Comparing the Use of Physiotherapy, Shockwave Therapy, Prolotherapy, and Platelet-Rich Plasma for Chronic Lateral Epicondylosis: A Prospective, Randomized Controlled Trial With 2-Year Follow-up

Background: Lateral epicondylosis is a degenerative condition affecting 1% to 3% of adults annually. Concerns over the sustained efficacy of corticosteroids have increased interest in regenerative treatments like platelet-rich plasma (PRP), prolotherapy, and extracorporeal shockwave therapy (ESWT), but comparative data remain limited. Purpose: To evaluate whether PRP, prolotherapy, and ESWT provide superior clinical outcomes at 24 months compared with physiotherapy alone in patients with chronic lateral epicondylosis. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Adults older than 35 years with lateral elbow pain lasting >6 months, diagnosed via physical examination and ultrasound, and refractory to at least 3 months of nonoperative treatment, were included. Exclusion criteria included recent corticosteroid or botulinum toxin injections and complete extensor tendon rupture. Patients were randomized into 4 treatment groups: physiotherapy, ESWT, prolotherapy, or PRP. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score, and the secondary outcome was the Subjective Satisfaction Score (SSS). Patients were followed for 2 years to assess the treatment efficacy. Results: A total of 231 patients were enrolled, with 202 completing the study. Baseline DASH scores were comparable across the groups ( P = .526). At 24 months, PRP significantly reduced DASH scores by 31.18 points compared with physiotherapy (18.70 points) and ESWT (17.62 points) ( P < .01). Prolotherapy (21.02 points) also showed greater improvement than physiotherapy at 18 months (15.61 points) ( P < .01). PRP yielded the highest SSS (4.60 ± 0.9), outperforming physiotherapy (3.00 ± 1.9) and ESWT (3.43 ± 1.7) ( P < .01). Prolotherapy also yielded higher SSS (4.24 ± 1.2) compared with physiotherapy ( P < .01) and ESWT ( P < .01) at 24 months. At 24 months, all groups demonstrated DASH score reductions exceeding the minimal clinically important difference of 10 points, indicating clinically meaningful improvement: PRP (31.18), prolotherapy (20.70), ESWT (17.62), and physiotherapy (18.70). Conclusion: PRP and prolotherapy yielded better clinical and functional outcomes than ESWT and physiotherapy in chronic lateral epicondylosis over a 2-year follow-up. The findings support the potential of these therapies as effective nonsurgical options for long-standing cases.