International Journal of Orthopedics (IJO)
ISSN: 2643-2692 | Vol. 7, Issue 1, 2026, pp. 8-15

Platelet-Rich Plasma Versus Corticosteroid Injection in Chronic Lateral Epicondylitis

Babic A1, Verhoeven E2, Hofer J3

1Department of Sports Medicine, University of Split, Split, Croatia
2Department of Orthopaedic Surgery, Ghent University, Ghent, Belgium
3Department of Musculoskeletal Radiology, University of Innsbruck, Innsbruck, Austria
DOI: 10.5281/zenodo.22328098 | Published: 2026-06-23 | Article page and PDF

Abstract

Background: Corticosteroid injection provides rapid short-term relief of chronic lateral epicondylitis but is repeatedly associated

with symptom recurrence, while platelet-rich plasma (PRP) has been promoted as a disease-modifying alternative.

Objective: To synthesise randomised and meta-analytic evidence comparing PRP and corticosteroid injection across short- and

long-term outcomes, recurrence, PRP preparation heterogeneity, and alternative injectates.

Methods: Narrative review of randomised controlled trials, systematic reviews, and meta-analyses identified through

PubMed/Cochrane-indexed literature. Findings: Corticosteroid produces superior pain and function at 4-8 weeks, but a crossover by 3-6 months leaves PRP with significantly better VAS, DASH, and PRTEE outcomes and lower recurrence at 1-2 years. Leukocyte-poor preparations and higher platelet concentration factors appear to improve PRP efficacy; autologous blood and dry needling show intermediate profiles. Conclusions: PRP offers superior sustained outcomes beyond six months despite a slower onset, supporting its selective use over corticosteroid in chronic, recalcitrant disease.

Keywords: Platelet-rich plasma; Corticosteroid injection; Lateral epicondylitis; Tennis elbow; Tendinopathy

Abstract

Background: Corticosteroid injection provides rapid short-term relief of chronic lateral epicondylitis but is repeatedly associated with symptom recurrence, while platelet-rich plasma (PRP) has been promoted as a disease-modifying alternative. Objective: To synthesise randomised and meta-analytic evidence comparing PRP and corticosteroid injection across short- and long-term pain and functional outcomes, recurrence, PRP preparation heterogeneity, and alternative injectates. Methods: Narrative review of randomised controlled trials, systematic reviews, and meta-analyses identified through PubMed/Cochrane-indexed literature. Findings: Corticosteroid produces superior pain and function at 4-8 weeks, but multiple trials and meta-analyses show a crossover by 3-6 months, with PRP producing significantly better VAS, DASH, and PRTEE outcomes and lower recurrence at 1-2 years. Leukocyte-poor preparations and higher platelet concentration factors appear to improve PRP efficacy. Autologous blood and dry needling show intermediate profiles. Conclusions: PRP offers superior sustained outcomes beyond six months despite a slower onset, supporting its selective use over corticosteroid in chronic, recalcitrant disease.

Keywords: platelet-rich plasma; corticosteroid injection; lateral epicondylitis; tennis elbow; tendinopathy

Introduction

Lateral epicondylitis, commonly termed tennis elbow, is a degenerative tendinopathy of the common extensor origin, principally the extensor carpi radialis brevis, rather than a true inflammatory "-itis." Population-based surveys estimate its prevalence at approximately 1-3% in working-age adults, with peak incidence between the fourth and fifth decades and strong associations with repetitive forceful wrist extension and smoking [1]. Most cases are self-limiting, but a substantial minority progress to chronic, recalcitrant pain lasting beyond six months, for which injection therapy remains a common second-line intervention after activity modification, bracing, and physiotherapy fail.

Corticosteroid injection has long been favoured for its rapid analgesic effect, but landmark trials demonstrated that this benefit is transient and, paradoxically, associated with worse intermediate- and long-term outcomes than physiotherapy or even a wait-and-see policy, implicating an adverse effect on tendon biology rather than genuine healing [2,3,4]. A broader systematic review of corticosteroid injection across multiple tendinopathies confirmed this pattern of short-term benefit reversing to long-term harm relative to placebo [5]. These findings catalysed interest in autologous biologic injectates, particularly PRP, which concentrates platelet-derived growth factors thought to stimulate tenocyte proliferation, collagen synthesis, and neovascularisation, thereby targeting the underlying angiofibroblastic degeneration rather than merely suppressing pain [6]. Diagnosis is clinical, based on point tenderness over the lateral epicondyle and pain reproduced by resisted wrist or middle-finger extension, with imaging reserved for atypical or refractory presentations. Outcome measurement across the injection literature is dominated by three complementary instruments: the visual analogue scale (VAS) for pain intensity, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for global upper-limb function, and the Patient-Rated Tennis Elbow Evaluation (PRTEE), a condition-specific composite of pain and disability subscales. Because these instruments are scored, timed, and reported inconsistently across trials, and because PRP itself is prepared by a range of commercial and in-house protocols that differ in platelet concentration factor and leukocyte content, comparative interpretation of the injection literature requires explicit attention to preparation method and follow-up duration rather than pooled headline effect sizes alone. This review synthesises randomised and meta-analytic evidence comparing PRP and corticosteroid injection for chronic lateral epicondylitis, with attention to the time-course of pain and function (VAS, DASH, PRTEE), recurrence, PRP preparation heterogeneity, and comparison with autologous blood, dry needling, and other injectates.

Short-Term Outcomes: The Corticosteroid Advantage

Across nearly all comparative trials, corticosteroid injection produces faster and often numerically superior symptom relief in the first four to eight weeks. In a three-way randomised trial of corticosteroid, dry needling, and PRP, corticosteroid achieved the lowest VAS scores at three months among the three arms, with dry needling intermediate and PRP slowest to respond [7]. A four-arm placebo-controlled trial found corticosteroid superior to PRP, hyaluronic acid, and saline only in the first month, after which the advantage dissipated [8]. This early-superiority pattern is corroborated by systematic synthesis: an updated meta-analysis of thirteen level 1-2 studies confirmed corticosteroid superiority at one month post-injection [9] (Table 1), and a further meta-analysis of eleven randomised trials similarly reported better corticosteroid-arm function under two months [10]. Mechanistically, corticosteroid's rapid local anti-inflammatory and analgesic action explains this early separation, whereas PRP requires a biological cascade of growth-factor release, cellular recruitment, and matrix remodelling that unfolds over weeks to months before clinical benefit becomes apparent [11].

Long-Term Outcomes and Recurrence

The clinically decisive divergence occurs beyond three to six months. Peerbooms and colleagues' double-blind randomised trial reported that at one year, treatment success (≥25% reduction in VAS or DASH without re-intervention) was achieved by 73% of PRP-treated patients versus 51% of corticosteroid-treated patients for DASH (P=.005), with baseline VAS falling from 70.1 to 25.3 in the PRP group versus 65.8 to 50.1 with corticosteroid [12]. Two-year follow-up of the same cohort showed the gap widening rather than narrowing: DASH success reached 72.5% with PRP versus 38.8% with corticosteroid, and mean VAS was 21.3 (PRP) versus 42.4 (corticosteroid), with corticosteroid-group scores having drifted back toward baseline (Figure 1, Figure 2) [13]. A separate double-blind, placebo-controlled Danish trial similarly found no benefit of either PRP or glucocorticoid over saline at three months, but longer profiling again favoured biologic recovery trajectories over the steroid arm's regression [14]. Pooled analyses corroborate this time-dependent crossover: an eleven-trial meta-analysis concluded corticosteroid gives better short-term (<2 months) function while PRP gives superior long-term (≥6 months) pain relief and function [10], and the Hohmann meta-analysis found PRP more effective at three and six months despite corticosteroid's one-month advantage, while cautioning that risk of bias in included trials limits firm recommendations [9]. Systematic review of overlapping meta-analyses similarly concluded PRP outperforms corticosteroid at intermediate-to-long-term follow-up despite heterogeneous methodology across the underlying reviews [15]. Ultrasonographic correlates parallel these clinical trajectories: recalcitrant-epicondylitis cohorts receiving corticosteroid showed progressive tendon thinning and cortical erosion, while PRP-treated tendons showed thickening consistent with biological repair, alongside lower six-month symptom recurrence [16,17].

Table 1: Selected randomized controlled trials comparing platelet-rich plasma, corticosteroid, and related injectates for chronic lateral epicondylitis. Study Comparison Design Follow-u Key outcome
Table 1: Selected randomized controlled trials comparing platelet-rich plasma, corticosteroid, and related injectates for chronic lateral epicondylitis. Study Comparison Design Follow-u Key outcome
Figure 1: Mean VAS pain score (0-100) at baseline, 1 year, and 2 years for platelet-rich plasma versus corticosteroid injection in chronic lateral epicondylitis, from a double-blind randomized controlled trial with 2-year follow-up [12,13].
Figure 1: Mean VAS pain score (0-100) at baseline, 1 year, and 2 years for platelet-rich plasma versus corticosteroid injection in chronic lateral epicondylitis, from a double-blind randomized controlled trial with 2-year follow-up [12,13].
Figure 2: DASH-based treatment success rate (proportion achieving ≥25% reduction in DASH score without re-intervention) at 1 and 2 years for platelet-rich plasma versus corticosteroid injection [12,13].
Figure 2: DASH-based treatment success rate (proportion achieving ≥25% reduction in DASH score without re-intervention) at 1 and 2 years for platelet-rich plasma versus corticosteroid injection [12,13].

Not all evidence favours PRP unreservedly. The 2021 Cochrane review pooling 32 trials (2,337 participants) concluded that autologous blood or PRP injections "probably provide little or no clinically important benefit" over placebo at three months, and showed no clinically meaningful advantage over corticosteroid either, though most included trials were small and at risk of bias [18]. This tempers otherwise favourable single-trial and meta-analytic signals and underscores substantial between-study heterogeneity in PRP preparation, injection technique, and outcome definitions.

A head-to-head comparison of PRP against autologous whole blood, its unfractionated precursor, found PRP produced significantly better six-month VAS pain scores with comparable DASH improvement, indicating that platelet concentration itself, not merely autologous injection, contributes to outcome [19]. A separate meta-analysis of seven randomised trials (515 patients) similarly found PRP statistically superior to corticosteroid in pain and function at six months with equivalent adverse-event rates [20].

PRP Preparation Heterogeneity: Leukocyte Content and Platelet Dose

PRP is not a standardised product, and leukocyte concentration is a key axis of variability. A randomised comparison of leukocyte-rich versus leukocyte-poor PRP found no significant between-group differences in VAS or Patient-Rated Tennis Elbow Evaluation (PRTEE) scores at eight weeks, with both formulations improving similarly on exercise co-therapy [21]. In contrast, a more recent double-blind trial incorporating single-cell platelet analysis found leukocyte-poor PRP produced significantly greater pain reduction and functional improvement than leukocyte-rich PRP or saline at six weeks, sustained to 55 weeks (Table 2) [22]. Platelet dose independent of leukocyte content also matters: a meta-regression of thirteen trials found that platelet concentration factor explained 58.5% of between-study variance in outcome, with only "high-dose" PRP (>3-fold whole-blood concentration) achieving clinically meaningful pain reduction (mean VAS difference -1.31) [23]. A minimal-clinically-important-difference-based meta-analysis of 26 studies found VAS, DASH, and Mayo Elbow scores met MCID thresholds throughout follow-up to 104 weeks regardless of leukocyte content, suggesting genuine effect sizes are being diluted, rather than negated, by preparation heterogeneity in pooled analyses [24].

Table 2: Studies addressing platelet-rich plasma preparation heterogeneity (leukocyte content and platelet dose) in lateral epicondylitis. Study Comparison Follow-up Key finding
Table 2: Studies addressing platelet-rich plasma preparation heterogeneity (leukocyte content and platelet dose) in lateral epicondylitis. Study Comparison Follow-up Key finding

Comparison with Autologous Blood and Other

Injectates

Autologous whole blood, PRP's biologically simpler precursor, has also outperformed corticosteroid long-term: a randomised trial found 95% complete recovery with autologous blood versus 62.5% with corticosteroid, despite corticosteroid's faster initial relief [25]. A network meta-analysis integrating PRP, autologous blood, and steroid trials found PRP superior for pain control with a safety profile comparable to steroid, while autologous blood produced the greatest functional gains but carried higher local complication rates (relative risk 1.78) [26]. Comparative work against non-injection interventions reinforces that injections alone are not curative: physiotherapy combined with, or in place of, corticosteroid outperformed corticosteroid alone at one year, with corticosteroid-only patients showing the highest relapse rates [3,4], and two-decades-old evidence already showed a wait-and-see policy outperforming corticosteroid injection at 52 weeks despite corticosteroid's clear early superiority at six weeks, a pattern that anticipated the later PRP-versus-corticosteroid crossover by a decade [2]. Dry needling, which mechanically disrupts degenerated tendon to stimulate a localised healing response without introducing any injectate, produced short-term pain relief statistically indistinguishable from corticosteroid and superior functional trajectory to PRP in one three-arm trial, suggesting that mechanical stimulation of the tendon may itself contribute meaningfully to outcome independent of the substance injected [7].

Discussion

The consistent pattern across sources is a therapeutic crossover: corticosteroid's rapid anti-inflammatory action gives way, from roughly three months onward, to a rebound characterised by tendon degeneration and symptom recurrence, whereas PRP's slower, biologically mediated recovery yields durable gains sustained to at least two years [12,13,10]. This has direct clinical implications: corticosteroid may still suit patients prioritising rapid short-term relief (e.g., before a defined event), whereas PRP is preferable for patients with chronic, recalcitrant disease in whom durable one-to-two-year outcomes are the priority. However, the Cochrane review's more skeptical pooled estimate [18], alongside evidence that outcomes depend heavily on leukocyte content and platelet dose [22,23], means PRP cannot be recommended as a uniform "one-size-fits-all" biologic; preparation standardisation (leukocyte-poor, high platelet-concentration-factor protocols) appears necessary to reproduce the superior outcomes seen in the strongest individual trials.

Conclusion

Corticosteroid injection provides faster but non-durable relief of chronic lateral epicondylitis, while PRP, particularly leukocyte-poor and high-platelet-dose formulations, produces superior VAS, DASH, and PRTEE outcomes and lower recurrence from approximately six months through at least two years, albeit with a slower onset and continued heterogeneity across preparations and trials. Clinicians should weigh timeframe of expected benefit, recurrence risk, and PRP standardisation when selecting between these two widely used injectates, and future trials should adopt uniform PRP preparation reporting to resolve residual heterogeneity in the evidence base.

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