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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 37-39

USG-Guided autologous PRP treatment for chronic tennis elbow with partial tear of extensor origin tendon of forearm


1 Impulse Pain Clinic, Ahmedabad, Gujarat, India
2 Daradia Pain Clinic, Aesculap Academy Pain Management Courses, Kolkata, West Bengal, India

Date of Submission25-Sep-2021
Date of Decision24-Dec-2021
Date of Acceptance30-Apr-2022
Date of Web Publication08-Mar-2023

Correspondence Address:
Pratik Maheshkumar Shah
Impulse Pain Clinic, 511, 5th Floor, Nobles Trade Centre, Opp. B. D. Rao Hall, Memnagar, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrap.jrap_13_21

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  Abstract 


Tennis elbow pain is a chronic pain disorder due to continuous movement and repetitive strain injury in extensor origin of forearm muscle. Many times, it presents with partial or interstitial tear in muscle. Platelet-rich plasma is a good treatment option for cure of chronic pain. Although medication and physiotherapy are primary treatment options, interventional pain procedure with ultrasonography-guided autologous platelet-rich plasma is a recent advance for the management of chronic tennis elbow pain.

Keywords: Partial tear of extensor origin tendon of forearm, platelet-rich plasma, tennis elbow pain


How to cite this article:
Shah PM, Das G. USG-Guided autologous PRP treatment for chronic tennis elbow with partial tear of extensor origin tendon of forearm. J Recent Adv Pain 2021;7:37-9

How to cite this URL:
Shah PM, Das G. USG-Guided autologous PRP treatment for chronic tennis elbow with partial tear of extensor origin tendon of forearm. J Recent Adv Pain [serial online] 2021 [cited 2023 Mar 31];7:37-9. Available from: http://www.jorapain.com/text.asp?2021/7/2/37/371249




  Introduction Top


Tennis elbow is a pain of lateral epicondylitis due to repetitive strain injury over muscle of extensor origin of forearm. It is associated with pain at lateral epicondyle of elbow and has difficulty in lifting weight. It is primarily managed with nonsteroidal anti-inflammatory drug (NSAID), cold pack, ultrasound therapy, and local steroid injection. Autologous platelet-rich plasma is a good curative treatment option after unsuccessful tennis elbow pain treatment with local steroid injection and medical management.[1],[3]


  Case Report Top


A 32-year-old man, a teacher by profession, presented with pain in the right lateral aspect of the elbow for 1 year. Pain had deteriorated while lifting a heavyweight from the right hand, and he had difficulty in writing on board. The intensity of pain was severe (Numerical rating score 8/10). The pain was referred up to the right side mid forearm. He did not have neck pain, radiating pain in the right upper limb. He had taken NSAID multiple times. The patient had also taken local steroid injection twice in a year as pain recurs every 6 months. The patient had no bad habits, his other medical history was insignificant.

On clinical examination, the patient had tenderness over the lateral epicondyle. Resisted dorsiflexion of the wrist generated pain over the lateral epicondyle area. The patient had no tenderness over the medial epicondyle. Flexion and extension of the elbow are not painful.

He was undergone magnetic resonance imaging (MRI) of the right elbow, which shows a partial and interstitial tear in the common extensor muscle of the right forearm [Figure 1]. As this patient had taken multiple time medications in the form of NSAID and two-time local steroid injections, we suggest him to undergo treatment with ultrasonography (USG)-guided autologous platelet-rich plasma therapy.
Figure 1: Magnetic resonance imaging of the right elbow showing partial and interstitial tear (Red arrow) in extensor origin muscle of the elbow

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Procedure

  • Informed written consent was obtained before the procedure
  • Preprocedure preparation was done with securing an IV line, given a prophylactic antibiotic. Multipara monitor was attached.


The patient's own 20 cc blood collection was done with the help of No 20 G scalp vein set in 20 cc syringe and transferred it to “DrPRP” kit. Blood was centrifuged with special refrigerated platelet-rich plasma (PRP) centrifuge machine. The first cycle of separation was of 12 min, which separates the red blood cell (RBC) and plasma. There was a lock in the middle of the kit to keep RBC and plasma separated. The second centrifuge for concentration of the platelet was done for 8 min. After the second cycle, PRP was concentrated in the lower part of the upper half of PRP kit. The upper part of platelet-poor plasma is discarded, and the remaining 3 ml of platelet-rich plasma was taken for treatment purposes.

The right upper limb was anesthetized with supraclavicular brachial plexus block, injection lignocaine (1%) 20 cc injected with USG guidance. Supine position was given to the patient. After all, aseptic and antiseptic precautions procedure was started. Diagnostic ultrasound examination was done and an interstitial tear was found in the common extensor muscle. Two milliliter of PRP solution was injected with a 23 G long hypodermic needle in the substance of common extensor origin muscle near the interstitial tear. Sterile dressing applied and right upper limb supported with arm pouch.

The patient was discharged on the same day, in the evening, as per the protocol. Post procedure, the patient was advised to keep his right elbow immobilized for 10 days. Oral antibiotic was given for 3 days. The patient was informed about increased pain in the right elbow for 3–5 days as there was artificial inflammation due to PRP injection. For pain relief, tablet tapentadol 50 mg twice a day was advised for 10 days. The patient was pain free (Numerical Rating Scale 2/10) after 10 days. No adverse effects related to the procedure were observed both in the immediate postprocedure period and during the follow-up. At 3-month and 1-year follow-up, the patient reported no pain in the right elbow.[2],[4] Follow-up MRI [Figure 2] study was performed to access the healing of partial and interstitial tear after 18 month period. In that follow-up MRI, there was no interstitial or partial tear in the right side common extensor origin tendon of the forearm.
Figure 2: Post platelet-rich plasma procedure magnetic resonance imaging image after 18 month of procedure showing complete healing of partial and interstitial tear of the extensor muscle

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  Discussion Top


Lateral epicondylitis is one of the most common lesions of the arm. Tennis elbow is defined as a pain on the facet of the lateral epicondyle, which reproduces by digital palpation on the above site. It is usually work-related or sports-related disorder of common extensor origin muscle of forearm usually caused by excessive, quick, monotonous, and repetitive movement of the wrist, especially in eccentric contractions and gripping activities causing a macroscopic and microscopic tear in the extensor origin tendon. It is a degenerative response characterized by the increased presence of fibroblasts, increased amounts of proteoglycans and glycosaminoglycan, vascular hyperplasia, and disorganized collagen in the origin of the extensor tendon.[5]

Platelets have been shown to contain growth factors such as platelet-derived growth factor, transforming growth factor-β, insulin-like growth factor, epidermal growth factor, vascular endothelial growth factor, and fibroblast growth factor. These factors are released from the alpha granules after injury and bind of target cells (e.g., mesenchymal stem cells, osteoblasts, fibroblasts, endothelial cells, and epidermal cells). These receptors activate an intracellular signal protein that causes the expression of a gene sequence that then directs cellular proliferation, matrix formation, osteoid production, or collagen synthesis dependent on the cell activated. PRP injection would increase collagen production and cell viability and stimulate angiogenesis due to the release of the above factors. PRP injection promotes the healing of tissue by causing inflammation, followed by fibrosis and tissue remodeling.[6],[7]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kim GM, Yoo SJ, Choi S, Park YG. Current trends for treating lateral epicondylitis. Clin Shoulder Elb 2019;22:227-34.  Back to cited text no. 1
    
2.
Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: A double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med 2014;42:463-71.  Back to cited text no. 2
    
3.
Hastie G, Soufi M, Wilson J, Roy B. Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention. J Orthop 2018;15:239-41.  Back to cited text no. 3
    
4.
Glanzmann MC, Audigé L. Platelet-rich plasma for chronic lateral epicondylitis: Is one injection sufficient? Arch Orthop Trauma Surg 2015;135:1637-45.  Back to cited text no. 4
    
5.
Lai WC, Erickson BJ, Mlynarek RA, Wang D. Chronic lateral epicondylitis: Challenges and solutions. Open Access J Sports Med 2018;9:243-51.  Back to cited text no. 5
    
6.
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. Int J Sports Phys Ther 2021;16:597-605.  Back to cited text no. 6
    
7.
Irianto KA, Bakri AH, Kloping NA. Platelet rich plasma injection for soft tissue musculoskeletal pain. Malays Orthop J 2021;15:96-100.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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