: Transverse US scan showedhoic area into (24 mm2). C3, C4 and C5: MRI coronal T2WI, STIR, and axial T2WI sixte signal (green arrow) at the site of CET.

Case 2 (continued)


P < 0.05 was considered statistically significant (S), p < 0.001was considered highly statistically significant (HS), and p � 0.05was considered non statistically significant (NS).

3. Results

All the patients (42 patients) included in the study were diag-nosed as lateral epicondylitis. The studied group related to a med-

ian age of 38 years old (range 30–50 years). They were 31 Females(73.8%) and 11 males (26.2%).The right arm (54.8%) was moreaffected than the left one (45.2%).

At the baseline 42 patients were classified sonographycally as19% mild cases (8 patients grade1b), 42.9% moderate cases (18patients grade 1c) and 38.1% severe cases (16 patients grade 2).Six months post procedure, degrees of the disease improved into85.7% mild cases (16 patients grade 1a and 21 patients grade 1b),


11.9% moderate cases (4 patients grade 1c) and 2.4% severe cases (1patient grade 2).These results were considered to be highly signif-icant improvement in the degree of the disease.

Table 1 showed that all patients were complaining of impairedgrip, restricted daily activities, and pain which all showed high sig-nificant improvement after treatment by PRP. Statistical analysisrevealed high significant decrease in PRTEE pain subscale sixmonths after treatment by PRP.

Table 2 showed at baseline, all patients had showed tendernessover lateral epicondyle and resisted wrist extension on clinicalexaminations, both signs showed high significant improvementafter treatment by PRP (p < 0.001). Six months post procedure, ten-derness over lateral epicondyle was relieved in 54.8% 0f patientsand resisted wrist extension improved in 38.1% of patients duringclinical examination.

Table 3 showed high significant improvement in all ultrasoundfindings of common extensor tendon CET in majority of patients.There was high significant improvement in the degree of the dis-ease. There was high significantly decrease in tendon thicknessfrom mean of 7.87 mm at baseline to 7.26 mm six months postprocedure (about 6.8% reduction) (p < 0.001). There was high sig-nificantly decrease in cross sectional area of CET from mean of80.34 mm2 at baseline to 69.85mm2 at six months post procedure(about 13.06% reduction) (p < 0.001). There was high significantlydecrease in number of partial tears from 16 case presented withpartial tear at baseline to just one case still preserve the partial tearafter six months (about 93.7% reduction) (p < 0.001). Calcificationwas decreased from 12 case at baseline to 6 cases at six months

Case 3. ‘‘Partial tear of common extensor tendon origin”. A female patient 37 years old ainjection PRTEE score was (79) that improved to (37) six months post-injection of PRP. ATransverse US scan: showed cross section of the CET (107 mm2), cross section of anecepicondylitis. A3, A4 and A5: MRI coronal T2WI, STIR and axial T2WI: showed high fluidarrow). B: During injection: US of CET during needle placement into the abnormal aredecreased thickness of CET into (6.28 mm) with the anechoic partial tear replaced by hetTransverse US scan showed decrease of both cross section of the tendon into (82 mm2) &ccoronal T2WI, STIR and axial T2WI showed marked decrease in high signal intensity int

post procedure (about 50% reduction), the difference was consid-ered highly significant by statistical analysis.

Table 4 showed a high statistically significant improvement indegree of tendinosis, signal intensity, and reduction of tendonthickness detected by MRI. Statistical analysis showed high signif-icant reduction in tendon thickening by MRI in 11.9% of tendons.Statistical analysis showed high significant improvement in signalintensity from 61.9% intermediate signals (8 cases (19%) of milddegree, 18 cases (42.9%) of moderate degree and 16 cases (38.1%)of severe degree at baseline, into 37 cases (88.1%) mild degree, 4cases (9.5%) of moderate degree and 1 case (2.4%) of severe degreeat six months post procedure.

Fig. 1 showed that during follow up sessions, the median ofPRTEE pain subscale was decreased from 29.50 (Range 12–47) to25.50 (Range 10–48) after three months. At six months post proce-dure, the pain subscale median decreased into 18 (Range 6–48).

During follow up sessions, the median of PRTEE functionsubscale was decreased from 30 (Range 11–48) to 26.50 (Range9–48). Six months post procedure, the function subscale mediandecreased into 19.50 (Range 4–48). PRTEE function subscaleshowed high significant improvement (p < 0.001) in 80% ofpatients six months post procedure. The mean at the base linewas 30.38 and six months post procedure it decreased into20.30.that was considered highly significant by statistical analysis.

During follow up sessions, PRTEE total score after three months,the median was decreased from 59.50 (Range 23–95) to 52 (Range19–96). Six months post procedure, PRTEE total score mediandecreased into 37.50 (Range 10–96). PRTEE pain subscale showed

ge with long history of right lateral elbow pain for more than 15 months. Total pre-: Pre-injection: A1: Longitudinal US scan: showed thickening of CET (7.81 mm). A2:hoic partial tear area (64.8 mm2), findings were consistent with grade (2) laterallike signal intensity at the origin of CET consistent with presence of partial tear (reda. C: Post- injection: C1: Longitudinal US scan six months post injection: showederogeneous hypoechoic area (green arrow) into less than 2/3 of total thickness. C2:ross section of the hypoechoic area (green arrow) into (29 mm2). C3, C4 and C5: MRIo intermediate at the site of CET.

Case 3 (continued)


high significant improvement (p < 0.001) in 75% of patients sixmonths post procedure. The mean at the base line was 29.97 andsix months post procedure it decreased into 19.92 that was consid-ered highly significant by statistical analysis.

PRTEE total score (for both pain and function) showed high sig-nificant improvement (p < 0.001). The mean at the base line was60.35 and six months post procedure it decreased into 40.23. Sta-tistical analysis revealed high significant decrease in PRTEE func-tion subscale six months after treatment by PRP.

Figs. 2 and 3 showed follow up changes in tendon thickness,cross sectional area, calcification, and degree of CET tendinosis at3 and 6 months post procedure (see Cases 1–3).

4. Discussion

Lateral epicondylitis is also known as Tennis elbow, remainsone of the most perplexing disorders of musculoskeletal system.Some studies have reported a female preponderance [11], and thisagreed with our results (73.8% females and 6.2% males).

Connell et al. [12] explained cause of function disability of CETin case of lateral epicondylitis is due to decrease the collagen syn-thesis during one of the healing phases (inflammatory, prolifera-tive and remodeling) with changes of repair tissue from cellularto fibrous. There is a gradual change from fibrous tissue to scar-like tendon tissue that interferes with the normal function of mus-


cles originating from CET, mainly extension, abduction and adduc-tion of the wrist causing impaired grip and restricted daily activity.They [12] reported a small (n = 15) randomized clinical trial of PRPtreatment for lateral epicondylitis. Subjects receiving PRP in a sin-gle injection session. They showed 60% improvement at 8 weeks,81% improvement at 6 months and 93% at 25 months comparedwith their baseline with no adverse effects or complications. Inour study, all patients showed high significant improvement aftertreatment by PRP (p < 0.001) at six months post procedure, tender-ness over lateral epicondyle was relieved in 54.8% of patients andresisted wrist extension improved in 38.1% of patients during clin-ical examination.

A qualitative study done by Connell et al. [13] examined thesonographic criteria in 72 patients with lateral epicondylitis andwere correlated with surgical and histological findings. The estab-lished Connell Criteria were a focal hypoechoic area on either anormal background or a diffuse decrease in echotexture with lossof normal fibrillar pattern, while anechoic foci with no intact fiberswere thought to represent partial or complete tears. In our studywe classify our findings in lateral epicondylitis according to Martinet al. [10] whom divided lateral epicondylitis echotexture intogrades which were more specific and easy to apply.

Lee et al. [14], designed a study for quantitative sonographicmeasurements of CET with higher diagnostic performance for lat-eral epicondylitis. The CET cross sectional area greater than orequal to (32 mm2) in transverse plane and (4.2 mm) thickness inlongitudinal plane correlated well with presence of lateral epi-condylitis, with sensitivity of 76.5% and specificity of 76.2%. Inagreement with these criteria, in our study, there was high signif-icant decrease in cross sectional area of CET from mean of 80.34 atbaseline to 69.85 six months post procedure (about 13.06% reduc-tion) (p < 0.001). And these findings were also agreed with Schwarz[15] who reported a decrease in tendon thickness and cross sec-tional area with normalization of hypoechoic portions of tendonafter PRP injection in most of the studies involved ultrasoundimaging.

Chaudhury et al. [16] investigated the altered tendon sono-graphic morphology following US-guided PRP injection in casesof lateral epicondylitis. This study prospectively evaluated sixpatients who had a baseline ultrasound confirming the diagnosis.Five patients demonstrated improved tendon morphology usingultrasound imaging 6 months post procedure (one patient was lostto follow up). They concluded that PRP therapy for lateral epi-condylitis can improve CET morphology following US guided PRPinjection. This agreed with our results, about 85.7% of tendonshad an improvement in the grade of tendenosis with significantp value (<0.001), the number of partial tears had decreased from16 (38.1%) at baseline to 1 (2.4%). Calcification was decreased from12 case at baseline to 6 cases (50% reduction), the difference wasconsidered highly significant by statistical analysis.

In our study MRI could predict abnormal findings in all the 42patients and it was our gold slandered to establish the ultrasoundfindings before and after treatment with PRP, and this agreedwith many previous studies [17–19] that found majority ofpatients with clinical diagnosis of chronic lateral epicondylitishave signal changes on MR. Also our MRI findings were agreedwith Martin CE and Schweitzer ME [20] about appearance ofCET tendinopathy in lateral epicondylitis which included anincreased T2WI and STIR signal within or around the CET and ten-don thickening. This is also confirmed by a meta-analysis studyshowing that 90% of patients with lateral epicondylitis had abnor-mal signal in CET of affected elbows compared with 14% of con-trols [21]. Our results were agreed with a study done byPeerbooms et al. [22], who mentioned that out of 51 patients

treated with PRP injection for lateral epicondylitis, 27 patientswere completed magnetic resonance imaging scans at 1 year fol-lowing PRP treatment and there was a significant improvement indegree tendinosis.

5. Conclusion

We concluded that ultrasound guided platelet-rich plasma(PRP) injection for treatment of lateral epicondylitis was a safe,minimally invasive and effective procedure in improving the sono-graphic and pathological changes of common extensor tendon(CET).

Conflict of interest

We have no conflict of interest to declare.

References

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