(PRP) Injection in Treatment of Lateral Epicondylitis ⇑ Enass M

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

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The Egyptian Journal of Radiology and Nuclear Medicine

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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 article info abstract

Article history: Background: Lateral epicondylitis is referred to a degenerative disorder that affects the common extensor Received 15 November 2016 tendon (CET) where it attaches to the lateral epicondyle of the humerus. Nowadays, one of minimally Accepted 4 March 2017 invasive interventions is platelet-rich plasma (PRP) injection that had been explored in some controlled Available online xxxx clinical studies to show its effectiveness in treating lateral epicondylitis through inducing inflammation rather than suppressing it. Keywords: Objectives: The aim of our study was to investigate the effectiveness of ultrasound guided platelet-rich Ultrasound plasma (PRP) injection in treating chronic lateral epicondylitis in addition to identifying the potential Injection of PRP sonographic morphological changes in the common extensor tendon (CET) after PRP injection. Lateral epicondylitis 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 However, medications like non-steroidal anti-inflammatory drugs (NSAIDS), physical therapy, shock wave therapy, botulism Lateral epicondylitis is referred as a degenerative disorder that toxin injection and corticosteroids injection were used to treat lat- affects the common extensor tendon (CET) where it attaches to the eral epicondylitis many studies showed that they did not alter poor lateral epicondyle of the humerus [1]. healing of the CET and had long term course of treatment. In addi- Waseem et al. [2] explained that this condition is not an inflam- tion, adverse side effects of long-run use of NSAIDs like bleeding matory process with no inflammatory cells (e.g. macrophages, lym- ulcers and renal failure and those of corticosteroids like tendon phocytes or neutrophils) could be detected in the affected tissue. atrophy and permanent structural changes, make these types of But, it is a form of tendinosis that affects the common extensor ten- treatments controversial [4]. don with a fibroblastic and vascular response called angio- Nowadays, minimally invasive interventions that stimulate fibroblastic degeneration of CET. Moreover, tennis elbow (TE) is healing response and counteracting the degenerative structural considered a misnomer since tennis player account for only about changes in lateral epicondylitis have been investigated. One of these 5% of all patients suffering from this condition. That make ‘‘lateral emerging technologies is platelet-rich plasma (PRP) injection [5]. epicondylosis” or ‘‘lateral elbow tendinosis” is the most appropriate Platelet-rich plasma is a volume of the plasma fraction of autol- term that express that condition. Despite of this lateral epicondyli- ogous blood having a platelet concentration of 5 times more than tis is more recognized and widely used in the scientific community. base line (5 Â 200,000 platelets/ul). Platelets in PRP contain growth The annual prevalence of lateral epicondylitis is about 1–3% of factors and build up reparative processes. The action of PRP population that induces morbidity secondary to pain and function therapy in chronic tendinopathies is varied and hypothesized to disability that prevents an active life style [3]. include angiogenesis, increase in growth factor expression and cell proliferation, increase the effect of repair cells and tensile strength. Peer review under responsibility of The Egyptian Society of Radiology and Nuclear Lateral epicondylitis may be characterized by complex changes in Medicine. the tendon in addition to an inflammatory process. Therefore, ⇑ Corresponding author. E-mail address: [email protected] (E.M. Khattab). 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 38 years old).The mean time of symptoms was19.95 months more effective as a healing agent [5]. (range 3–36 months). Patients were diagnosed, treated and fol- Diagnostic ultrasound and MRI before PRP injection will help to lowed up in the ultrasound unit in the Radiology Department by confirm clinical diagnosis and establish baseline findings. sonographic assessments at baseline diagnosis, during injection Ultrasound guidance of the injection will ensure precise targeting of PRP, three and six months post procedure. of tissue needle placement and real-time visualization of needle during injection with documentation of changes in tendon mor- 2.1.2. Subjects included in the study phology & structure after PRP injection [6]. US is an excellent option for diagnostic imaging evaluation of Inclusion criteria: lateral epicondylitis, with a reported sensitivity of approximately 1. All patients were suspected to have chronic lateral epi- 80% and specificity of approximately 50%. Tendinosis appears as condylitis as determined on clinical examination (based on tendon enlargement and heterogeneity. Tendon tears are depicted symptoms, site of tenderness and pain elicited with resisted as hypoechoic regions with adjacent tendon discontinuity. Sur- active extension of the wrist in pronation and elbow in rounding fluid and calcification also may be seen [7]. extension) and confirmed with base line ultrasonographic The normal MR imaging appearance of the CET is that of a ver- examination and MRI examinations. tically oriented structure that originates from the lateral epi- 2. History of at least two periods of elbow pain lasting condyle. The tendon should show uniform low signal intensity, >10 days; symptoms lasting at least 3 months or longer. regardless of the imaging sequence used. Tendon morphology is Exclusion criteria: best assessed on coronal and axial images. The MR imaging find- 1. Patients with normal base line ultrasonographic imaging. ings of lateral epicondylitis on both T1- and T2-weighted images 2. Presence of full tendon tear. include intermediate signal intensity within the substance of the 3. Patients received local steroid injection within 3 months of tendon with or without tendon thickening. Partial thickness tears randomization; are seen as a region with the signal intensity of fluid extending 4. Patients received oral non-steroidal anti-inflammatory or partway across the tendon [8]. corticosteroids within 15 days before inclusion in the study. The aim of the present study is to investigate the effectiveness 5. Patients unable to comply with scheduled visits. of ultrasound guided (PRP) injection in treating chronic lateral epi- 6. History of trauma. condylitis in addition to identify the potential sonographic mor- 7. Medical history of rheumatic disorder. phological changes in the CET after PRP injection with respect to All patients were subjected to: the baseline sonographic findings. 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 2. Patients and methods 0 to 10 according to a validated questionnaire called PRTEE Questionnaire (Patient Rated Tennis Elbow Evaluation). It 2.1. Technical design consists of two subscales, PAIN subscale (0 = no pain, 10 = worst imaginable) and FUNCTION subscale (0 = no diffi- 2.1.1. Site of the study, sample size and methods of collection of culty, 10 = unable to do). In addition to the individual sub- patients scale scores, a total score was computed on a scale of 100 Forty-two patients (31 females and 11 males), were included in (0 = no disability) where pain and functional problems are the study with age range from 30 to 50 years old (median of age weighted equally [9]

Table 1 Symptoms before and 6 months after treatment.

Symptoms Before treatment (N = 42) 6 months after treatment Test p-value (Sig.) (N = 42) No. % No. % Impaired grip No 0 0% 16 38.1% 19.765§ <0.001 (HS) Yes 42 100% 26 61.9% Restricted daily activities No 0 0% 9 21.4% 10.080§ <0.001 (HS) Yes 42 100% 33 78.6% Pain No 0 0% 16 38.1% 19.765§ <0.001 (HS) Yes 42 100% 26 61.9% PRTEE pain subscale Mean ± SD 29.97 ± 10.35 19.92 ± 11.61 À5.306a <0.001 (HS) Median (range) 29.50 (12–47) 18 (6–48) PRTEE function subscale Mean ± SD 30.38 ± 11.02 20.30 ± 11.31 À5.297a <0.001 (HS) Median (range) 30 (11–48) 19.50 (4–48) PRTEE total score Mean ± SD 60.35 ± 21.36 40.23 ± 22.79 À5.382a <0.001 (HS) Median (range) 59.50 (23–95) 37.50 (10–96) p < 0.05 is signiﬁcant. Sig.: signiﬁcance. a Wilcoxon signed ranks test. § McNemar test.

3. The pre-procedure gray scale images were classified at base- thickening, abnormal signal intensity or a fluid filled gap in line according to echotexture grading scale system of a study T2WI and STIR sequences. According to these findings we protocol reported by Martin et al. [10] which divided lateral classify the lateral epicondylitis into three grades (mild: ten-

epicondylitis echotexture into grade 1(a),1(b),1(c), 2 and 3. don thickening with abnormal intermediate signal intensity Grade 1(a): hypoechoic lesion less than one third of CET at T2 weighted images, moderate: tendon thickening with Grade 1(b): hypoechoic lesion between one third and two abnormal high signal intensity involving less than two thirds thirds of the tendon. Grade 1(c): hypoechoic lesion more than of tendon thickness, severe: tendon thickening with abnor- two thirds of CET Grade 2: presence of partial tear. Grade 3: mal high signal intensity involving more than two thirds of presence of complete tear. As a protocol of the study, we tendon thickness) [11].

considered grade 1a and 1b as mild cases, grade 1c and 2 as 6. A single injection of platelet-rich plasma (PRP) guided by moderate cases and grade 3 as severe cases. ultrasonography after written consent was performed to 4. Radiological evaluation at baseline by ultrasonographic all the patients. examination of the affected elbow was confirmed by MRI examination before PRP injection. 2.1.3. Preparation of PRP 5. MRI was performed to all patient at baseline and six months Blood was extracted from the patient in a 10 ml syringe, pre- post procedure to confirm the sonographic findings. The pre- loaded with citrate phosphate dextrose (CPD) and then centrifuged procedure MRI findings were including presence of tendon 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 Test p-value (Sig.) (N = 42) No. % No. % Tenderness over lateral epicondyle Absent 0 0% 23 54.8% 31.672§ <0.001 (HS) Present 42 100% 19 45.2% Resisted wrist extension test Absent 0 0% 16 38.1% 19.765§ <0.001 (HS) Present 42 100% 26 61.9% 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 Test p-value (Sig.) (N = 42) No. % No. % Texture Focal 24 57.1% 38 90.5% 12.070§ 0.001 (S) Diffuse 18 42.9% 4 9.5% Grade 1a 0 0% 16 38.1% 43.972à <0.001 (HS) 1b 8 19% 21 50% 1c 18 42.9% 4 9.5% 2 16 38.1% 1 2.4% Thickness of tendon (mm) Mean ± SD 7.87 ± 1.07 7.26 ± 1.10 À18.126* <0.001 (HS) Median (range) 7.94 (5.27–9.70) 7.24 (4.80–9.63) Cross sectional (mm2) Mean ± SD 80.34 ± 15.59 69.85 ± 17.21 À5.283a <0.001 (HS) Median (range) 81.37 (53.6–115.2) 68.51 (43.95–122) Tendon tear No tear 26 61.9% 41 97.6% 16.594§ <0.001 (HS) Partial tear 16 38.1% 1 2.4% Calcification Absent 30 71.4% 36 85.7% 17.500§ 0.031 (NS Present 12 28.6% 6 14.3% Degree of tendinosis Mild 8 19% 36 85.7% 38.401à <0.001 (HS) Moderate 18 42.9% 5 11.9% Severe 16 38.1% 1 2.4% 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 Test p-value (Sig.) (N = 42) No. % No. % Tendon thickening Absent 0 0% 5 11.9% 5.316§ <0.001 (HS) Present 42 100% 37 88.1% T2WI and STIR signal intensity Intermediate 26 61.9% 41 97.6% 1.665§ <0.001 (HS) High 16 38.1% 1 2.4% Degree of tendinosis Mild 8 19% 37 88.1% 40.833à <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. 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.

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 E.M. Khattab, M.H. Abowarda / The Egyptian Journal of Radiology and Nuclear Medicine xxx (2017) xxx–xxx 5 from other blood components. Then 2 mL of platelet-rich plasma precautions local anaesthetic injection (2% xylocaine) was done (with absolute platelet count of 1 million platelets/mm3 as con- followed by PRP injection into the affected site with 18-guage ﬁrmed by manual counting) was injected into the affected site. needle, the patient is advised to rest for approximately 1 h after the procedure. 2.1.4. Procedure of injection The patient is placed supine with affected upper limb in neu- 7. Patients were informed about the post procedure protocol. tral position, the site is palpated for maximum point of tender- They were rescheduled for a follow up appointment three and ness before giving a local anaesthetic. Under complete aseptic 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 2 2 (65.87 mm ), red arrow showed cross section of the hypo-echoic area (28 mm ) 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 3. Physical therapy should be avoided at least two weeks after the were performed six months after PRP injection with compar- procedure. ison between both pre and post procedure clinical and radiolog- 4. Gradual return to activity over 6–8 weeks. ical findings. 2.3. Follow-up program 2.2. Post-procedure protocol All patients were evaluated at baseline clinically and radiologi- Patients were educated for short-term and long-term cally (US & MRI). The following visit was after three months, expectations: patients were re-evaluated clinically and sonographically and findings were recorded. 1. PRP injection promotes local inflammation, so we told them Final follow up was done after six months with post procedure that pain should be expected, and can be treated with ice and clinical and radiological re-evaluation and recording the findings. narcotic prescription such as Acetaminophen. 2. Anti-inflammatory drugs (NSAIDs) should be avoided for at 1. Clinical reevaluation by: least two weeks. – Answering PRTEE Pain Subscale Questionnaire.

– Answering PRTEE Function Subscale Questionnaire. MedCalc 13 for windows (MedCalc Software bvba, Ostend, – Computing the total PRTEE Total Score where pain and func- Belgium). tion equally weighted. Quantitative data were expressed as the mean ± SD & median 2. Radiological re-evaluation by: (range), and qualitative data were expressed as absolute frequen- – Ultrasound. cies ‘‘number”& relative frequencies (percentage). – MRI. 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 2.4. Statistical analysis test was used for non-normally distributed data. Percent of paired categorical variables were compared using All data were collected, tabulated and statistically analyzed Chi-square test or McNemar test when appropriate. All tests were using SPSS 19.0 for windows (SPSS Inc., Chicago, IL, USA) & 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 2 2 CET showing cross section of the tendon (108 mm ), and cross section of the hypo-echoic area (78 mm ), 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 ian age of 38 years old (range 30–50 years). They were 31 Females was considered highly statistically significant (HS), and p 0.05 (73.8%) and 11 males (26.2%).The right arm (54.8%) was more was considered non statistically significant (NS). affected than the left one (45.2%). At the baseline 42 patients were classified sonographycally as 3. Results 19% mild cases (8 patients grade1b), 42.9% moderate cases (18 patients grade 1c) and 38.1% severe cases (16 patients grade 2). All the patients (42 patients) included in the study were diag- Six months post procedure, degrees of the disease improved into nosed as lateral epicondylitis. The studied group related to a med- 85.7% mild cases (16 patients grade 1a and 21 patients grade 1b),

11.9% moderate cases (4 patients grade 1c) and 2.4% severe cases (1 post procedure (about 50% reduction), the difference was consid- patient grade 2).These results were considered to be highly signif- ered highly significant by statistical analysis. icant improvement in the degree of the disease. Table 4 showed a high statistically significant improvement in Table 1 showed that all patients were complaining of impaired degree of tendinosis, signal intensity, and reduction of tendon grip, restricted daily activities, and pain which all showed high sig- thickness detected by MRI. Statistical analysis showed high signif- nificant improvement after treatment by PRP. Statistical analysis icant reduction in tendon thickening by MRI in 11.9% of tendons. revealed high significant decrease in PRTEE pain subscale six Statistical analysis showed high significant improvement in signal months after treatment by PRP. intensity from 61.9% intermediate signals (8 cases (19%) of mild Table 2 showed at baseline, all patients had showed tenderness degree, 18 cases (42.9%) of moderate degree and 16 cases (38.1%) over lateral epicondyle and resisted wrist extension on clinical of severe degree at baseline, into 37 cases (88.1%) mild degree, 4 examinations, both signs showed high significant improvement cases (9.5%) of moderate degree and 1 case (2.4%) of severe degree after treatment by PRP (p < 0.001). Six months post procedure, ten- at six months post procedure. derness over lateral epicondyle was relieved in 54.8% 0f patients Fig. 1 showed that during follow up sessions, the median of and resisted wrist extension improved in 38.1% of patients during PRTEE pain subscale was decreased from 29.50 (Range 12–47) to clinical examination. 25.50 (Range 10–48) after three months. At six months post proce- Table 3 showed high significant improvement in all ultrasound dure, the pain subscale median decreased into 18 (Range 6–48). findings of common extensor tendon CET in majority of patients. During follow up sessions, the median of PRTEE function There was high significant improvement in the degree of the dis- subscale was decreased from 30 (Range 11–48) to 26.50 (Range ease. There was high significantly decrease in tendon thickness 9–48). Six months post procedure, the function subscale median from mean of 7.87 mm at baseline to 7.26 mm six months post decreased into 19.50 (Range 4–48). PRTEE function subscale procedure (about 6.8% reduction) (p < 0.001). There was high sig- showed high significant improvement (p < 0.001) in 80% of nificantly decrease in cross sectional area of CET from mean of patients six months post procedure. The mean at the base line 80.34 mm2 at baseline to 69.85mm2 at six months post procedure was 30.38 and six months post procedure it decreased into (about 13.06% reduction) (p < 0.001). There was high significantly 20.30.that was considered highly significant by statistical analysis. decrease in number of partial tears from 16 case presented with During follow up sessions, PRTEE total score after three months, partial tear at baseline to just one case still preserve the partial tear the median was decreased from 59.50 (Range 23–95) to 52 (Range after six months (about 93.7% reduction) (p < 0.001). Calcification 19–96). Six months post procedure, PRTEE total score median was decreased from 12 case at baseline to 6 cases at six months 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 pre- injection 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 4. Discussion months post procedure. The mean at the base line was 29.97 and six months post procedure it decreased into 19.92 that was consid- Lateral epicondylitis is also known as Tennis elbow, remains ered highly significant by statistical analysis. one of the most perplexing disorders of musculoskeletal system. PRTEE total score (for both pain and function) showed high sig- Some studies have reported a female preponderance [11], and this nificant improvement (p < 0.001). The mean at the base line was agreed with our results (73.8% females and 6.2% males). 60.35 and six months post procedure it decreased into 40.23. Sta- Connell et al. [12] explained cause of function disability of CET tistical analysis revealed high significant decrease in PRTEE func- in case of lateral epicondylitis is due to decrease the collagen syn- tion subscale six months after treatment by PRP. thesis during one of the healing phases (inflammatory, prolifera- Figs. 2 and 3 showed follow up changes in tendon thickness, tive and remodeling) with changes of repair tissue from cellular cross sectional area, calcification, and degree of CET tendinosis at to fibrous. There is a gradual change from fibrous tissue to scar- 3 and 6 months post procedure (see Cases 1–3). like tendon tissue that interferes with the normal function of mus-

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 E.M. Khattab, M.H. Abowarda / The Egyptian Journal of Radiology and Nuclear Medicine xxx (2017) xxx–xxx 11 cles originating from CET, mainly extension, abduction and adduc- treated with PRP injection for lateral epicondylitis, 27 patients tion of the wrist causing impaired grip and restricted daily activity. were completed magnetic resonance imaging scans at 1 year fol- They [12] reported a small (n = 15) randomized clinical trial of PRP lowing PRP treatment and there was a significant improvement in treatment for lateral epicondylitis. Subjects receiving PRP in a sin- degree tendinosis. gle injection session. They showed 60% improvement at 8 weeks, 81% improvement at 6 months and 93% at 25 months compared 5. Conclusion with their baseline with no adverse effects or complications. In our study, all patients showed high significant improvement after We concluded that ultrasound guided platelet-rich plasma treatment by PRP (p < 0.001) at six months post procedure, tender- (PRP) injection for treatment of lateral epicondylitis was a safe, ness over lateral epicondyle was relieved in 54.8% of patients and minimally invasive and effective procedure in improving the sono- resisted wrist extension improved in 38.1% of patients during clin- graphic and pathological changes of common extensor tendon ical examination. (CET). A qualitative study done by Connell et al. [13] examined the sonographic criteria in 72 patients with lateral epicondylitis and Conflict of interest were correlated with surgical and histological findings. The estab- lished Connell Criteria were a focal hypoechoic area on either a We have no conflict of interest to declare. normal background or a diffuse decrease in echotexture with loss of normal fibrillar pattern, while anechoic foci with no intact fibers References were thought to represent partial or complete tears. In our study we classify our findings in lateral epicondylitis according to Martin [1] Cohen M, Motta Filho GR. Lateral epicondylitis of the elbow. Rev Bras Ortop et al. [10] whom divided lateral epicondylitis echotexture into 2012;47(4):414–20. grades which were more specific and easy to apply. [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. Lee et al. [14], designed a study for quantitative sonographic [3] Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and measurements of CET with higher diagnostic performance for lat- impact of musculoskeletal disorders of the upper limb in the general eral epicondylitis. The CET cross sectional area greater than or population. Arthritis Rheum 2004;51:642–51. 2 [4] Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous equal to (32 mm ) in transverse plane and (4.2 mm) thickness in platelet concentrate in lateral epicondylitis in a double-blind randomized longitudinal plane correlated well with presence of lateral epi- controlled trial: platelet-rich plasma versus corticosteroid injection with a 1- condylitis, with sensitivity of 76.5% and specificity of 76.2%. In year 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 agreement with these criteria, in our study, there was high signif- plasma and corticosteroids in the treatment of lateral epicondylitis of icant decrease in cross sectional area of CET from mean of 80.34 at humerus. J Clin Diagn Res: JCDR 2015;9(7):RC05–7. baseline to 69.85 six months post procedure (about 13.06% reduc- [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. tion) (p < 0.001). And these findings were also agreed with Schwarz [7] Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, [15] who reported a decrease in tendon thickness and cross sec- and treatment. RadioGraphics 2010;30:167–84. tional area with normalization of hypoechoic portions of tendon [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 after PRP injection in most of the studies involved ultrasound treatment. J Should Elbow Surg 2005;14:172–7. imaging. [9] Rompe JD, Overend TJ, MacDermid JC. Validation of the patient-rated tennis Chaudhury et al. [16] investigated the altered tendon sono- elbow evaluation questionnaire. J Hand Ther 2007;20(1):3–10 [quiz 11]. graphic morphology following US-guided PRP injection in cases [10] Martin IJ, Merino J, Atilano L, Areizaga ML, Gomez-Fernandez CM, Burgos- Alonso NM, et al. Platelet-rich plasma (PRP) in chronic epicondylitis: study of lateral epicondylitis. This study prospectively evaluated six protocol for a randomized controlled trial. Trials 2013;14:410. patients who had a baseline ultrasound confirming the diagnosis. [11] Walz DM, Newman JS, Konin GP, et al. Epicondylitis: pathogenesis, imaging, Five patients demonstrated improved tendon morphology using and treatment. Radiographics 2010;30:167–84. [12] Connell DA, Ali KE, Ahmed M, Lambert S, Corbett S, Curtis. Ultrasound-guided ultrasound imaging 6 months post procedure (one patient was lost autologous blood injection for tennis elbow. Skeletal Radiol 2006;35:371–7. to follow up). They concluded that PRP therapy for lateral epi- [13] Connell D, Burke F, Coombes P, McNealy S, Freeman D, Pryde D, et al. condylitis can improve CET morphology following US guided PRP Sonographic examination of lateral epicondylitis. AJR Am J Roentgenol 2001;176:777–82. injection. This agreed with our results, about 85.7% of tendons [14] Lee MH, Cha JG, Jin W, Kim BS, Park JS, Lee HK. Utility of sonographic had an improvement in the grade of tendenosis with significant measurement of the common tensor tendon in patients with p value (<0.001), the number of partial tears had decreased from lateralepicondylitis. AJR Am J Roentgenol 2011;196:1363–7. [15] Schwarz A. A promising treatment for athletes, in blood. The New York Times; 16 (38.1%) at baseline to 1 (2.4%). Calcification was decreased from February 17, 2009. 12 case at baseline to 6 cases (50% reduction), the difference was [16] Chaudhury S, Lama M, Adler RS, Gulotta LV, Skonieczki B, Chang A, et al. considered highly significant by statistical analysis. Platelet-rich plasma for the treatment of lateral epicondylitis: sonographic assessment of tendon morphology and vascularity (pilot study). Skeletal In our study MRI could predict abnormal findings in all the 42 Radiol 2013;42:91–7. patients and it was our gold slandered to establish the ultrasound [17] Van Kollenburg JA, Brouwer KM, Jupiter JB, et al. Magnetic resonance imaging findings before and after treatment with PRP, and this agreed signal abnormalities in enthesopathy of the extensor carpi radialis longus with many previous studies [17–19] that found majority of origin. J Hand Surg Am 2009;34:1094–8. [18] Savnik A, Jensen B, Norregaard J, et al. Magnetic resonance imaging in the patients with clinical diagnosis of chronic lateral epicondylitis evaluation of treatment response of lateral epicondylitis of the elbow. Eur have signal changes on MR. Also our MRI findings were agreed Radiol 2004;14:964–9. with Martin CE and Schweitzer ME [20] about appearance of [19] Thornton R, Riley GM, Steinbach LS. Magnetic resonance imaging of sports injuries of the elbow. Top Magn Reson Imag 2003;14:69–86. CET tendinopathy in lateral epicondylitis which included an [20] Martin CE, Schweitzer ME. MR imaging of epicondylitis. Skeletal Radiol increased T2WI and STIR signal within or around the CET and ten- 1998;27:133–8. don thickening. This is also confirmed by a meta-analysis study [21] Pasternack I, Tuovinen EM, Lohman M, et al. MR findings in humeral epicondylitis. A systematic review. Acta Radiol 2001;42:434–40. showing that 90% of patients with lateral epicondylitis had abnor- [22] Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous mal signal in CET of affected elbows compared with 14% of con- platelet concentrate in lateral epicondylitis in a double-blind randomized trols [21]. Our results were agreed with a study done by controlled trial: platelet-rich plasma versus corticosteroid injection with a 1- year follow-up. Am J Sports Med 2010;38:255–62. Peerbooms et al. [22], who mentioned that out of 51 patients

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