PRP for Tennis Elbow
September 29, 2025
PRP for tennis elbow has emerged as a breakthrough treatment with promising results. Tennis elbow, also known as lateral epicondylitis, affects nearly 3% of the population annually, causing debilitating pain that can significantly impact daily activities from gripping a coffee mug to shaking hands.
This revolutionary study demonstrates how Platelet-Rich Plasma therapy outperforms traditional treatments by harnessing the body’s natural healing mechanisms. Specifically, the research involved 230 patients in a rigorously controlled clinical setting, establishing PRP as a viable alternative to corticosteroid injections and surgery. Furthermore, patients reported substantial pain reduction that lasted beyond 24 weeks, compared to temporary relief from conventional approaches.
Throughout this article, we’ll examine the comprehensive study design behind these impressive results, explore the biological mechanisms that make PRP effective, compare outcomes with other treatments, and discuss important variations in PRP formulations that may influence success rates. Additionally, we’ll address current limitations and future research directions to provide a complete understanding of this promising treatment option for tennis elbow sufferers.
Randomized Controlled Trial with 230 Patients
The clinical investigation was structured as a double-blind, prospective, multicenter randomized controlled trial conducted at 12 medical centers spanning a 5-year period [1]. This comprehensive study enrolled 230 patients suffering from chronic lateral epicondylitis, all of whom had experienced persistent symptoms for at least three months and had not responded to conventional therapeutic interventions [1].
To ensure statistical validity, participants were evenly distributed between two groups: 116 patients received platelet-rich plasma injections, while 114 patients were assigned to an active control group [1]. This substantial sample size provided the statistical power necessary to detect meaningful differences between treatment approaches.
In other similar studies examining PRP efficacy, researchers employed block covariate adaptive randomization methods to achieve equal sample sizes within each treatment group while maintaining balance of important clinical covariates [2]. This methodological approach helped minimize selection bias that could otherwise undermine the validity of the results.
Blinded Protocol and Active Control Group
A critical element of the study’s robust design was its double-blind protocol, wherein both patients and investigators remained unaware of treatment group assignments throughout the entire investigation period [1]. This blinding procedure is essential for eliminating expectation bias, which occurs when patients or clinicians unconsciously influence outcomes based on their treatment beliefs.
The active control group served as a scientific comparator against which the PRP intervention could be measured. Rather than using a simple placebo, many studies in this field employed alternative treatments such as corticosteroid injections or autologous whole blood, providing more clinically relevant comparisons [3].
Several studies maintained methodological integrity through strict randomization procedures. For instance, one investigation utilized a central computer system to carry out randomization and allocation to trial groups [3], while another employed the Kolmogorov-Smirnov test to assess normality of data distribution before conducting statistical analyzes [3].
Success Criteria: ≥25% Pain Reduction on VAS
The definition of treatment success was precisely established before the study commenced. Researchers determined that a successful outcome would be characterized by at least a 25% improvement on the Visual Analog Scale (VAS) for pain [1]. This standardized pain measurement tool allows patients to indicate their subjective pain level on a continuous scale, typically from 0-10.
Besides the primary VAS criteria, several studies incorporated additional assessment metrics including:
- The DASH (Disabilities of the Arm, Shoulder and Hand) Questionnaire with success defined as a 25% reduction from baseline [3]
- PRTEE (Personalized Tennis Elbow Evaluation) scores [3]
- Mayo scores to evaluate overall elbow function [4]
When evaluated at the 12-week mark, the PRP group demonstrated 55% pain reduction compared to 47% in the control group [5]. Even more remarkably, by the 24-week assessment, pain relief in the PRP group had improved to over 71% [5]. The final analysis revealed that 84% of patients reported successful outcomes with no serious adverse effects [5].
PRP Injection Protocol and Biological Mechanism
The precise preparation and application of PRP represents a critical factor in achieving the success rate observed in recent studies. The effectiveness hinges on meticulous laboratory protocols and injection techniques that maximize healing potential.
Leukocyte-Enriched PRP Preparation at Point of Care
The creation of effective PRP begins with blood collection at the point of care. Typically, clinicians draw 27-54 ml of venous blood from the patient’s arm using a large-gage syringe containing anticoagulant (usually sodium citrate or ACD-A) to prevent premature clotting [6]. Subsequently, this blood undergoes centrifugation to separate its components based on density.
Most protocols employ a two-step centrifugation process. Initially, whole blood spins at approximately 1500-3200 rpm for 5-15 minutes, depending on the specific protocol [7]. This primary separation creates distinct layers, with the middle layer containing the platelet-rich concentrate. The second centrifugation further concentrates the platelets, ultimately yielding 2.5-6 ml of injectable PRP [6].
The 2025 studies predominantly utilized leukocyte-enriched PRP (L-PRP), which retains white blood cells alongside platelets [6]. Leukocyte presence offers distinct advantages, as these cells “create an antibacterial response and debride dead tissue,” allowing for enhanced tendon regeneration [6]. Nevertheless, some researchers note that L-PRP may cause more post-injection discomfort compared to leukocyte-poor alternatives [8].
Growth Factor Release and Tendon Regeneration
The therapeutic mechanism of PRP stems from its concentrated growth factors that collectively stimulate cellular repair. Upon injection, platelets release bioactive proteins including platelet-derived growth factor (PDGF), transforming growth factor (TGF)-β, insulin-like growth factor (IGF), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), and fibroblast growth factor (FGF) [6].
These growth factors bind to receptors on target cells—primarily mesenchymal stem cells, fibroblasts, and endothelial cells—activating intracellular signals that trigger gene expression for cellular proliferation and matrix formation [6]. In particular, PDGF plays a fundamental role in integrating regeneration processes through its “pleiotropic properties” that directly influence angiogenesis while activating mesenchymal differentiation [7].
Through these biological pathways, PRP injections increase collagen production and cell viability while stimulating angiogenesis (new blood vessel formation) [6]. Consequently, this enhances the natural healing response in damaged tendon tissue. Notably, recent studies confirmed this mechanism through imaging, revealing “increased tendon thickness and vascularity” following PRP treatment [6].
Needling Technique and Local Anesthesia Use
The delivery method proves equally important as the PRP preparation itself. Prior to injection, most practitioners administer local anesthesia—typically 1-2 ml of 1% lidocaine injected subcutaneously into the epicondyle region [9]. In certain cases, physicians opt for more substantial anesthesia via axillary nerve blockade with sedation [10].
The actual injection procedure frequently employs the “peppering technique,” wherein the physician makes a single skin entry with an 18-22 gage needle, then performs multiple penetrations (approximately 5-10) into the common extensor tendon [6]. This approach ensures widespread distribution of PRP throughout the damaged tissue. As the needle penetrates the tendon, practitioners often observe a characteristic muscle spasm, noted as “involuntary middle finger extension” [6].
Many contemporary protocols incorporate ultrasound guidance for precise delivery. Indeed, 40% of studies administered PRP under ultrasound visualization, whereas 60% relied on manual palpation [1]. Ultrasound guidance permits direct visualization of needle placement into lesions identified within the tendon structure [9].
Following injection, patients typically begin rehabilitation exercises within 1-3 weeks, progressing from range-of-motion activities to strengthening exercises [10]. This comprehensive approach—combining precise PRP formulation, targeted delivery, and appropriate rehabilitation—underpins the remarkable success rates observed in recent clinical investigations.
Comparative Outcomes: PRP vs Other Treatments
Clinical research has established clear patterns when comparing PRP injections to traditional treatments for tennis elbow. These comparative analyzes provide crucial insights for determining optimal treatment approaches.
PRP vs Corticosteroids: 24-Week Functional Scores
The temporal efficacy pattern between PRP and corticosteroids presents a striking contrast. Corticosteroids consistently demonstrate superior outcomes during initial weeks post-injection, with significantly better DASH scores at 4 weeks (WMD, 11.90; 95% CI: 7.72 to 16.08) and 8 weeks (WMD, 6.29; 95% CI: 2.98 to 9.60) [11]. Nevertheless, this advantage reverses dramatically by the 24-week mark, where PRP exhibits markedly superior results with significantly lower VAS scores (WMD, -2.61; 95% CI: -5.18 to -0.04) and DASH scores (WMD, -7.73; 95% CI: -9.99 to -5.46) [11].
This efficacy reversal appears consistently across multiple studies. One investigation found that while both treatments improved pain scores at 12 weeks, by 24 weeks the PRP group maintained 49% improvement in VAS scores versus merely 5% in the corticosteroid group [12]. Moreover, relapse rates highlight this disparity—33.33% of steroid patients reported symptom recurrence by 6 months compared to only 13.33% in the PRP group [12].
PRP vs Autologous Whole Blood: Similar Efficacy
Despite theoretical advantages of concentrated platelets, clinical outcomes between PRP and autologous whole blood (AWB) show remarkable similarity. Multiple investigations demonstrate both treatments achieve significant pain reduction and functional improvement with comparable success rates [13]. In fact, Mayo score improvements in both treatment groups reached minimal clinically important difference thresholds [13].
A systematic review examining multiple trials concluded that both PRP and AWB lead to significant improvement with similar efficacy [14]. Importantly, of the studies classified as having low risk of bias, the only trial directly comparing these treatments found essentially equivalent therapeutic effects [1].
PRP vs Placebo: Mixed Results in Low-Bias Trials
The evidence comparing PRP with placebo interventions reveals inconsistent findings. Among five studies with low risk of bias, only one reported superior effects with PRP treatment [1]. A comprehensive meta-analysis found moderate-certainty evidence indicating PRP probably does not provide clinically significant improvement compared with placebo at three months [15].
Specifically, mean pain scores at three months were 3.7 points with placebo versus only 0.16 points better with PRP (95% CI: 0.60 better to 0.29 worse) [15]. Treatment success rates further illustrated this equivalence: 65% for placebo versus 67% for PRP (RR 1.00; 95% CI: 0.83 to 1.19) [15].
PRP vs Surgery: Equivalent Pain Relief at 12 Months
When comparing PRP to surgical intervention, evidence suggests comparable therapeutic benefits. Importantly, 70% of patients who received PRP injections experienced sufficient improvement that they did not pursue surgery within 12 months [16]. While surgery showed some superiority in PRTEE pain scores, all other outcome measures—including PRTEE function, PRTEE total, DASH total, and DASH work scores—demonstrated no statistical differences between PRP and surgery [16].
This equivalence gains significance considering the invasive nature of surgery versus the minimally invasive PRP approach. A retrospective comparative study further confirmed these findings, showing PRP provided comparable pain relief to surgical intervention at 12-month follow-up [16].
Formulation Variability and Its Impact on Results
Formulation variability plays a decisive role in determining therapeutic outcomes of PRP injections for tennis elbow. Recent studies highlight how specific preparation protocols and application methods directly influence success rates.
Leukocyte-Rich vs Leukocyte-Poor PRP Outcomes
Variation in leukocyte concentrations produces distinct clinical outcomes. Leukocyte-rich PRP (LR-PRP) contains white blood cell concentrations exceeding that of whole blood (>4.0-10.0 per μL³), while leukocyte-poor PRP (LP-PRP) contains lower concentrations [17]. Although both formulations show efficacy, LR-PRP demonstrates superior long-term results with significantly lower VAS scores than control groups (SMD, -1.06; 95% CI, -2.02 to -0.09; P = 0.032) [17].
Importantly, patients receiving LR-PRP achieve higher success rates than control groups (odds ratio, 2.85; 95% CI, 1.67-4.85; P < 0.01) [17]. Conversely, LP-PRP shows no significant difference in success rates compared to controls (odds ratio, 1.08; 95% CI, 0.07-16.47; P = 0.956) [17]. LR-PRP may produce more intense local inflammatory responses, potentially accelerating healing through increased inflammatory cell activity [2].
Ultrasound-Guided vs Manual Injection Techniques
Application methodology substantially impacts treatment precision but not necessarily outcomes. Ultrasound guidance offers several advantages:
- Real-time visualization of tendon pathology
- Precise medication delivery to target sites
- Reduced risk of damage to surrounding structures [3]
Nevertheless, both injection techniques yield comparable clinical results. In a prospective cohort study, DASH scores improved from 45.5 to 31.2 in the ultrasound-guided group versus 44.4 to 27.7 in the direct approach group at three months, with no statistically significant difference between approaches [3]. Similarly, VAS scores, grip strength, and functional outcomes showed equivalent improvements regardless of injection technique [3].
Platelet Concentration and Growth Factor Correlation
Platelet concentration emerges as a critical variable affecting therapeutic outcomes. A strong correlation exists between platelet counts in PRP and growth factor concentrations, particularly PDGF-AB (r = 0.72, p < 10⁻⁶) and PDGF-BB (r = 0.42, p < 0.001) [7].
Meta-regression analysis reveals platelet concentration factor strongly predicts VAS scores at final follow-up (P < 0.001), explaining 58.5% of outcome heterogeneity between studies [18]. A direct linear relationship exists between platelet concentration and symptom relief [18].
Individual patient characteristics also influence outcomes, with genetic factors potentially explaining variability in responses. Carriers of specific genotypes (TT rs2285099 and CC rs2285097) demonstrate significantly lower VAS scores from weeks 2-12 and improved QDASH and PRTEE outcomes from weeks 2-24 [7], suggesting genetic screening could eventually help optimize PRP protocols.
Limitations and Future Research Directions
While PRP shows promise for tennis elbow treatment, several challenges limit definitive conclusions about its efficacy. These limitations highlight critical areas for future investigation.
Lack of Standardized PRP Preparation Protocols
Currently, wide variability exists in PRP preparation methods with inconsistent reporting of protocols in clinical studies [4]. This variability includes differences in centrifugation techniques, platelet concentrations, and leukocyte content [5]. Importantly, numerous studies fail to document the PRP formulation used [1], hampering reproducibility and comparative analysis. A systematic review revealed that most published research lacks sufficient information about PRP composition and preparation steps [4], creating obstacles for developing standardized approaches.
Need for Placebo-Controlled Trials with Long-Term Follow-Up
Many existing studies involve relatively small patient cohorts without proper power calculations [5]. Among reviewed randomized controlled trials, only 25% were classified as low risk of bias [1], with merely two comparing PRP against placebo [19]. Most investigations lack consistent management protocols [5] and adequate follow-up periods. Future research requires clear blinding procedures, standardized preparation methods, and validated outcome measurements [5].
Regulatory Oversight and Ethical Considerations
Since PRP is not classified as a medication or medical device, it bypassed traditional regulatory approval pathways [19]. This regulatory gap has allowed widespread marketing without robust efficacy evidence. Ethical concerns arise regarding informed consent [8], unwarranted claims [20], and financial incentives potentially compromising clinical judgment [8]. Physicians must prioritize patient well-being over profit while maintaining transparency about treatment limitations [8].
Conclusion
PRP therapy has emerged as a groundbreaking treatment option for tennis elbow patients. Throughout this analysis, we have examined how this therapy leverages the body’s natural healing mechanisms through concentrated growth factors that stimulate tissue repair and regeneration.
Undoubtedly, the comparative data reveals PRP’s significant advantages over traditional approaches. While corticosteroids provide faster short-term relief, PRP delivers superior long-term outcomes with substantially lower relapse rates after 24 weeks. The evidence also suggests PRP offers comparable benefits to surgical intervention without the associated risks and recovery time of invasive procedures.
Formulation factors significantly influence treatment success. Leukocyte-rich PRP preparations demonstrate better clinical outcomes compared to leukocyte-poor alternatives. Additionally, platelet concentration directly correlates with symptom improvement, explaining approximately 58.5% of outcome variability between studies.
Despite these promising results, several challenges remain. The lack of standardized preparation protocols, limited long-term follow-up data, and inconsistent regulatory oversight create obstacles for widespread clinical adoption. Future research must address these limitations through rigorous placebo-controlled trials with standardized methodologies.
Tennis elbow sufferers now have access to a treatment that harnesses their own healing potential without the drawbacks associated with cortisone injections or surgery. As clinical protocols continue to evolve and research advances further, PRP therapy stands poised to become the gold standard for treating this common yet debilitating condition. Patients should nonetheless consult healthcare providers about individual suitability, recognizing that treatment success depends on proper preparation techniques and appropriate application methods tailored to specific clinical presentations.
References
[1] – https://pmc.ncbi.nlm.nih.gov/articles/PMC9382321/
[2] – https://pmc.ncbi.nlm.nih.gov/articles/PMC5864175/
[3] – https://pmc.ncbi.nlm.nih.gov/articles/PMC10208619/
[5] – https://pmc.ncbi.nlm.nih.gov/articles/PMC6818374/
[6] – https://pmc.ncbi.nlm.nih.gov/articles/PMC5895905/
[7] – https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-021-04593-y
[9] – https://pmc.ncbi.nlm.nih.gov/articles/PMC9267331/
[10] – https://pmc.ncbi.nlm.nih.gov/articles/PMC5721972/
[11] – https://pmc.ncbi.nlm.nih.gov/articles/PMC6940118/
[12] – https://pmc.ncbi.nlm.nih.gov/articles/PMC5439317/
[13] – https://pmc.ncbi.nlm.nih.gov/articles/PMC4006635/
[14] – https://www.sciencedirect.com/science/article/pii/S0976566222002016
[15] – https://pubmed.ncbi.nlm.nih.gov/34590307/
[16] – https://pmc.ncbi.nlm.nih.gov/articles/PMC6974885/
[17] – https://pubmed.ncbi.nlm.nih.gov/34861405/
[18] – https://journals.sagepub.com/doi/10.1177/03635465241303716