Professional athletes across multiple sports are increasingly turning to orthobiologic treatments for common elbow conditions, representing a broader shift in sports medicine toward regenerative therapies that promise to harness the body’s natural healing mechanisms.
Yet comprehensive research reveals a more nuanced picture of these innovative treatments. While platelet-rich plasma (PRP) and stem cell therapies continue to generate significant interest among patients and clinicians, the scientific evidence supporting their widespread use remains limited and, in some cases, contradictory.
Elbow injuries affect millions of Americans annually, with lateral epicondylitis—commonly known as tennis elbow—being the most prevalent condition. The disorder, which involves degeneration of the tendon that attaches to the lateral epicondyle, affects approximately 1-3% of the general population and up to 15% of workers in high-risk occupations requiring repetitive arm motions.
Tennis elbow represents a degenerative condition rather than a purely inflammatory one, a distinction that has important implications for treatment. According to Johns Hopkins Medicine, the pain of tennis elbow is caused by damage to the tendons that bend the wrist backward away from the palm. This understanding has shifted treatment approaches from simply reducing inflammation to promoting actual tissue regeneration.
For athletes, particularly baseball pitchers, ulnar collateral ligament (UCL) injuries present an even greater challenge. These injuries often require surgical reconstruction—the infamous Tommy John surgery—which sidelines players for 12-18 months and doesn’t guarantee a successful return to peak performance.
Orthobiologic treatments represent a paradigm shift from traditional symptom management toward biological healing. PRP therapy involves extracting a patient’s blood, concentrating the platelets through centrifugation, and injecting the platelet-rich solution directly into the injured tissue. The platelets contain growth factors that can trigger cell proliferation, speed healing and stimulate tissue regeneration in the treated area.
Stem cell therapy takes this concept further by introducing mesenchymal stem cells—typically harvested from bone marrow or adipose tissue—that can theoretically differentiate into various tissue types needed for repair. The use of biologics, including stem cells, is being investigated for their potential to aid in the healing and regeneration of the ulnar collateral ligament, a key ligament in the elbow that is often injured in athletes, particularly baseball pitchers.
The clinical evidence for PRP in treating elbow conditions presents a complex picture that challenges initial enthusiasm. A comprehensive 2021 Cochrane review analyzing multiple randomized controlled trials found concerning results. The review found insufficient evidence to support the ongoing use of autologous blood or PRP injections in the treatment of tennis elbow, concluding these injections probably provide little or no clinically important benefit for pain or function.
However, not all studies paint such a pessimistic picture. A significant multicenter randomized controlled trial of 230 patients published in the American Journal of Sports Medicine found more encouraging results. “No significant differences were found at 12 weeks in this study. At 24 weeks, however, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group.”
The discrepancy in results highlights a critical challenge in orthobiologic research: the lack of standardization in preparation methods, injection techniques, and patient selection criteria. Recent research has begun to explore why PRP therapy works for some patients but not others, with genetic factors emerging as a potential explanation.
A 2021 study published in BMC Musculoskeletal Disorders investigated genetic variations in growth factor genes that might influence treatment response. The purpose of this study was to identify polymorphic variants of the platelet-derived growth factor beta polypeptide gene (PDGFB) that determine an improved individual response to PRP therapy in tennis elbow patients.
This personalized medicine approach suggests that future PRP treatments might be tailored based on individual genetic profiles, potentially improving success rates and patient selection.
While PRP has at least been subjected to numerous randomized controlled trials, stem cell therapy for elbow conditions remains largely in the investigational stage. The evidence base consists primarily of case reports and small case series, making it difficult to draw definitive conclusions about efficacy.
Laboratory research has shown a higher concentration of growth factors in BMAC (bone marrow aspirate concentrate) compared to PRP. This biological rationale has led some clinicians to view BMAC as a more potent treatment option, particularly for cases where PRP has failed.
Dr. Andrews and his colleagues at the Andrews Institute have reported using bone marrow-derived stem cells for partial UCL tears in professional baseball pitchers, with some players returning to competitive play without requiring traditional surgery. However, these positive outcomes must be weighed against the lack of controlled studies and long-term safety data.
The FDA’s position on stem cell therapies adds another layer of complexity. While autologous stem cell treatments (using a patient’s own cells with minimal manipulation) are generally permitted, the regulatory landscape continues to evolve as the agency grapples with the proliferation of stem cell clinics making unsubstantiated claims.
In clinical practice, the decision to recommend orthobiologic treatments often comes down to individual patient factors and the failure of conservative treatments. Medical experts emphasize the need for proper patient selection and realistic expectations when considering these emerging therapies.
The cost factor cannot be ignored. PRP treatments typically range from $500 to $1,500 per injection, while stem cell procedures can cost $3,000 to $8,000 or more. Most insurance plans don’t cover these treatments, classifying them as experimental or investigational.
Several factors complicate orthobiologic research in elbow conditions. First, the heterogeneity in PRP preparation methods makes it difficult to compare studies. Variables include centrifugation protocols, platelet concentrations, the inclusion or exclusion of white blood cells, and activation methods.
Second, the natural history of conditions like tennis elbow includes significant spontaneous improvement rates, making it challenging to distinguish treatment effects from natural healing. Studies must include appropriate control groups and follow patients for sufficient periods to account for this natural variability.
Third, outcome measures vary widely across studies. Some focus on pain reduction using visual analog scales, others emphasize functional improvements through validated questionnaires like the DASH (Disabilities of the Arm, Shoulder and Hand) score, and still others rely on imaging changes that may not correlate with clinical symptoms.
A recent prospective study published in the Journal of Clinical Medicine attempted to address some of these challenges by examining blood morphological parameters that might predict PRP treatment success. The aim of the study was to assess whether there are correlations between the levels of individual morphotic elements determined in whole blood and the outcomes of tennis elbow treatment with PRP injection, as measured using patient-reported outcome measures.
For professional and amateur athletes, the appeal of orthobiologic treatments extends beyond their potential efficacy. The prospect of avoiding surgery and lengthy rehabilitation periods makes these treatments attractive even when evidence is limited.
Stem cell therapy can repair damaged tendons and get players back on the court without invasive surgery and long recovery times. Injuries like muscle tears, back strains, knee tendonitis, labrum tears and tennis elbow can halt weight training.
However, this appeal has led to concerns about athletes pursuing unproven treatments instead of established therapies. The trend of injured MLB pitchers opting for unproven stem cell injections over Tommy John surgery has raised questions about whether short-term career considerations are overriding evidence-based medical decision-making.
The field of orthobiologics continues to evolve rapidly, with several promising research directions emerging. Combination therapies that use both PRP and stem cells are being investigated, as are novel delivery methods including ultrasound-guided injection techniques and scaffolds to enhance cell retention at injection sites.
Biomarker research aims to identify patients most likely to respond to specific treatments. Recent studies have explored inflammatory markers, genetic polymorphisms, and imaging characteristics that might predict treatment success.
Advanced imaging techniques, including ultrasound elastography and magnetic resonance imaging with contrast enhancement, are being developed to better assess tissue healing and treatment response in real-time.
Given the current evidence landscape, patient education becomes crucial. Patients considering orthobiologic treatments should understand that these therapies are not miracle cures and that success rates vary significantly. The decision should be made in consultation with qualified sports medicine physicians who can provide realistic expectations based on current evidence.
Healthcare providers emphasize the importance of thoroughly discussing both the potential benefits and limitations of these treatments before proceeding.
The regulatory environment for orthobiologic treatments continues to evolve. The FDA has increased scrutiny of stem cell clinics making unsubstantiated claims, while simultaneously working to establish clear guidelines for legitimate research and clinical practice.
Healthcare providers must navigate this complex landscape while ensuring patient safety and maintaining ethical standards. Professional organizations, including the American Orthopaedic Society for Sports Medicine and the International Association of Athletics Federations, have developed position statements to guide clinical practice.
The growing popularity of orthobiologic treatments has significant healthcare economic implications. While these treatments can be expensive upfront, proponents argue they may reduce long-term healthcare costs by avoiding surgery and prolonged rehabilitation.
However, without robust evidence of efficacy, healthcare systems and insurance providers remain reluctant to provide coverage. This creates a two-tiered system where access to these treatments is often limited by financial resources rather than medical need.
The field of orthobiologic therapies for elbow disorders represents both the promise and challenges of modern regenerative medicine. While the biological rationale for these treatments is compelling and some studies show encouraging results, the overall evidence base remains insufficient to support widespread adoption as first-line therapy.
Current evidence suggests that PRP may provide modest benefits for some patients with tennis elbow, particularly when other conservative treatments have failed. However, the effect sizes are generally small, and not all patients respond favorably. For stem cell therapy, the evidence is even more limited, consisting primarily of case reports and small series.
As the field moves forward, several priorities emerge: the development of standardized protocols for treatment preparation and delivery, the identification of biomarkers to predict treatment response, and the completion of large-scale randomized controlled trials with long-term follow-up.
Until more definitive evidence becomes available, orthobiologic treatments should be considered investigational therapies best suited for patients who have failed conservative management and wish to avoid or delay surgical intervention. Patients considering these treatments should be fully informed about the current limitations in evidence, potential risks, and costs involved.
The future of orthobiologic therapies for elbow disorders likely lies not in replacing traditional treatments entirely, but in finding the right patients for whom these innovative approaches can provide meaningful benefits. As our understanding of the biological mechanisms underlying tissue healing continues to advance, so too will our ability to harness these processes for therapeutic benefit.
For now, the promise of regenerative medicine in treating elbow disorders remains just that—a promise that requires continued research, clinical validation, and careful patient selection to fulfill its potential in improving outcomes for the millions affected by these common and often debilitating conditions.