Lateral epicondylitis (LE), widely known as “tennis elbow,” is a common, activity-limiting tendinopathy of the forearm extensor muscles—most notably the extensor carpi radialis brevis (ECRB). Affecting 1–3% of the general population, LE often presents with persistent pain, localized tenderness over the lateral epicondyle, and impaired upper limb function.1-3 While it can affect both athletes and non-athletes, chronic cases are frequently seen in individuals exposed to repetitive wrist and forearm movements, particularly in occupational settings.4,5

Histopathologically, LE is now recognized as a degenerative condition rather than an inflammatory one, characterized by microtears, angiofibroblastic hyperplasia, and collagen disorganization—collectively termed tendinosis.6,7 As a result, conventional anti-inflammatory approaches such as corticosteroid injections, though effective for short-term pain relief, are often limited in long-term efficacy and may hinder tendon healing when used repetitively.8-10

In contrast, prolotherapy with hypertonic dextrose has emerged as a regenerative treatment modality. It operates by initiating a localized inflammatory response that stimulates fibroblastic activity, collagen synthesis, and extracellular matrix repair.11-13 Several recent trials have suggested that dextrose prolotherapy may offer superior and longer-lasting pain relief compared to steroids, especially in cases of chronic tendinopathy.12,14,15

While the Visual Analog Scale (VAS) has traditionally been used to measure overall pain intensity, it does not fully capture how pain interacts with functional elbow use. The Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire offers a more nuanced and clinically relevant assessment by measuring pain severity in context of elbow-related activities. Specifically, the PRTEE Pain Subscale evaluates pain during tasks such as lifting, gripping, and carrying—functions directly impacted by LE.16

This study aims to assess and compare the pain relief trajectory between hypertonic dextrose and corticosteroid injections using the PRTEE Pain Subscale at multiple time points: baseline, 1 week, 6 weeks, and 3 months. By focusing on pain experienced during functional elbow use, this analysis provides a more comprehensive understanding of how each treatment affects real-world patient experience and recovery dynamics.

Study Design and Setting

This prospective, randomized clinical trial was conducted at the Department of Orthopaedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti, Solan, over a 12-month period. The aim was to compare the pain relief trajectory in patients with lateral epicondylitis treated with either hypertonic dextrose or corticosteroid injections, using the PRTEE Pain Subscale as the primary outcome measure.

Participants

A total of 60 adult patients diagnosed with lateral epicondylitis (LE) were enrolled from the outpatient department. Diagnosis was based on clinical history and physical examination findings including localized tenderness over the lateral epicondyle, and positive Cozen’s and Mill’s tests. Radiographs were performed to exclude bony pathology.

Inclusion Criteria

• Age between 20–65 years
• Pain duration exceeding 1 month
• Failed conservative management
• Positive clinical signs of LE

Exclusion Criteria

• Pregnancy
• Diabetes mellitus or neuromuscular disorders
• Recent trauma or fracture near the elbow
• Refusal to undergo injection treatment

Randomization and Interventions

Participants were randomly assigned using a lottery method into two treatment groups of 30 patients each:

• Group A (Dextrose Group): Received an intralesional injection of 1 ml of 25% hypertonic dextrose combined with 1 ml of 2% lignocaine, administered at the point of maximal tenderness using a 20-gauge needle.
• Group B (Steroid Group): Received an intralesional injection of 1 ml of triamcinolone acetonide (40 mg/ml) with 1 ml of 2% lignocaine, using the same technique.

All injections were administered aseptically. Post-injection, patients were advised rest for 3 days, followed by unrestricted activity. No additional physiotherapy or analgesics were prescribed during the follow-up period to eliminate confounding.

Outcome Measure

Pain during elbow function was assessed using the Pain Subscale of the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire. This subscale consists of 5 items, each scored on an 11-point numerical rating scale, yielding a total pain score from 0 (no pain) to 50 (maximum pain).

Pain scores were recorded at the following time intervals:

• Baseline (pre-injection)
• 1 week
• 6 weeks
• 3 months

Statistical Analysis

All data were analyzed using SPSS version 26.0. Continuous variables were expressed as mean ± standard deviation (SD).

• Intergroup comparisons of PRTEE Pain Subscale scores at each time point were assessed using independent t-tests.
• Intragroup comparisons over time were analyzed using paired t-tests. A p-value < 0.05 was considered statistically significant.

Ethical Approval

The study received ethical clearance from the Institutional Ethics Committee of Maharishi Markandeshwar Medical College and Hospital (Approval No: MMMCH/IEC/22/583). Informed written consent was obtained from all participants prior to enrolment, in accordance with the Declaration of Helsinki.

Table 1. Baseline Demographic Profile of Participants

Table 1 presents the baseline demographic characteristics of the study population randomized into the dextrose and corticosteroid groups. The mean age of participants was comparable between Group A (42.66 ± 11.15 years) and Group B (43.36 ± 12.88 years), with no statistically significant difference (p = 0.823). Gender distribution was well-balanced across both groups, with Group A comprising 56.7% males and 43.3% females, while Group B had an equal distribution of males and females (50% each; p = 0.605). Similarly, the laterality of elbow involvement showed no significant difference, with right-sided symptoms slightly more common in both groups (76.7% in Group A vs. 70.0% in Group B; p = 0.559). These findings confirm the demographic homogeneity between the two cohorts, thereby strengthening the validity of subsequent interventional comparisons.

Table 2. Intergroup Comparison of PRTEE Pain Subscale Scores at Different Time Intervals

Table 2 provides a detailed intergroup analysis of PRTEE Pain Subscale scores at baseline and during post-injection follow-ups. The mean baseline score for Group A (Dextrose) was 34.60 ± 4.43 and for Group B (Steroid) was 35.63 ± 3.98. This difference was not statistically significant (p = 0.346), confirming equivalency in pre-treatment pain levels.

From the 1-week follow-up onward, statistically significant differences emerged. Group A consistently exhibited greater reductions in pain scores across all time points. At 1 week, the dextrose group had a mean score of 27.50 ± 5.19 compared to 30.33 ± 4.61 in the steroid group (p = 0.029). This gap widened at 6 weeks (19.90 vs. 22.83; p = 0.007) and further at 3 months (10.76 vs. 15.00; p < 0.001).

These findings clearly demonstrate that hypertonic dextrose injection leads to superior and more sustained relief in elbow-use-related pain, as captured by the PRTEE Pain Subscale. This supports the hypothesis that dextrose prolotherapy promotes longer-lasting tissue healing effects in contrast to the more transient suppression provided by corticosteroids.

Table 3. Intragroup Comparison of PRTEE Pain Scores in Group A (Dextrose) at Different Time Intervals

Table 3 presents the intragroup trajectory of PRTEE Pain Subscale scores in Group A (Dextrose) across the study’s follow-up periods. The analysis reveals a significant, progressive decline in pain intensity during elbow-related functional tasks following dextrose injection.

At baseline, patients in Group A reported a mean PRTEE pain score of 34.16 ± 4.41, which reduced to 26.93 ± 4.93 at 1 week (mean difference = 7.23; p < 0.001). Pain scores further dropped to 19.50 ± 3.66 at 6 weeks (mean difference = 14.6; p < 0.001), and eventually reached 10.43 ± 3.56 by 3 months (mean difference = 23.7; p < 0.001).

These findings reflect a statistically robust and clinically meaningful reduction in pain associated with functional elbow use over time. The consistent and widening pain relief effect highlights the regenerative and reparative potential of hypertonic dextrose in treating lateral epicondylitis, offering not just symptomatic control but sustained healing.

Table 4. Intragroup Comparison of PRTEE Pain Scores in Group B (Steroid) at Different Time Intervals

Table 4 displays the longitudinal changes in PRTEE Pain Subscale scores within Group B (Steroid). All comparisons revealed statistically significant reductions in pain scores from baseline to each subsequent follow-up, indicating effective short-to-intermediate term pain relief.

At baseline, the mean pain score was 36.10 ± 4.17. This decreased to:

• 86 ± 4.93 at 1 week (mean difference = 5.23; p < 0.001)
• 20 ± 4.43 at 6 weeks (mean difference = 12.90; p < 0.001)
• 26 ± 4.18 at 3 months (mean difference = 20.83; p < 0.001)

Although the reduction was substantial and statistically significant across all time points, comparison with Group A (dextrose) shows a smaller magnitude of change, particularly beyond the 6-week mark. This supports the clinical view that corticosteroids offer strong early relief, but the duration of their therapeutic effect may be less sustainable than that of regenerative agents like dextrose.

Lateral epicondylitis (LE), commonly known as "tennis elbow," represents one of the most frequently encountered upper limb overuse syndromes in clinical practice, with an incidence ranging from 1% to 3% in the general population.1,2 Characterized by localized lateral elbow pain and functional impairment, LE significantly affects occupational productivity and quality of life. Though historically labeled an inflammatory condition, histopathological evidence has redefined it as a tendinosis, marked by angiofibroblastic hyperplasia, neovascularization, and disorganized collagen fibers rather than inflammatory infiltrates.6.7,17 This evolving understanding has prompted a re-evaluation of treatment strategies that extend beyond transient anti-inflammatory relief.

The current study was designed to evaluate and compare the pain trajectory in LE patients treated with hypertonic dextrose versus corticosteroid injections, using the Patient-Rated Tennis Elbow Evaluation (PRTEE) Pain Subscale—a validated tool that integrates subjective pain perception with functional use of the elbow.16 The choice of PRTEE over conventional pain metrics such as the Visual Analog Scale (VAS) allowed for a more nuanced assessment of therapeutic response within the real-world context of movement and activity. At baseline, both groups were comparable in terms of PRTEE Pain scores, confirming the success of randomization. At 1-week follow-up, patients treated with corticosteroids showed marginally greater pain relief, which aligns with previous findings that corticosteroids exert potent short-term anti-inflammatory and analgesic effects.8-10 However, by 6 weeks and more evidently at 3 months, patients in the dextrose group reported significantly greater and more sustained reductions in PRTEE Pain scores, indicating a fundamentally different and more reparative mechanism of action.

The observed improvement in the dextrose group is consistent with the prolotherapy hypothesis, which suggests that hypertonic dextrose acts as an osmotic and chemical irritant, initiating a localized inflammatory cascade. This leads to macrophage recruitment, fibroblast proliferation, and ultimately extracellular matrix remodeling and collagen deposition.11-13 Over time, this regenerative response may correct the underlying tendinopathic pathology, explaining the progressive and durable pain reduction observed in our study. These findings are supported by previous studies, who demonstrated significant and sustained improvement in patients with chronic elbow tendinopathy treated with dextrose prolotherapy.9,10 Similarly, past literature found dextrose to be superior to saline and lignocaine at long-term follow-up intervals.13,14  On the other hand, randomized controlled trials evaluating corticosteroid therapy, have shown that although corticosteroids offer fast symptomatic relief, they are frequently associated with recurrence of symptoms and functional deterioration beyond the initial weeks.9,10

The intergroup comparison in our study highlighted that while corticosteroids may temporarily suppress symptoms, dextrose therapy promotes structural healing, resulting in deeper and longer-lasting pain relief. Notably, by the 3-month mark, the mean difference in PRTEE Pain scores between the groups had widened to 4.23 points (p < 0.001), emphasizing the durability of dextrose efficacy.

In terms of intragroup trajectory, both groups showed significant reductions in PRTEE Pain scores over time. However, the magnitude of improvement was consistently greater in the dextrose group (mean reduction of 23.7 points from baseline to 3 months) compared to the steroid group (mean reduction of 20.83 points). While both interventions are clinically effective, this consistent trend underscores the superiority of prolotherapy in achieving sustained outcomes.

Importantly, the use of the PRTEE Pain Subscale, rather than general pain scores, adds depth and clinical relevance to these findings. By capturing pain associated with real-life functional tasks (e.g., gripping, lifting, or rotating objects), it provides actionable insights for patients and clinicians when selecting treatment modalities that influence return to work or sport.

Strengths and Limitations

Strengths of this study include its randomized design, homogenous patient distribution, and use of a validated, function-specific outcome measure. Additionally, no concurrent therapies such as physiotherapy, NSAIDs, or bracing were allowed during the follow-up, isolating the treatment effect of the injectables. However, some limitations warrant consideration. First, the study's follow-up period was limited to 3 months; while adequate for evaluating early to intermediate outcomes, it may not fully reflect long-term structural healing. Second, the lack of imaging-based follow-up (e.g., ultrasonography or MRI) precluded direct visualization of tendon regeneration, which could have objectively corroborated the clinical improvements. Lastly, while PRTEE provides valuable subjective data, combining it with grip strength or objective functional testing would enhance interpretability.

This study demonstrates that both hypertonic dextrose and corticosteroid injections are effective in reducing activity-related pain in patients with lateral epicondylitis, as measured by the PRTEE Pain Subscale. However, hypertonic dextrose produced significantly greater and more sustained pain relief over the 3-month follow-up period compared to corticosteroids.

While corticosteroid injections offered early symptomatic benefit, their effect plateaued over time, whereas dextrose prolotherapy showed a progressive and long-lasting decline in pain. These findings support the regenerative and reparative potential of dextrose therapy in addressing the underlying tendinopathic pathology, rather than providing short-term symptom suppression alone.

Given its superior pain trajectory and functional relevance, hypertonic dextrose prolotherapy should be considered a more favorable long-term treatment option for managing lateral epicondylitis, particularly in patients where tendon healing and durability of response are clinical priorities. Further studies with extended follow-up and imaging-based outcomes are warranted to consolidate these findings and guide evidence-based practice.

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