Introduction
Lateral epicondylitis or Tennis Elbow is a common cause of musculoskeletal pain involving common extensor origin at elbow, thought due to overuse of the Extensor Carpi Radialis Brevis (ECRB) muscle by repetitive micro trauma, which results in its primary tendinosis, with or without involvement of the Extensor Digitorum Communis (EDC) and Extensor Carpi Radialis Longus (ECRL) [1]. It is common in people whose occupation requires frequent rotatory motions of the forearm (plumbers, carpenters, tennis players)[2].
Clinically, a patient with tennis elbow has pain around the lateral elbow and forearm, which radiates toward the extensor region. Rotation, extension of forearm and grasp is reduced. Clinical testing reveals painful resistance against dorsiflexion of the wrist. The diagnosis of tennis elbow is mainly clinical and special tests like Cozen’s test, Mill’s maneuver or investigations like ultrasound, radiographic examination, MRI and electro-myophysiological testing are indicated when there is difficulty in establishing diagnosis, which can be helpful in identifying other causes of lateral elbow pain [3,4].
The condition is usually a self-limiting condition which resolves in 6–12 months regardless of treatment, but sometimes complaints may last longer [5]. There has been no consensus on the optimal management strategy for the condition and various modalities including the newer modalities like local injection of Platelet Rich Plasma (PRP), autologous blood, dry needling, prolotherapy and extracorporeal shockwave therapy are used with varied results [6-10].
Local steroid injection has been proven to provide consistent and predictable short term pain relief, but long term results are inconsistent [7].
Tennis elbow, an angio-fibroblastic degenerative and inflammatory condition of the tendon, is benefitted by autologous PRP as it is a healing agent containing growth factors that build up reparative processes by angiogenesis, increase in growth factor expression, cell proliferation and increases the recruitment of repair cells and tensile strength [11-13].
Dry Needling is used to treat myofascial pain and dysfunction, by deactivating the myofascial trigger points and releasing the taut band of muscle[14,15].
We evaluated and compared the short term effects of intra-lesional injection of dry needling, autologous platelet rich plasma and corticosteroid in patients of recalcitrant lateral epicondylitis.
Material and Methods
This prospective study was conducted at our center in patients of resistant lateral epicondylitis after proper patients consent and institutional ethical committee approval. Patients with clinical pain and tenderness at lateral epicondyle, with restriction of forearm rotation and positive Cozen and Mill’s tests were diagnosed as cases with lateral epicondylitis.
All these patients were initially given conservative treatment with analgesics, anti-inflammatory drugs and physiotherapy. Patients with resistant lateral epicondylitis between age 18 to 70 years not responding to conservative treatment for 3 months were included in the study. All patients with age less than 18 years and more than 70 years or had a chronic inflammatory disease like rheumatoid arthritis, uncontrolled diabetes, systemic hypertension, history of trauma to the elbow, prior history of injection at elbow or with infection at the injection site were excluded from the study.
Patients were sequentially randomized into three groups for intra-lesional corticosteroid injection, PRP injection and dry needling as 1st patient was given corticosteroid injection, 2nd was given PRP injection, 3rd patient underwent dry needling and 4th patient underwent corticosteroid injection and so on.
All injections were done using strict sterile precautions, with no touch technique with sterile needles. Area was cleaned with povidone iodine followed with chlorhexidine solution and point of maximum tenderness was marked using sterile marker. Injection was given on this point of maximum tenderness using peppering technique i.e. single skin entry, partially withdrawing the needle without emerging the skin, slightly redirecting and reinserting.
1. Corticosteroid injection – 40 mg triamcinolone (Kenacort) mixed with 2 ml of 2% lidocaine was used.
2. Platelet Rich Plasma injection–27 ml of autologous blood was taken with 3ml of sodium citrate in a vaccutainer, which was centrifuged for 15 min at 3200 revolutions per minute. The plasma portion of the centrifuged mixture was discarded and the PRP portion so harvested was buffered with 8.4% sodium bicarbonate, to increase the pH to normal physiological levels. 2 ml of PRP was obtained and injected at most tender point.
3. Dry Needling - Five 0.25 × 25-mm stainless steel needles in the trigger point regions were inserted, directed through the skin and fascia to the bone (3–5 mm). They were rotated three to four times and left in place for ten minutes. Applications were repeated twice per week for a total of five sessions.
