The effects of inclusion of minimal-dose corticosteroid in autologous whole blood and dextrose injection for the treatment of lateral epicondylitis

Abstract

BACKGOUND:

Lateral epicondylitis (LE) is one of the most common musculoskeletal disorders that causes pain.

OBJECTIVES:

We evaluated the effect of the inclusion of a minimal dose of corticosteroid in a solution comprising autologous whole blood (AWB), 20% dextrose, and 2% lidocaine for treating LE.

METHODS:

In this randomized prospective trial LE patients were allocated to the CS $+$ group ( $n=$ 70; solution comprising 1 mL AWB, 1 mL 20% dextrose, 0.4 mL 2% lidocaine, and 0.1 mL (0.4 mg) dexamethasone palmitate; injected into the common wrist extensor tendon) or the CS $-$ group ( $n=$ 70; same solution as above but without dexamethasone palmitate). Five injections were administered at monthly intervals. At each visit, pain intensity was evaluated using the numeric rating scale (NRS), and grip strength was measured using a hand-grip dynamometer.

RESULTS:

In the CS $+$ and CS $-$ groups, 1 and 10 patients dropped out, respectively. In both groups, the NRS scores at each evaluation were significantly lower than the pretreatment scores. The NRS scores from pretreatment to the second and third visits were significantly lower in the CS $+$ group than those in the CS $-$ group. However, at the fourth and fifth visits, and 6 months after the last injection (the sixth visit), the degree of pain reduction between the groups was not significantly different. Grip strength increased significantly over time in both groups. At each evaluation, grip strength was significantly higher than that at the pretreatment stage. However, the degree of increase was not significantly different between groups.

CONCLUSIONS:

The inclusion of a minimal dose of corticosteroid in the AWB and 20% dextrose injection can reduce pain, especially during early treatment.

Keywords

Lateral epicondylitis pain corticosteroid autologous whole blood dextrose

1. Introduction

Lateral epicondylitis (LE) is one of the most common musculoskeletal disorders that causes pain and occurs in 1–3% of the general population each year [1]. The site of pain is the lateral part of the elbow, and this pain is aggravated when extending the wrist joint and lifting objects [2, 3]. LE-related pain can cause disability and impact a patient’s emotional state [4]. Corticosteroid injection is the most common treatment for LE [5, 6]. However, corticosteroid injection only has a short-term pain-reducing effect and can induce several adverse effects, such as fat atrophy, tendon tear, and hypothalamic-pituitary-adrenal axis deterioration [7, 8]. In addition, as LE is a degenerative disorder, regeneration-inducing treatments are more appropriate than corticosteroid injections.

Recently, the injection of autologous blood products (ABPs) has been suggested as an alternative treatment for LE [9, 10, 11]. ABPs include autologous whole blood (AWB) and platelet-rich plasma (PRP), both of which contain growth factors that can aid the healing of injured soft tissues [10]. Although centrifugation is required to isolate and concentrate platelets for the preparation of PRP, no preparation is necessary for AWB injections. Several previous studies have demonstrated the pain-reducing effect of AWB injections [6, 9, 11].

Prolotherapy is a regenerative or proliferative therapy [12, 13]. The primary principle of prolotherapy is the injection of a relatively small volume of an irritant or sclerosing solution in painful ligaments or tendons [14]. Among the solutions available for prolotherapy, hypertonic dextrose is the most commonly used in clinical practice because it is inexpensive and induces few adverse effects. Hypertonic dextrose induces the osmotic rupture of tissue cells, which results in the release of growth factors, neovascularization, and sclerosis [15, 16, 17, 18]. These phenomena induce the healing of damaged tissue and reduce musculoskeletal disorder-associated pain.

However, during and after AWB injection or prolotherapy, patients experience moderate pain and soreness. For prolotherapy, injections should be administered every 2–6 weeks, and some patients might abstain from treatment in the middle of the prolotherapy course. Low-dose corticosteroid injections provide immediate and short-term pain relief [19]. Therefore, we propose that they may enhance patient compliance and increase the pain-reducing effect of AWB injection and prolotherapy. In the current study, we evaluated the effect of the inclusion of a minimal dose of corticosteroid (0.1 mL of dexamethasone palmitate) in a solution comprising 1 mL of AWB, 1 mL of 20% dextrose, and 0.4 mL of 2% lidocaine for treating patients with LE.

2. Methods

2.1 Patients

This single-center, prospective, randomized, comparative study was conducted in an outpatient pain clinic. We included 140 consecutive patients who met the following inclusion criteria: 1) $\geqslant$ 20 years of age; 2) lateral elbow pain of at least 2 months; 3) experiencing pain upon palpation of the lateral epicondyle (or the origin of the common wrist extensor tendon at the elbow) and resistance in wrist extension test; 4) common wrist extensor tendon tear at its origin confirmed by ultrasound; 5) refractory to oral medication or other treatment modalities; 6) pain intensity of $\geqslant$ 4 on the numeric rating scale (NRS), where 0 indicated no pain and 10 indicated the worst pain imaginable; 7) normal anteroposterior and lateral radiographs of the affected elbow; and 8) pain intensity had not changed over the last 4 weeks. The following exclusion criteria were employed: 1) bilateral LE, 2) rheumatoid arthritis, 3) infectious disease, 4) pregnancy, 5) overweight (body mass index $<$ 30 kg/m ${}^{2}$ ), 6) uncontrolled high blood sugar, 7) concurrent shoulder, neck, arm (proximal to the elbow), or medial elbow pain on the affected side; 8) neurological symptoms or abnormal neurological findings in the affected upper arm; 9) psychological problems; and 10) history of elbow surgery. A randomization table was used to assign each of the 140 patients to one of two groups: the CS $+$ group (comprising 70 patients (age range: 37–71 years) who received injections containing a minimal dose of corticosteroid) or the CS $-$ group (comprising 70 patients (age range: 38–67 years) who received injections without corticosteroids]. The Institutional Review Board of Yeungnam University Hospital, Daegu, Republic of Korea (number 2018-03-14) approved this study, and all patients signed an informed consent form.

Table 1
Subject demographics and baseline clinical data

	CS $+$ group	CS $-$ group	$p$
Number ( $n$ )	69	60
Age (years) (range)	50.0 $\pm$ 6.8 (37–71)	49.3 $\pm$ 7.4 (38–67)	0.57
Male:Female ( $n$ )	28:41	28:32	0.48
NRS (pre-treatment)	7.0 $\pm$ 0.4	6.9 $\pm$ 0.5	0.15
Grip strength (kg) (pre-treatment)	20.9 $\pm$ 8.0	22.0 $\pm$ 7.7	0.36
Pain duration (weeks)	22.5 $\pm$ 20.0	193 $\pm$ 167	0.32

The values presented are numbers or the mean $\pm$ standard deviation. Abbreviations: NRS, numeric rating scale.

2.2 Injections

The patients were blinded to the treatments. The injection was administered under ultrasound guidance (Venue 50, GE Healthcare, Seoul, Republic of Korea) with the subject in the supine position (Fig. 1). The patients in the CS $+$ group were injected with a solution comprising 1 mL of AWB, 1 mL of 20% dextrose, 0.4 mL of 2% lidocaine, and 0.1 mL (0.4 mg) of dexamethasone palmitate (Limethason). Patients in the CS $-$ group were injected with a solution comprising 1 mL of AWB, 1 mL of 20% dextrose, and 0.4 mL of 2% lidocaine. For the injection, a 3-milliliter syringe was used. AWB was withdrawn from the ipsilateral upper extremity. The injection was administered at the tear site of the common wrist extensor tendon such that the torn tendon was not opened too much. The injection volume was between 0.2 mL and 1 mL, and was dependent on the degree of tearing. Therefore, the injected dose of dexamethasone palmitate was set at 0.032–0.16 mg per patient. We determined the dose of dexamethasone palmitate on the basis of the previous study. In this previous study, 10 ${}^{-7}$ M ( $=$ 0.036 mg) dexamethasone was used for inducing proliferation and terminal differentiation of osteogenic cells [20]. Considering the usual dose (10 mg) of dexamethasone injected to control LE-related pain [21], the dose used in our patients (0.032–0.16 mg) seems to be the minimal dose. Each patient received five injections at monthly intervals. All injections were administered by an experienced physician. During the injections, a nurse assisted the physician.

Figure 1.

A solution comprising 1 mL of AWB, 1 mL of 20% dextrose, 0.4 mL of 2% lidocaine, and 0.1 mL of dexamethasone palmitate was administered under ultrasound guidance into the common wrist extensor tendon.

2.3 Outcome assessment

All outcome assessments were performed by a single investigator who was blinded to the group allocation and did not participate in any treatment. The primary outcome was pain intensity, and the secondary outcome was grip strength. Pain intensity was measured using the NRS (0 indicated no pain and 10 was the worst imaginable pain; range: 0–10). Current pain intensity in the relaxed hand was measured immediately before each injection on the first to fifth visits. In addition, current pain intensity was measured 6 months (the sixth visit) after the fifth injection. The average monthly pain intensity calculated from the second to the fifth visit was also evaluated.

In addition to the NRS score, grip strength (in kg) was measured using a hand-grip dynamometer (MSD Europe Bvba, Belgium) when the patient was in the sitting position (from the first to the fifth visit). The subjects were asked to grip the dynamometer with their hand on the affected side and apply maximum force. The maximum values from the three tests were recorded. A 1-minute rest period was allowed between each trial. During each trial, the investigator encouraged the patients to grip the dynamometer with maximum force.

2.4 Statistical analysis

The data were analyzed using SPSS (version 24.0; IBM Corporation, Armonk, NY, USA). Demographic data were compared between the groups using the independent $t$ -test, chi-square test, and Fisher’s exact test. The changes in the NRS score and grip strength in each group were evaluated using repeated-measure one-factor analysis. A repeated-measure two-factor analysis was used to compare the changes between the groups over time. The Bonferroni correction was used to adjust for multiple comparisons. A $p$ -value $<$ 0.05 indicated significance.

3. Results

Demographic data, including age, sex, symptom duration, initial NRS, and initial grip strength were not significantly different between the CS $+$ and CS $-$ groups ( $p>$ 0.05, independent $t$ -test and chi-square test) (Table 1). In the CS $+$ group, one patient dropped out and did not return for the fifth injection. In the CS $-$ group, 10 patients dropped out (two, three, three, and two patients were lost to follow-up visits 2, 3, 4, and 5, respectively). One patient in each group declined to participate in this study for personal reasons. The other nine patients refused to participate in the study owing to pain during or after the injection. Therefore, the dropout rates were 1.4% and 14.3% in the CS $+$ and CS $-$ groups, respectively. The dropout rate was significantly higher in the CS $-$ group than that in the CS $+$ group ( $p<$ 0.01, Fisher’s exact test). No major adverse events were observed in either group.

Regarding the primary outcome (pain intensity), the current pain intensities in the relaxed hand at the first to the fifth visit and 6 months after the last injection were significantly different over time in both the CS $+$ and CS $-$ groups ( $p<$ 0.01) (Table 2). In both groups, the NRS scores at each evaluation were significantly lower than the pretreatment scores ( $p<$ 0.01) (Table 2). The reduction in the NRS score over time was significantly different between the groups ( $p<$ 0.01) (Table 2). The NRS scores from pretreatment to the second and third visits were significantly more reduced in the CS $+$ group than those in the CS $-$ group (second visit: $p<$ 0.01; third visit: $p=$ 0.04) (Table 2). However, at the fourth and fifth visits, and 6 months after the last injection (the sixth visit), the degree of pain reduction between the groups was not significantly different (third visit: $p=$ 0.82; fourth visit: $p=$ 0.93; fifth visit $=$ 0.68) (Table 2).

Table 2
Current pain intensity (numeric rating scale score) in the relaxed hand measured just before the injection from the to the first to the fifth visit and 6 months after the last injection (6th visit)

	CS $+$ group ( $n=$ 69)	CS $-$ group ( $n=$ 60)
1st visit (pretreatment, measured	7.0 $\pm$ 0.4	6.9 $\pm$ 0.5
just before the injection)
2nd visit	4.0 $\pm$ 0.6 ${}^{*{\dagger}}$	4.7 $\pm$ 0.8 ${}^{*{\dagger}}$
3rd visit	3.7 $\pm$ 0.7 ${}^{*{\dagger}}$	3.9 $\pm$ 0.8 ${}^{*{\dagger}}$
4th visit	3.5 $\pm$ 1.0 ${}^{*}$	3.4 $\pm$ 0.9 ${}^{*}$
5th visit	2.8 $\pm$ 0.8 ${}^{*}$	2.8 $\pm$ 0.6 ${}^{*}$
6th visit	2.2 $\pm$ 0.5 ${}^{*}$	2.1 $\pm$ 0.3 ${}^{*}$

${}^{*}p<$ 0.05: Intragroup comparison between pretreatment (first visit) and post-treatment (second to sixth visits) (repeated-measures one-factor analysis). ${}^{\dagger}p<$ 0.05: Intergroup comparison at each time point (repeated measures two-factor analysis).

Table 3

Average pain intensity (numeric rating scale score) during the 1 month between each visit from the second to the fifth visit

	CS $+$ group ( $n=$ 69)	CS $-$ group ( $n=$ 60)
1st visit (pretreatment, measured	7.0 $\pm$ 0.4	6.9 $\pm$ 0.5
just before the injection)
1st–2nd visits	2.3 $\pm$ 0.4 ${}^{*{\dagger}}$	5.1 $\pm$ 0.8 ${}^{*{\dagger}}$
2nd–3rd visits	2.3 $\pm$ 0.5 ${}^{*{\dagger}}$	4.4 $\pm$ 0.8 ${}^{*{\dagger}}$
3rd–4th visits	2.2 $\pm$ 0.4 ${}^{*{\dagger}}$	3.8 $\pm$ 0.7 ${}^{*{\dagger}}$
4th–5th visits	2.2 $\pm$ 0.4 ${}^{*{\dagger}}$	2.9 $\pm$ 0.5 ${}^{*{\dagger}}$

${}^{*}p<$ 0.05: Intragroup comparison between pretreatment (first visit) and post-treatment (second to fifth visits) (repeated-measures one-factor analysis). ${}^{\dagger}p<$ 0.05: Intergroup comparison at each time point (repeated measures two-factor analysis).

The average monthly pain intensity from the second to the fifth visit was significantly different over time in both the CS $+$ and CS $-$ groups ( $p<$ 0.01) (Table 3). The average NRS scores over each 1-month period between the first and second, second and third, third and fourth, and fourth and fifth visits were significantly more reduced in the CS $+$ group than those in the CS $-$ group ( $p<$ 0.01) (Table 3).

Grip strength, the secondary outcome, increased significantly over time. Grip strengths measured just before the injection at the first to fifth visits were significantly different over time in both the CS $+$ and CS $-$ groups ( $p<$ 0.01) (Table 4). At each evaluation, grip strength was significantly higher than that at the pretreatment stage ( $p<$ 0.01) (Table 4). However, the increase in grip strength was not significantly different between the groups ( $p=$ 0.42) (Table 4).

Table 4

Grip strength (in kg) measured just before the injection from the first to the fifth visit and 6 months after the last injection (sixth visit)

	CS $+$ group ( $n=$ 69)	CS $-$ group ( $n=$ 60)
1st visit (pretreatment)	20.8 $\pm$ 8.0	22.0 $\pm$ 7.7
2nd visit	25.4 $\pm$ 8.9 ${}^{*}$	25.2 $\pm$ 8.1 ${}^{*}$
3rd visit	26.0 $\pm$ 9.0 ${}^{*}$	26.3 $\pm$ 8.6 ${}^{*}$
4th visit	26.6 $\pm$ 9.0 ${}^{*}$	27.5 $\pm$ 8.8 ${}^{*}$
5th visit	28.2 $\pm$ 9.1 ${}^{*}$	28.7 $\pm$ 8.8 ${}^{*}$

4. Discussion

In this study, we evaluated the effect of the addition of a minimal dose of corticosteroid to a mixture of AWB and 20% dextrose for treating LE patients.

NRS scores were significantly reduced after the injection of AWB and 20 mL of dextrose, regardless of the inclusion of a minimal dose of corticosteroid. Once the entire treatment course (five injections) was completed, the painreducing effect was sustained for at least 6 months. The current pain intensity in the relaxed arm was significantly lower in the CS $+$ group than that in the CS $-$ group at the second and third visits. However, from the fourth visit, the painreducing effects were not significantly different between the groups. Thus, the inclusion of corticosteroids in a combination AWB and 20% dextrose reduces LE-related pain during the initial treatment period (from 2 months after treatment initiation).

In addition, a greater reduction in average pain intensity was observed in the CS $+$ group than that in the CS $-$ group over the 4-month treatment period. This result indicates the superior pain-reducing effect of the combination of corticosteroids with a mixture of AWB and 20% dextrose. After AWB and prolotherapy with dextrose, local pain and soreness in the injection site usually persist for 5 to 7 days after treatment [14]. Although a minimal dose of corticosteroid was used, we believe that it might reduce the pain generated in response to the injection of AWB and prolotherapy. This incorporation of corticosteroid appeared to be correlated with a lower dropout rate following the treatment.

Grip strength increased following injection. However, the degree of increase in grip strength did not differ between groups. Grip strength increases when the wrist extension position is between 15 ${}^{\circ}$ and 30 ${}^{\circ}$ [22]. Therefore, pain during wrist extension interferes with grip strength. The reduction in elbow pain during wrist extension after treatment appears to increase grip strength [23].

AWB and prolotherapy activate tendon repair and regeneration by recruiting growth factors and growth hormones, stimulating fibroblast proliferation, migration and collagen production, and inducing angiogenesis [10, 15, 16, 17, 18]. The healing of the degenerated common wrist extensor tendon appears to result in a reduction in LE-related pain. We mixed 0.1 mL of dexamethasone palmitate with the 2.4-milliliter solution containing AWB, 20% dextrose, and 2% lidocaine and injected 0.2–1 mL of this solution. Therefore, the total injected dose of dexamethasone was 0.032–0.16 mg. Corticosteroids have a strong anti-inflammatory effect; accordingly, they hinder the secretion and action of growth factors and hormones [24] and may induce tendon rupture [7]. However, in our study, the dose of dexamethasone injected was extremely low. Therefore, the corticosteroid did not significantly interfere with the regeneration of the degenerated tendon. Instead, it reduced pain during the early period of treatment.

Several studies have shown the positive pain-reducing effect of AWB and prolotherapy with 20% dextrose in LE patients [25, 26, 27, 28, 29, 30]. The short-term pain-reducing effects of AWB and prolotherapy with 20% dextrose were lower than those of corticosteroid; however, the injection of AWB or prolotherapy with 20% dextrose is more efficacious than that of corticosteroids over longer periods [5, 11]. In our study, we injected AWB and 20% dextrose, which effectively managed LE-related pain.

Our study had some limitations. First, we did not include a control or placebo group. Second, the age range of the included patients was relatively large. Third, the level of habitual physical activity of each patient was not considered. Fourth, the handgrip strength of the uninvolved hand of the patients was not assessed. Fifth, we did not consider which hand was dominant for each patient. Sixth, when interpreting the results of grip strength, the difference in sex ratio between groups was not considered. Finally, we did not confirm regeneration of the common wrist extensor tendon. Further studies are required to address these limitations.

5. Conclusion

In our study on patients with LE, the inclusion of a minimal dose of corticosteroid during AWB and 20% dextrose injection reduced pain, especially during the early treatment period. Thus, our results suggest that the inclusion of a minimal dose of corticosteroid reduces the pain induced by AWB injection and prolotherapy. To the best of our knowledge, this study is the first to investigate the effect of the addition of a minimal dose of corticosteroid to the injection solution for tissue regeneration.

Footnotes

Acknowledgments

This study was supported by National Research Foundation of Korea Grant funded by the Korean government (Grant no. NRF-2021R1A2C1013073).

Conflict of interest

None of the authors have any conflicts of interest to report.

References

Cohen

da Rocha Motta Filho

. Lateral epicondylitis of the elbow. Rev Bras Ortop 2015; 47: 414-20.

Cutts

Gangoo

Modi

Pasapula

. Tennis elbow: a clinical review article. J Orthop 2019; 17: 203-207.

Vaquero-Picado

Barco

Antuna

. Lateral epicondylitis of the elbow. EFFORT Open Rev 2016; 1: 391-7.

Gao

Dwivedi

DeFroda

Bokshan

Ready

Cole

Owens

. The therapeutic benefits of saline solution injection for lateral epicondylitis: a meta-analysis of randomized controlled trials comparing saline injections with nonsurgical injection therapies. Arthroscopy 2019; 35: 1847-59.

Barnett

Bernacki

Kainer

Smith

Zaharoff

Subramanian

. The effects of regenerative injection therapy compared to corticosteroids for the treatment of lateral Epicondylitis: a systematic review and meta-analysis. Arch Physiother 2019; 9: 12.

Houck

Kraeutler

Thornton

McCarty

Bravman

. Treatment of lateral epicondylitis with autologous blood, platelet-rich plasma, or corticosteroid injections: a systematic review of overlapping meta-analyses. Orthop J Sports Med 2019; 7: 2325967119831052.

McQuillan

Gregan

. Tendon rupture as a complication of corticosteroid therapy. Palliat Med 2005; 19: 352-3.

Park

Choi

Kim

. Hypopigmentation and subcutaneous fat, muscle atrophy after local corticosteroid injection. Korean J Anesthesiol 2013; 65(6 Suppl): S59-61.

Calandruccio

Steiner

. Autologous blood and platelet-rich plasma injections for treatment of lateral epicondylitis. Orthop Clin North Am 2017; 48: 351-357.

10.

Kampa

Connell

. Treatment of tendinopathy: is there a role for autologous whole blood and platelet rich plasma injection? Int J Clin Pract 2010; 64: 1813-23.

11.

Tang

Wang

, et al. Platelet-rich plasma vs autologous blood vs corticosteroid injections in the treatment of lateral epicondylitis: a systematic review, pairwise and network meta-analysis of randomized controlled trials. PM R 2019; 12: 397-409.

12.

Reeves

Sit

Rabago

. Dextrose prolotherapy: a narrative review of basic science, clinical research, and best treatment recommendations. Phys Med Rehabil Clin N Am 2016; 27: 783-823.

13.

Nair

. Prolotherapy for tissue repair. Transl Res 2011; 158: 129-31.

14.

Rabago

Slattengren

Zgierska

. Prolotherapy in primary care practice. Prim Care 2010; 37: 65-80.

15.

Di Paolo

Gesualdo

Ranieri

Grandaliano

Schena

. High glucose concentration induces the overexpression of transforming growth factor-beta through the activation of a platelet-derived growth factor loop in human mesangial cells. Am J Pathol 1996; 149: 2095-106.

16.

Murphy

Godson

Cannon

Kato

Mackenzie

Martin

Brady

. Suppression subtractive hybridization identifies high glucose levels as a stimulus for expression of connective tissue growth factor and other genes in human mesangial cells. J Biol Chem 1999; 274: 5830-4.

17.

Rabago

Slattengren

Zgierska

. Prolotherapy in primary care practice. Prim Care 2010; 37: 65-80.

18.

Scarpone

Rabago

Zgierska

Arbogast

Snell

. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med 2008; 18: 248-54.

19.

Liu

Zhou

Liu

. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. Phys Sportsmed 2017; 45: 97-104.

20.

McCulloch

Tenenbaum

. Dexamethasone induces proliferation and terminal differentiation of osteogenic cells in tissue culture. Anat Rec 1986; 215: 397-402.

21.

Stefanou

Marshall

Holdan

Siddiqui

. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg Am 2012; 37: 104-9.

22.

Bhardwaj

Nayak

Kiswar

Sabapathy

. Effect of static wrist position on grip strength. Indian J Plast Surg 2011; 44: 55-8.

23.

Lee

Choi

Chang

. The Effect of Botulinum Toxin Injection into the Common Extensor Tendon in Patients with Chronic Lateral Epicondylitis: A Randomized Trial. Pain Med. 2019 Dec 5. [ahead of print].

24.

Yasir

Goyal

Bansal

Sonthalia

. Corticosteroid Adverse Effects. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020.

25.

Connell

Ali

Ahmad

Lambert

Corbett

Curtis

. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol 2006; 35: 371-7.

26.

Edwards

Calandruccio

. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg [Am] 2003; 28: 272-8.

27.

Moon

Song

, et al. Autologous bone marrow plasma injection after arthroscopic debridement for elbow tendinosis. Ann Acad Med Singapore 2008; 37: 559-63.

28.

Mishra

Pavelko

. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006; 34: 1774-8.

29.

Rabago

Lee

Ryan

Chourasia

Sesto

Zgierska

Kijowski

Grettie

Wilson

Miller

. Hypertonic dextrose and morrhuate sodium injections (prolotherapy) for lateral epicondylosis (tennis elbow): results of a single-blind, pilot-level, randomized controlled trial. Am J Phys Med Rehabil 2013; 92: 587-96.

30.

Scarpone

Rabago

Zgierska

Arbogast

Snell

. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med 2008; 18: 248-54.

The effects of inclusion of minimal-dose corticosteroid in autologous whole blood and dextrose injection for the treatment of lateral epicondylitis

Abstract

BACKGOUND:

OBJECTIVES:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Methods

2.1 Patients

Table 1 Subject demographics and baseline clinical data

2.4 Statistical analysis

3. Results

Table 2 Current pain intensity (numeric rating scale score) in the relaxed hand measured just before the injection from the to the first to the fifth visit and 6 months after the last injection (6th visit)

5. Conclusion

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Subject demographics and baseline clinical data

Table 2
Current pain intensity (numeric rating scale score) in the relaxed hand measured just before the injection from the to the first to the fifth visit and 6 months after the last injection (6th visit)