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

The Egyptian Journal of Radiology and Nuclear Medicine xxx (2017) xxx–xxx

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Original Article

Role of Ultrasound Guided Platelet-Rich Plasma (PRP) Injection in Treatment of Lateral Epicondylitis Enass M. Khattab ⇑, Mohamad H. Abowarda Department of Radiodiagnosis, Faculty of Medicine, Zagazig University, Egypt

a r t i c l e

i n f o

Article history: Received 15 November 2016 Accepted 4 March 2017 Available online xxxx Keywords: Ultrasound Injection of PRP Lateral epicondylitis

a b s t r a c t Background: Lateral epicondylitis is referred to a degenerative disorder that affects the common extensor tendon (CET) where it attaches to the lateral epicondyle of the humerus. Nowadays, one of minimally invasive interventions is platelet-rich plasma (PRP) injection that had been explored in some controlled clinical studies to show its effectiveness in treating lateral epicondylitis through inducing inflammation rather than suppressing it. Objectives: The aim of our study was to investigate the effectiveness of ultrasound guided platelet-rich plasma (PRP) injection in treating chronic lateral epicondylitis in addition to identifying the potential sonographic morphological changes in the common extensor tendon (CET) after PRP injection. Results: Statistical analysis showed high significant improvement in all ultrasound findings of common extensor tendon (CET) including echotexture, thickness, cross section, partial tear and calcification in majority of patients. Conclusion: We concluded that US-guided platelet-rich plasma (PRP) injection for treatment of lateral epicondylitis was a safe, minimally invasive and effective procedure in improving the sonographic and pathological changes of common extensor tendon (CET). Ó 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/).

1. Introduction Lateral epicondylitis is referred as a degenerative disorder that affects the common extensor tendon (CET) where it attaches to the lateral epicondyle of the humerus [1]. Waseem et al. [2] explained that this condition is not an inflammatory process with no inflammatory cells (e.g. macrophages, lymphocytes or neutrophils) could be detected in the affected tissue. But, it is a form of tendinosis that affects the common extensor tendon with a fibroblastic and vascular response called angiofibroblastic degeneration of CET. Moreover, tennis elbow (TE) is considered a misnomer since tennis player account for only about 5% of all patients suffering from this condition. That make ‘‘lateral epicondylosis” or ‘‘lateral elbow tendinosis” is the most appropriate term that express that condition. Despite of this lateral epicondylitis is more recognized and widely used in the scientific community. The annual prevalence of lateral epicondylitis is about 1–3% of population that induces morbidity secondary to pain and function disability that prevents an active life style [3]. Peer review under responsibility of The Egyptian Society of Radiology and Nuclear Medicine. ⇑ Corresponding author. E-mail address: [email protected] (E.M. Khattab).

However, medications like non-steroidal anti-inflammatory drugs (NSAIDS), physical therapy, shock wave therapy, botulism toxin injection and corticosteroids injection were used to treat lateral epicondylitis many studies showed that they did not alter poor healing of the CET and had long term course of treatment. In addition, adverse side effects of long-run use of NSAIDs like bleeding ulcers and renal failure and those of corticosteroids like tendon atrophy and permanent structural changes, make these types of treatments controversial [4]. Nowadays, minimally invasive interventions that stimulate healing response and counteracting the degenerative structural changes in lateral epicondylitis have been investigated. One of these emerging technologies is platelet-rich plasma (PRP) injection [5]. Platelet-rich plasma is a volume of the plasma fraction of autologous blood having a platelet concentration of 5 times more than base line (5  200,000 platelets/ul). Platelets in PRP contain growth factors and build up reparative processes. The action of PRP therapy in chronic tendinopathies is varied and hypothesized to include angiogenesis, increase in growth factor expression and cell proliferation, increase the effect of repair cells and tensile strength. Lateral epicondylitis may be characterized by complex changes in the tendon in addition to an inflammatory process. Therefore,

http://dx.doi.org/10.1016/j.ejrnm.2017.03.002 0378-603X/Ó 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/).

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PRP owing to its high content of various growth factors may be more effective as a healing agent [5]. Diagnostic ultrasound and MRI before PRP injection will help to confirm clinical diagnosis and establish baseline findings. Ultrasound guidance of the injection will ensure precise targeting of tissue needle placement and real-time visualization of needle during injection with documentation of changes in tendon morphology & structure after PRP injection [6]. US is an excellent option for diagnostic imaging evaluation of lateral epicondylitis, with a reported sensitivity of approximately 80% and specificity of approximately 50%. Tendinosis appears as tendon enlargement and heterogeneity. Tendon tears are depicted as hypoechoic regions with adjacent tendon discontinuity. Surrounding fluid and calcification also may be seen [7]. The normal MR imaging appearance of the CET is that of a vertically oriented structure that originates from the lateral epicondyle. The tendon should show uniform low signal intensity, regardless of the imaging sequence used. Tendon morphology is best assessed on coronal and axial images. The MR imaging findings of lateral epicondylitis on both T1- and T2-weighted images include intermediate signal intensity within the substance of the tendon with or without tendon thickening. Partial thickness tears are seen as a region with the signal intensity of fluid extending partway across the tendon [8]. The aim of the present study is to investigate the effectiveness of ultrasound guided (PRP) injection in treating chronic lateral epicondylitis in addition to identify the potential sonographic morphological changes in the CET after PRP injection with respect to the baseline sonographic findings.

2. Patients and methods 2.1. Technical design 2.1.1. Site of the study, sample size and methods of collection of patients Forty-two patients (31 females and 11 males), were included in the study with age range from 30 to 50 years old (median of age

38 years old).The mean time of symptoms was19.95 months (range 3–36 months). Patients were diagnosed, treated and followed up in the ultrasound unit in the Radiology Department by sonographic assessments at baseline diagnosis, during injection of 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 epicondylitis as determined on clinical examination (based on symptoms, site of tenderness and pain elicited with resisted active extension of the wrist in pronation and elbow in extension) and confirmed with base line ultrasonographic examination 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 from 0 to 10 according to a validated questionnaire called PRTEE Questionnaire (Patient Rated Tennis Elbow Evaluation). It consists of two subscales, PAIN subscale (0 = no pain, 10 = worst imaginable) and FUNCTION subscale (0 = no difficulty, 10 = unable to do). In addition to the individual subscale scores, a total score was computed on a scale of 100 (0 = no disability) where pain and functional problems are weighted equally [9]

Table 1 Symptoms before and 6 months after treatment. Symptoms

Before treatment (N = 42)

6 months after treatment (N = 42)

Test

p-value (Sig.)

No.

%

No.

%

Impaired grip No Yes

0 42

0% 100%

16 26

38.1% 61.9%

19.765§

<0.001 (HS)

Restricted daily activities No Yes

0 42

0% 100%

9 33

21.4% 78.6%

10.080§

<0.001 (HS)

Pain No Yes

0 42

0% 100%

16 26

38.1% 61.9%

19.765§

<0.001 (HS)

PRTEE pain subscale Mean ± SD Median (range)

29.97 ± 10.35 29.50 (12–47)

19.92 ± 11.61 18 (6–48)

5.306a

<0.001 (HS)

PRTEE function subscale Mean ± SD Median (range)

30.38 ± 11.02 30 (11–48)

20.30 ± 11.31 19.50 (4–48)

5.297a

<0.001 (HS)

PRTEE total score Mean ± SD Median (range)

60.35 ± 21.36 59.50 (23–95)

40.23 ± 22.79 37.50 (10–96)

5.382a

<0.001 (HS)

p < 0.05 is significant. Sig.: significance. a Wilcoxon signed ranks test. § McNemar test.

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3. The pre-procedure gray scale images were classified at baseline according to echotexture grading scale system of a study protocol reported by Martin et al. [10] which divided lateral epicondylitis echotexture into grade 1(a), 1(b), 1(c), 2 and 3. Grade 1(a): hypoechoic lesion less than one third of CET Grade 1(b): hypoechoic lesion between one third and two thirds of the tendon. Grade 1(c): hypoechoic lesion more than two thirds of CET Grade 2: presence of partial tear. Grade 3: presence of complete tear. As a protocol of the study, we considered grade 1a and 1b as mild cases, grade 1c and 2 as moderate cases and grade 3 as severe cases. 4. Radiological evaluation at baseline by ultrasonographic examination of the affected elbow was confirmed by MRI examination before PRP injection. 5. MRI was performed to all patient at baseline and six months post procedure to confirm the sonographic findings. The preprocedure MRI findings were including presence of tendon

thickening, abnormal signal intensity or a fluid filled gap in T2WI and STIR sequences. According to these findings we classify the lateral epicondylitis into three grades (mild: tendon thickening with abnormal intermediate signal intensity at T2 weighted images, moderate: tendon thickening with abnormal high signal intensity involving less than two thirds of tendon thickness, severe: tendon thickening with abnormal high signal intensity involving more than two thirds of tendon thickness) [11]. 6. A single injection of platelet-rich plasma (PRP) guided by ultrasonography after written consent was performed to all the patients. 2.1.3. Preparation of PRP Blood was extracted from the patient in a 10 ml syringe, preloaded with citrate phosphate dextrose (CPD) and then centrifuged for 15 min at 3500 rpm to separate and concentrate the platelets

Table 2 Signs before and 6 months after treatment. Signs

Before treatment (N = 42)

6 months after treatment (N = 42)

No.

Test

p-value (Sig.)

%

No.

%

Tenderness over lateral epicondyle Absent 0 Present 42

0% 100%

23 19

54.8% 45.2%

31.672§

<0.001 (HS)

Resisted wrist extension test Absent 0 Present 42

0% 100%

16 26

38.1% 61.9%

19.765§

<0.001 (HS)

Test

p-value (Sig.)

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

Table 3 US findings before and 6 months after treatment. U/S findings

Before treatment (N = 42)

6 months after treatment (N = 42)

No.

%

No.

%

Texture Focal Diffuse

24 18

57.1% 42.9%

38 4

90.5% 9.5%

12.070§

0.001 (S)

Grade 1a 1b 1c 2

0 8 18 16

0% 19% 42.9% 38.1%

16 21 4 1

38.1% 50% 9.5% 2.4%

43.972à

<0.001 (HS)

Thickness of tendon (mm) Mean ± SD Median (range)

7.87 ± 1.07 7.94 (5.27–9.70)

7.26 ± 1.10 7.24 (4.80–9.63)

18.126*

<0.001 (HS)

Cross sectional (mm2) Mean ± SD Median (range)

80.34 ± 15.59 81.37 (53.6–115.2)

69.85 ± 17.21 68.51 (43.95–122)

5.283a

<0.001 (HS)

Tendon tear No tear Partial tear

26 16

61.9% 38.1%

41 1

97.6% 2.4%

16.594§

<0.001 (HS)

Calcification Absent Present

30 12

71.4% 28.6%

36 6

85.7% 14.3%

17.500§

0.031 (NS

Degree of tendinosis Mild Moderate Severe

8 18 16

19% 42.9% 38.1%

36 5 1

85.7% 11.9% 2.4%

38.401à

<0.001 (HS)

p < 0.05 is significant. Sig.: significance. * Paired t-test. a Wilcoxon signed ranks test. § McNemar test. à Chi-square test.

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Table 4 MRI 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 thickening Absent Present

0 42

0% 100%

5 37

11.9% 88.1%

5.316§

<0.001 (HS)

T2WI and STIR signal intensity Intermediate High

26 16

61.9% 38.1%

41 1

97.6% 2.4%

1.665§

<0.001 (HS)

Degree of tendinosis Mild Moderate Severe

8 18 16

19% 42.9% 38.1%

37 4 1

88.1% 9.5% 2.4%

40.833à

<0.001 (HS)

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

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.

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from other blood components. Then 2 mL of platelet-rich plasma (with absolute platelet count of 1 million platelets/mm3 as confirmed by manual counting) was injected into the affected site. 2.1.4. Procedure of injection The patient is placed supine with affected upper limb in neutral position, the site is palpated for maximum point of tenderness before giving a local anaesthetic. Under complete aseptic

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precautions local anaesthetic injection (2% xylocaine) was done followed by PRP injection into the affected site with 18-guage needle, the patient is advised to rest for approximately 1 h after the procedure. 7. Patients were informed about the post procedure protocol. They were rescheduled for a follow up appointment three and six months after PRP injection.

Fig. 3. Changes in the degree of tendinosis during ultrasound follow up sessions.

Case 1. Mild degree of lateral epicondylitis. A male patient 38 years old age with long history of left lateral elbow pain for more than 10 months. Total pre-injection PRTEE score was (29) that improved to (10) six months post-injection of PRP. H = Humerus, R = Radius, U = Ulna, CET = Common Extensor Tendon, RH = Radial Head, LE = Lateral Epicondyle, Cap = Capitellum. A. Pre injection: A1: Longitudinal US scan: of left lateral elbow region showed thickening of CET (6.64 mm), heterogeneity (red arrow) of less than 2/3 of the tendon, and osteophyte formation (purple arrow) suggesting grade 1b lateral epicondylitis. A2: Transverse US scan: showing cross section of the tendon (65.87 mm2), red arrow showed cross section of the hypo-echoic area (28 mm2) consistent with grade (1b) lateral epicondylitis. A3, A4 and A5: MRI coronal T2WI, STIR, and axial T2WI of left elbow: showed intermediate signal intensity at the site of CET (red arrow). B. During injection: US of CET during needle placement into the abnormal areas of the tendon, yellow arrows showed (22-gauge, 1.5 in. needle), red arrow showed the heterogeneous hypoechoic area & purple arrow showing the osteophyte. C. Post injection: C1, C2 and C3: MRI coronal T2WI, STIR, and axial T2WI of left elbow six months post injection showed decrease of signal intensity at the site of CET (green arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

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Case 1 (continued)

8. Final radiological and clinical follow up of the affected elbow were performed six months after PRP injection with comparison between both pre and post procedure clinical and radiological findings.

3. Physical therapy should be avoided at least two weeks after the procedure. 4. Gradual return to activity over 6–8 weeks. 2.3. Follow-up program

2.2. Post-procedure protocol Patients were expectations:

educated

for

short-term

and

long-term

1. PRP injection promotes local inflammation, so we told them that pain should be expected, and can be treated with ice and narcotic prescription such as Acetaminophen. 2. Anti-inflammatory drugs (NSAIDs) should be avoided for at least two weeks.

All patients were evaluated at baseline clinically and radiologically (US & MRI). The following visit was after three months, patients were re-evaluated clinically and sonographically and findings were recorded. Final follow up was done after six months with post procedure clinical and radiological re-evaluation and recording the findings. 1. Clinical reevaluation by: – Answering PRTEE Pain Subscale Questionnaire.

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– Answering PRTEE Function Subscale Questionnaire. – Computing the total PRTEE Total Score where pain and function equally weighted. 2. Radiological re-evaluation by: – Ultrasound. – MRI.

2.4. Statistical analysis All data were collected, tabulated and statistically analyzed using SPSS 19.0 for windows (SPSS Inc., Chicago, IL, USA) &

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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 frequencies ‘‘number”& relative frequencies (percentage). Continuous data were checked for normality by using Shapiro Walk test. Paired t-test was used to compare two dependent groups of normally distributed data while Wilcoxon signed ranks test was used for non-normally distributed data. Percent of paired categorical variables were compared using Chi-square test or McNemar test when appropriate. All tests were two sided.

Case 2. Moderate degree of lateral epicondylitis. A female patient 35 years old age with long history of left lateral elbow pain for more than 12 months. Total pre-injection PRTEE score was (56) that improved to (22) six months post-injection of PRP. A. Pre-injection: A1: Longitudinal US scan: showed thickening of CET (7.64 mm), heterogeneity (red arrow) of more than 2/3 of the tendon, osteophyte formation (purple arrow) &cortical irregularity of the lateral epicondyle surface. A2: Transverse US scan: of the same CET showing cross section of the tendon (108 mm2), and cross section of the hypo-echoic area (78 mm2), findings were consistent with grade (1c) lateral epicondylitis. A3, A4 and A5: MRI coronal T2WI, STIR and axial T2WI: showed intermediate signal replacing the whole thickness of CET extending from the cortical surface of LE (red arrow). B: During PRP injection: US of CET during needle placement into the abnormal area. C: Post injection: C1: Longitudinal US scan six months post injection: showed decreased thickness of CET into (6.4 mm) with reduction of the hypoechoic heterogeneous area (green arrow) into less than 1/3 of total thickness. C2: Transverse US scan showed decrease both cross section of the tendon into (89 mm2) and cross section of the hypoechoic area into (24 mm2). C3, C4 and C5: MRI coronal T2WI, STIR, and axial T2WI six months post-injection: showed marked decrease in the signal intensity into intermediate signal (green arrow) at the site of CET. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

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Case 2 (continued)

P < 0.05 was considered statistically significant (S), p < 0.001 was considered highly statistically significant (HS), and p  0.05 was considered non statistically significant (NS). 3. Results All the patients (42 patients) included in the study were diagnosed 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 more affected than the left one (45.2%). At the baseline 42 patients were classified sonographycally as 19% mild cases (8 patients grade1b), 42.9% moderate cases (18 patients grade 1c) and 38.1% severe cases (16 patients grade 2). Six months post procedure, degrees of the disease improved into 85.7% mild cases (16 patients grade 1a and 21 patients grade 1b),

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11.9% moderate cases (4 patients grade 1c) and 2.4% severe cases (1 patient grade 2).These results were considered to be highly significant improvement in the degree of the disease. Table 1 showed that all patients were complaining of impaired grip, restricted daily activities, and pain which all showed high significant improvement after treatment by PRP. Statistical analysis revealed high significant decrease in PRTEE pain subscale six months after treatment by PRP. Table 2 showed at baseline, all patients had showed tenderness over lateral epicondyle and resisted wrist extension on clinical examinations, both signs showed high significant improvement after treatment by PRP (p < 0.001). Six months post procedure, tenderness over lateral epicondyle was relieved in 54.8% 0f patients and resisted wrist extension improved in 38.1% of patients during clinical examination. Table 3 showed high significant improvement in all ultrasound findings of common extensor tendon CET in majority of patients. There was high significant improvement in the degree of the disease. There was high significantly decrease in tendon thickness from mean of 7.87 mm at baseline to 7.26 mm six months post procedure (about 6.8% reduction) (p < 0.001). There was high significantly decrease in cross sectional area of CET from mean of 80.34 mm2 at baseline to 69.85mm2 at six months post procedure (about 13.06% reduction) (p < 0.001). There was high significantly decrease in number of partial tears from 16 case presented with partial tear at baseline to just one case still preserve the partial tear after six months (about 93.7% reduction) (p < 0.001). Calcification was decreased from 12 case at baseline to 6 cases at six months

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post procedure (about 50% reduction), the difference was considered highly significant by statistical analysis. Table 4 showed a high statistically significant improvement in degree of tendinosis, signal intensity, and reduction of tendon thickness detected by MRI. Statistical analysis showed high significant reduction in tendon thickening by MRI in 11.9% of tendons. Statistical analysis showed high significant improvement in signal intensity from 61.9% intermediate signals (8 cases (19%) of mild degree, 18 cases (42.9%) of moderate degree and 16 cases (38.1%) of severe degree at baseline, into 37 cases (88.1%) mild degree, 4 cases (9.5%) of moderate degree and 1 case (2.4%) of severe degree at six months post procedure. Fig. 1 showed that during follow up sessions, the median of PRTEE pain subscale was decreased from 29.50 (Range 12–47) to 25.50 (Range 10–48) after three months. At six months post procedure, the pain subscale median decreased into 18 (Range 6–48). During follow up sessions, the median of PRTEE function subscale was decreased from 30 (Range 11–48) to 26.50 (Range 9–48). Six months post procedure, the function subscale median decreased into 19.50 (Range 4–48). PRTEE function subscale showed high significant improvement (p < 0.001) in 80% of patients six months post procedure. The mean at the base line was 30.38 and six months post procedure it decreased into 20.30.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 (Range 19–96). Six months post procedure, PRTEE total score median decreased into 37.50 (Range 10–96). PRTEE pain subscale showed

Case 3. ‘‘Partial tear of common extensor tendon origin”. A female patient 37 years old age with long history of right lateral elbow pain for more than 15 months. Total preinjection PRTEE score was (79) that improved to (37) six months post-injection of PRP. A: Pre-injection: A1: Longitudinal US scan: showed thickening of CET (7.81 mm). A2: Transverse US scan: showed cross section of the CET (107 mm2), cross section of anechoic partial tear area (64.8 mm2), findings were consistent with grade (2) lateral epicondylitis. A3, A4 and A5: MRI coronal T2WI, STIR and axial T2WI: showed high fluid like signal intensity at the origin of CET consistent with presence of partial tear (red arrow). B: During injection: US of CET during needle placement into the abnormal area. C: Post- injection: C1: Longitudinal US scan six months post injection: showed decreased thickness of CET into (6.28 mm) with the anechoic partial tear replaced by heterogeneous hypoechoic area (green arrow) into less than 2/3 of total thickness. C2: Transverse US scan showed decrease of both cross section of the tendon into (82 mm2) &cross section of the hypoechoic area (green arrow) into (29 mm2). C3, C4 and C5: MRI coronal T2WI, STIR and axial T2WI showed marked decrease in high signal intensity into intermediate at the site of CET. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

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Case 3 (continued)

high significant improvement (p < 0.001) in 75% of patients six months post procedure. The mean at the base line was 29.97 and six months post procedure it decreased into 19.92 that was considered highly significant by statistical analysis. PRTEE total score (for both pain and function) showed high significant improvement (p < 0.001). The mean at the base line was 60.35 and six months post procedure it decreased into 40.23. Statistical analysis revealed high significant decrease in PRTEE function 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 at 3 and 6 months post procedure (see Cases 1–3).

4. Discussion Lateral epicondylitis is also known as Tennis elbow, remains one of the most perplexing disorders of musculoskeletal system. Some studies have reported a female preponderance [11], and this agreed with our results (73.8% females and 6.2% males). Connell et al. [12] explained cause of function disability of CET in case of lateral epicondylitis is due to decrease the collagen synthesis during one of the healing phases (inflammatory, proliferative and remodeling) with changes of repair tissue from cellular to fibrous. There is a gradual change from fibrous tissue to scarlike tendon tissue that interferes with the normal function of mus-

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cles originating from CET, mainly extension, abduction and adduction of the wrist causing impaired grip and restricted daily activity. They [12] reported a small (n = 15) randomized clinical trial of PRP treatment for lateral epicondylitis. Subjects receiving PRP in a single injection session. They showed 60% improvement at 8 weeks, 81% improvement at 6 months and 93% at 25 months compared with their baseline with no adverse effects or complications. In our study, all patients showed high significant improvement after treatment by PRP (p < 0.001) at six months post procedure, tenderness over lateral epicondyle was relieved in 54.8% of patients and resisted wrist extension improved in 38.1% of patients during clinical examination. A qualitative study done by Connell et al. [13] examined the sonographic criteria in 72 patients with lateral epicondylitis and were correlated with surgical and histological findings. The established Connell Criteria were a focal hypoechoic area on either a normal background or a diffuse decrease in echotexture with loss of normal fibrillar pattern, while anechoic foci with no intact fibers were thought to represent partial or complete tears. In our study we classify our findings in lateral epicondylitis according to Martin et al. [10] whom divided lateral epicondylitis echotexture into grades which were more specific and easy to apply. Lee et al. [14], designed a study for quantitative sonographic measurements of CET with higher diagnostic performance for lateral epicondylitis. The CET cross sectional area greater than or equal to (32 mm2) in transverse plane and (4.2 mm) thickness in longitudinal plane correlated well with presence of lateral epicondylitis, with sensitivity of 76.5% and specificity of 76.2%. In agreement with these criteria, in our study, there was high significant decrease in cross sectional area of CET from mean of 80.34 at baseline to 69.85 six months post procedure (about 13.06% reduction) (p < 0.001). And these findings were also agreed with Schwarz [15] who reported a decrease in tendon thickness and cross sectional area with normalization of hypoechoic portions of tendon after PRP injection in most of the studies involved ultrasound imaging. Chaudhury et al. [16] investigated the altered tendon sonographic morphology following US-guided PRP injection in cases of lateral epicondylitis. This study prospectively evaluated six patients who had a baseline ultrasound confirming the diagnosis. Five patients demonstrated improved tendon morphology using ultrasound imaging 6 months post procedure (one patient was lost to follow up). They concluded that PRP therapy for lateral epicondylitis can improve CET morphology following US guided PRP injection. This agreed with our results, about 85.7% of tendons had an improvement in the grade of tendenosis with significant p value (<0.001), the number of partial tears had decreased from 16 (38.1%) at baseline to 1 (2.4%). Calcification was decreased from 12 case at baseline to 6 cases (50% reduction), the difference was considered highly significant by statistical analysis. In our study MRI could predict abnormal findings in all the 42 patients and it was our gold slandered to establish the ultrasound findings before and after treatment with PRP, and this agreed with many previous studies [17–19] that found majority of patients with clinical diagnosis of chronic lateral epicondylitis have signal changes on MR. Also our MRI findings were agreed with Martin CE and Schweitzer ME [20] about appearance of CET tendinopathy in lateral epicondylitis which included an increased T2WI and STIR signal within or around the CET and tendon thickening. This is also confirmed by a meta-analysis study showing that 90% of patients with lateral epicondylitis had abnormal signal in CET of affected elbows compared with 14% of controls [21]. Our results were agreed with a study done by Peerbooms et al. [22], who mentioned that out of 51 patients

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treated with PRP injection for lateral epicondylitis, 27 patients were completed magnetic resonance imaging scans at 1 year following PRP treatment and there was a significant improvement in degree 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 sonographic and pathological changes of common extensor tendon (CET). Conflict of interest We have no conflict of interest to declare. References [1] Cohen M, Motta Filho GR. Lateral epicondylitis of the elbow. Rev Bras Ortop 2012;47(4):414–20. [2] Waseem M, Nuhmani S, Ram CS, Sachin Y. Lateral epicondylitis: a review of the literature. J Back Musculoskelet Rehab 2012;25(2):131–42. [3] Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum 2004;51:642–51. [4] Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1year follow-up. Am J Sports Med 2010;38(2):255–62. [5] 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: JCDR 2015;9(7):RC05–7. [6] Lee KS, Wilson JJ, Rabago PD, Baer GS, Jacobson JA, Borrero CG. Musculoskeletal applications of platelet-rich plasma: fad or future? AJR 2011;196:628–36. [7] Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. RadioGraphics 2010;30:167–84. [8] Aoki M, Wada T, Isogai S, Kanaya K, Aiki H, Yamashita T. Magnetic resonance imaging findings of refractory tennis elbows and their relationship to surgical treatment. J Should Elbow Surg 2005;14:172–7. [9] Rompe JD, Overend TJ, MacDermid JC. Validation of the patient-rated tennis elbow evaluation questionnaire. J Hand Ther 2007;20(1):3–10 [quiz 11]. [10] Martin IJ, Merino J, Atilano L, Areizaga ML, Gomez-Fernandez CM, BurgosAlonso NM, et al. Platelet-rich plasma (PRP) in chronic epicondylitis: study protocol for a randomized controlled trial. Trials 2013;14:410. [11] Walz DM, Newman JS, Konin GP, et al. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics 2010;30:167–84. [12] Connell DA, Ali KE, Ahmed M, Lambert S, Corbett S, Curtis. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol 2006;35:371–7. [13] Connell D, Burke F, Coombes P, McNealy S, Freeman D, Pryde D, et al. Sonographic examination of lateral epicondylitis. AJR Am J Roentgenol 2001;176:777–82. [14] Lee MH, Cha JG, Jin W, Kim BS, Park JS, Lee HK. Utility of sonographic measurement of the common tensor tendon in patients with lateralepicondylitis. AJR Am J Roentgenol 2011;196:1363–7. [15] Schwarz A. A promising treatment for athletes, in blood. The New York Times; February 17, 2009. [16] Chaudhury S, Lama M, Adler RS, Gulotta LV, Skonieczki B, Chang A, et al. Platelet-rich plasma for the treatment of lateral epicondylitis: sonographic assessment of tendon morphology and vascularity (pilot study). Skeletal Radiol 2013;42:91–7. [17] Van Kollenburg JA, Brouwer KM, Jupiter JB, et al. Magnetic resonance imaging signal abnormalities in enthesopathy of the extensor carpi radialis longus origin. J Hand Surg Am 2009;34:1094–8. [18] Savnik A, Jensen B, Norregaard J, et al. Magnetic resonance imaging in the evaluation of treatment response of lateral epicondylitis of the elbow. Eur Radiol 2004;14:964–9. [19] Thornton R, Riley GM, Steinbach LS. Magnetic resonance imaging of sports injuries of the elbow. Top Magn Reson Imag 2003;14:69–86. [20] Martin CE, Schweitzer ME. MR imaging of epicondylitis. Skeletal Radiol 1998;27:133–8. [21] Pasternack I, Tuovinen EM, Lohman M, et al. MR findings in humeral epicondylitis. A systematic review. Acta Radiol 2001;42:434–40. [22] Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1year follow-up. Am J Sports Med 2010;38:255–62.

Please cite this article in press as: Khattab EM, Abowarda MH. . Egypt J Radiol Nucl Med (2017), http://dx.doi.org/10.1016/j.ejrnm.2017.03.002