Marc Darrow MD,JD

Systemic and local side-effects of corticosteroid injections including joint destruction

A patient will often come into our office with conflicting ideas about cortisone injections. The patient will tell us that his/her other doctors told them that cortisone injections are safe, effective, and will help their pain, if used sparingly. But, intuitively, the patient had doubts and concerns.

But as this patient continued to wait for a surgery, decisions had to be made as to how much pain management would be needed to “hold them over,” until the surgical date.

Corticosteroids are powerful anti-inflammatory substances. They are not used to relieve pain, but rather, to reduce inflammation, which in turn can lessen a patient’s level of discomfort. Numerous studies over the years have shown that prolonged use of cortisone will eventually cause degenerative joint disease in the joints they are injected into.

UNDERSTANDING THE POSSIBLE COMPLICATIONS OF CORTISONE INJECTIONS.

A December 2020 paper in the medical journal Radiology (1) says this:

• Current management of osteoarthritis is primarily focused on symptom control.
• Intra-articular corticosteroid injections are often used for pain management of hip and knee osteoarthritis in patients who have not responded to oral or topical analgesics.
• “Recent case series suggested that negative structural outcomes including accelerated osteoarthritis progression, subchondral insufficiency fracture (stress fractures in the bone beneath cartilage), complications of pre-existing osteonecrosis, and rapid joint destruction (including bone loss) may be observed in patients who received Intra-articular corticosteroid injections .
• The true cause and natural history of these complications are unclear and require further study. To determine the cause and natural history, large prospective studies evaluating the risk of osteoarthritis or joint destruction after Intra-articular corticosteroid injections are needed.

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Marc Darrow MD,JD

We will often see patients who have lingering elbow pain. They continue to receive and remedy themselves with traditional “conservative” treatments that include resting, icing, anti-inflammatory medications and various other health care provided treatments including physical therapy, massage, cortisone injections and even acupuncture. While some will respond to these treatments the patients who come into our office have not. They have been scheduled for one of the many surgical procedures often suggested for treatment of lateral epicondylitis. Most will be recommended to a debridement, the removal of tissue “too far gone,” to be saved.For many, removing tissue may not be their optimal way way to go. These people will reach out to us to discuss the realistic surgical alternatives we can offer. In this report we will discuss PRP and stem cell treatments as well as look at some new research on tennis elbow surgery.

TENNIS ELBOW IN OFFICE WORKERS AND LABORERS

There is a great likelihood that people reading this article have been diagnosed with tennis elbow that have never played tennis in their life. We have seen patients with tennis elbow who were carpenters, rock climbers, office workers, landscapers, golfers, and more. Many never having picked up a racquet.

• Tennis Elbow (lateral epicondylitis) is a term for severe elbow tendonitis, or an inflammation, soreness, or pain on the outside (lateral) part of the upper arm near the elbow.
• It’s usually caused by a partial tear in the tendon fibers, which connect muscle to the bone.
• Symptoms include elbow pain that gradually worsens and radiates outside of the elbow to the forearm and to the back of the hand.

While many of these people have never picked up a racquet, they usually have picked up a shopping cart filled with elbow tapes, braces, and sleeves that they hope will help them.

WHY TAPE, SLEEVES AND PHYSICAL THERAPY DID NOT HELP YOUR ELBOW.

Some people find great comfort in taping up their elbow or getting elbow sleeves. If it helps, then it is a good thing. For many however, sleeves, kinesiotaping, and ace bandages are not really helpful. Some people get great benefit from physical therapy.

A study from July 2019 (1) had three groups of people (10 in each group) with a new onset of elbow pain go to physical therapy. At the physical therapist’s they would receive treatment and taping.

• Ten patients received kinesiotaping plus exercises
• Ten patients received sham taping (Tape that would not help) plus exercises
• Ten patients received  exercises only.

Findings:

• “Kinesiotaping in addition to exercises is more effective than sham taping and exercises only in improving pain in daily activities and arm disability due to lateral epicondylitis.” In other words, this conservative care option of kinesiotaping did not fix the problem of the elbow degeneration.

When conservative treatments do no respond, often a patient is suggested to surgery. In 2018, Australian surgeons made headlines when they published their study in the  American Journal of Sports Medicine comparing tennis elbow surgery to placebo surgery.

HEADLINE: ONE TYPE OF TENNIS ELBOW SURGERY, WITH A TRACK RECORD OF “EXCELLENT” RESULTS, IS FOUND TO BE NO MORE EFFECTIVE THAN PLACEBO OR SHAM SURGERY

Here is what the research team wrote: “A number of surgical techniques for managing tennis elbow have been described. One of the most frequently performed involves excising (shaving away) the affected portion of the extensor carpi radialis brevis (ECRB, a muscle of the forearm). The results of this technique, as well as most other described surgical techniques for this condition, have been reported as excellent, yet none have been compared with placebo surgery.”

When the surgery was compared to a sham surgery, the doctors concluded: “this study failed to show additional benefit of the surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow.”(2) So the surgical removal of damaged tissue did not help the patient anymore than the conservative treatments. How about regenerative treatments?

PRP AND STEM CELLS FOR TENNIS ELBOW – ARE THEY REALISTIC TREATMENT OPTIONS OR NOT?

Platelet Rich Plasma therapy extracts the healing platelets from your blood and then re-injects the Platelet-Rich Plasma into the injured elbow. The research below from leading medical universities and research centers from around the world helps confirm our own observations of these treatments.

PRP injections vs. Cortisone

In December 2018 a multi-national team of doctors wrote in the journal Current reviews in musculoskeletal medicine compared PRP treatments to cortisone for tennis elbow. They wrote that, “The response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis. PRP injection does not seem to have the potential complications associated with a steroid injection such as skin atrophy, discoloration, and secondary tendon tears.” They also noted that in comparison with extracorporeal shockwave, dry needling, or surgical treatments, (PRP injections in tennis elbow seems to be the best-studied intervention.”(3)

• University researchers in India suggest Platelet-rich plasma (PRP) offers a better option for the treatment of lateral epicondylitis. In a comparison of PRP and cortisone injections, the doctors say  PRP is a superior treatment option in the long-term. (4)
• A second study published in the Indian journal of orthopaedics compared single injection of platelet-rich plasma for tennis elbow as compared with single injections of triamcinolone (corticosteroid) and placebo (normal saline) over a short term period.
  • Both the PRP and triamcinolone groups had better pain relief at 3 and 6 months as compared to normal saline group, but at 6 months followup, the PRP group had statistically significant better pain relief than triamcinolone group.
  • In the triamcinolone group, 13 patients had injection site hypopigmentation (loss of skin color) and 3 patients had subdermal (skin and subdermal fat layer) atrophy. (5)
• In the journal The Physician and sportsmedicine, doctors found steroid could slightly relieve pain and significantly improve function of elbow in the short-term (2 to 4 weeks, 6 to 8 weeks). PRP appears to be more effective in relieving pain and improving function in the intermediate-term (12 weeks) and long-term (half year and one year). Considering the long-term effectiveness of PRP, the researchers recommend PRP as the preferred option for tennis elbow.(6)
• Doctors from teaching universities in Thailand examined injections of cortisone, autologous blood injection (simple blood injection) and PRP.  What they found was the blood injection and the PRP injection provided superior results to cortisone for pain reduction and functional improvement. The autologous blood injection had a higher rate of site complication that was significant enough to note.(7)
• A November 2019 study compared the effectiveness of Platelet Rich Plasma injections versus autologous blood injection (blood without making it Platelet Rich), and cortisone. The findings were “PRP was associated with more improvement in pain intensity and 29 function in the long-term than the comparators.”(8)

Long term-benefit of PRP vs Cortisone

• Dutch researchers writing in the American Journal of Sports Therapies documented the positive effects of PRP on tennis elbow. Treatment of patients with PRP reduced elbow pain and increased function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years.”(9)
• British doctors agree – research in the British Journal of Sports Medicine says cortisone should never be used and that injections therapies including PRP can be effective and excellent long-term treatments for elbow pain.(10)

Long term-benefit of PRP vs Physical Therapy

• In some of the more research reported in the surgical journal – Journal of Hand and Microsurgery doctors reviewed and presented their evidence on the effectiveness of PRP injections. They found PRP injections have an important and effective role in the treatment of elbow instability. Here is what they wrote:
  • The majority of sufferers recover within 1 year with conservative management which includes physical therapy. The most effective treatment for chronic lateral epicondylitis, however, is argued amongst experts.
  • In the opinion of this study, after review of the literature, PRP injections have an important and effective role in the treatment of debilitating tennis elbow pathology, in cases where physical therapy has been unsuccessful.
  • Previously, cases that persisted despite physical therapy have been treated with corticosteroid injections. Steroid injections are reported to give short-term pain relief, however the proven recurrence rates and complications (including dermal depigmentation, subcutaneous atrophy, and a theoretical risk of increased tendon rupture) should limit their use.
  • PRP has been shown to provide a continuing long-term benefit in cases of chronic lateral epicondylosis, in the recent literature. It is superior to autologous blood injection injections and placebo/dry needling procedures.(11)

PRP can eliminate the need for elbow surgery

A team of researchers in the United Kingdom wrote in the Journal of orthopaedics (12)

• “Our study adds to the evidence that PRP injection for intractable lateral epicondylitis of the elbow is an acceptable and useful treatment with improvement in symptoms in 56 out of 64 patients (87.5%). It adds to the literature in that we have tried to ascertain the effect of PRP on reducing the need for a complex, risk laden, surgical intervention. . .we consider PRP injection, for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms and have shown it has reduced the need for surgical intervention in this difficult cohort of patients.”

BONE MARROW DERIVED STEM CELLS FOR THE TREATMENT OF TENNIS ELBOW

A study in the Journal of natural science, biology, and medicine (13) found that a bone marrow aspirate (containing plasma rich in growth factors and mesenchymal stem cells) injection was an effective treatment for tennis elbow. In this study, treatment of tennis elbow patients with single injection of bone marrow derived stem cells showed a significant improvement in short to medium term follow-up. In future, such growth factors and/or stem cells based injection therapy can be developed as an alternative conservative treatment for patients of tennis elbow, especially who have failed non-operative treatment before surgical intervention is taken.

The research team suggested that: “In the future, growth factors and/or stem cells based injection can be developed as second line conservative treatment in chronic tendinopathy as they could potentially reverse the degenerative process and encourage the regeneration of healthy tendon.”

More recently a 2018 study in the Journal of orthopaedics (14) commented on the above study:

“Bone marrow aspirate concentrate (BMAC) is an emerging, novel treatment for various bone and cartilage pathology and injury. Similar to other orthobiologic intra-articular injections like hyaluronic acid and PRP, BMAC gives patients the opportunity to restore the natural microenvironment of their damaged or diseased tissue. Bone marrow concentrate is commonly taken from pelvic bone, and contains mesenchymal and hematopoetic stem cells, platelets, growth factors, cytokines, and anti-inflammatory and immunomodulatory cells. . . Further evaluating the efficacy of bone marrow injections, thirty patients who were untreated for Lateral Epicondylitis were evaluated with the Patient-rated Tennis Elbow Evaluation (PRTEE) prior to and following the treatment of a single administration of Iliac Bone Marrow Aspirate. – This concentrate, composed of iliac bone marrow aspirate. . . was effective in simplicity and safety, avoiding further complications as other modes of treatment. Evaluated at 2, 6, and 12 weeks after administration, these patients showed drastic improvement in the two week evaluations, thus showing the efficacy of this treatment’s recovery time. Although (the authors} explained the limitation of their study in long term treatment, they believe that this treatment, when paired with growth factor and other stem cell treatment, can be an effective alternative in lieu of surgery.”

Do you have questions? Ask Dr. Darrow

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

1 Giray E, Bingul DK, Akyuz G. The effectiveness of kinesiotaping, sham taping or exercises only in treatment of lateral epicondylitis: A randomized controlled study. PM&R. 2019 Jan 4.
2 Kroslak M, Murrell GAC. Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial. Am J Sports Med. 2018 Mar 1:363546517753385. doi: 10.1177/0363546517753385.
3 Kwapisz A, Prabhakar S, Compagnoni R, Sibilska A, Randelli P. Platelet-Rich Plasma for Elbow Pathologies: a Descriptive Review of Current Literature. Current reviews in musculoskeletal medicine. 2018 Sep 25:1-9.
4 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. 2015 Jul;9(7):RC05-7. doi: 10.7860/JCDR/2015/14087.6213.
5 Seetharamaiah VB, Gantaguru A, Basavarajanna S. A comparative study to evaluate the efficacy of platelet-rich plasma and triamcinolone to treat tennis elbow. Indian journal of orthopaedics. 2017 May;51(3):304.
6 Mi B, Liu G, Zhou W, Lv H, Liu Y, Wu Q, Liu J. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. The Physician and Sportsmedicine. 2017 Apr 3;45(2):97-104.
7 Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2015 Sep 11.
8 Tang S, Wang X, Wu P, Wu P, Yang J, Du Z, Liu S, Wei F. Platelet-rich plasma versus autologous blood versus corticosteroid injections in the treatment of lateral epicondylitis: a systematic review, pairwise and network meta-analysis of randomized controlled trials. PM R. 2019 Nov 17. doi: 10.1002/pmrj.12287. [Epub ahead of print]
9 Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up.Am J Sports Med. 2011 Jun;39(6):1200-8. Epub 2011 Mar 21.
10 Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, Kong FL, Welle K, Jiang ZC, Kabir K. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med. 2015 Sep 21. pii: bjsports-2014-094387. doi: 10.1136/bjsports-2014-094387.
11 Murray DJ, Javed S, Jain N, Kemp S, Watts AC. Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence.J Hand Microsurg. 2015 Dec;7(2):320-5. doi: 10.1007/s12593-015-0193-3. Epub 2015 Jul 8.
12 Hastie G, Soufi M, Wilson J, Roy B. Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention. Journal of orthopaedics. 2018 Mar 1;15(1):239-41.
13 Singh, A., Gangwar, D. S., & Singh, S. (2014). Bone marrow injection: A novel treatment for tennis elbow. Journal of Natural Science, Biology, and Medicine, 5(2), 389–391. http://doi.org/10.4103/0976-9668.136198
14 Tarpada SP, Morris MT, Lian J, Rashidi S. Current advances in the treatment of medial and lateral epicondylitis. J Orthop. 2018 Feb 2;15(1):107-110. doi: 10.1016/j.jor.2018.01.040. PMID: 29657450; PMCID: PMC5895908.