Tennis Elbow and CortisoneTennis Elbow, or Lateral Epicondylitis is a very common entity seen in a busy Sports Medicine office.  Tennis Elbow is a  condition where the tendons on the outer side of the elbow degenerate, or fray and tear from chronic use.   We used to believe it was due to inflammation of the tendons. Interestingly, there are no signs of inflammation within the tendons seen in surgical specimens.  We now know that tennis elbow is caused by tendinosis.  

Some patients with tennis elbow have very mild pain, but some patients are truly disabled by the pain.

 

Do I have Tennis Elbow?

Tennis Elbow and Cortisone InjectionsTennis elbow presents as pain on the outer, or lateral side of elbow.  The pain tends to center around a boney prominence we call the lateral epicondyle. The pain may spread down the arm a little into the muscles on the side of the forearm.  Tennis elbow should not be associated with numbness or tingling.  Patients with Tennis Elbow will complain about severe pain when lifting an object, especially with the palm facing downwards.  Severely afflicted patients with tennis elbow can not even lift a cup of coffee without wincing in pain.

 

Treatments for Tennis Elbow

Luckily, for most patients their tennis elbow symptoms are mild and their course is self-limiting.  That means that the pain will subside or go away on its own.  Many patients tell me that a compression sleeve helps with the pain. Some report improvement with natural anti-inflammatory supplements. . For patients with more severe discomfort, many orthopedists will recommend physical therapy, but conventional therapy has led to disappointing results in treating tennis elbow.  A few years ago, researchers realized that a unique form of stretching, called eccentric stretching led to a significant response in many patients being treated for Tennis Elbow.  This led to the invention of the FlexBar.  The majority of you will respond to using the flex bar, if it is used properly.  There are many videos to show you how on YouTube.  You can obtain a flex bar here.  Even the NY Times wrote about the Flexbar in an article a few years back.

Cortisone Injections For Tennis Elbow

For a very long time, the initial treatment chosen for a patient with severe pain due to tennis elbow was a cortisone injection.  Cortisone is a steroid, and a strong anti-inflammatory.  Initially most of these  injected patients were very satisfied ,  but many patients note that when the injection wears off,  they feel worse than they did prior to the injection.

Cortisone injections into a tendon, should, in general be avoided.  This research paper  reveals the downside of cortisone injections directly into a tendon. They conclude:

Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.

A recent paper in the Journal of American Medical Association revealed that patients with tennis elbow might actually become worse when the effects of the cortisone wear off a few weeks or months after the injection.

Among patients with chronic unilateral lateral epicondylalgia (tennis elbow), the use of corticosteroid (cortisone) injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences

 PRP Treatment For Tennis Elbow

PRP Injection Tennis ElbowA tremendous effort has been underway to define whether or not PRP or Platelet Rich Plasma has a role in the treatment of tennis elbow.  PRP therapy involves an injection of a portion of your own blood back into the painful tissues.  The thought is that the regenerative chemicals and cells in the blood will enable the tendons of the elbow to heal themselves.  The scientific literature is mixed, but many agree that PRP is a reasonable option in patients who have failed to improve with rest, ice, moist heat, therapy, Flexbar and even acupuncture. The recovery from a PRP injection is generally brief, and it is viewed as a worthy treatment to attempt when all else fails and you are told that surgery is your only other option.

With the success we have seen with both the flexbar and prp we have found that very very few patients ever go on to require surgery to treat their tennis elbow.

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Bottom Line…

You should likely avoid a cortisone injection for tennis elbow unless you clearly understand the risks, and are truly miserable because of the pain.  Talk to your doctor about a compression sleeve, or flexbar, try to lift with your palm facing up and try to avoid offending activities as best you can.

Thoughts?

 

Disclaimer

 

About the author:

Howard J. Luks, MD

A Board Certified Orthopedic Surgeon in Hawthorne, NY. Dr Luks specializes in the treatment of the shoulder, knee, elbow, and ankle. He has a very "social" patient centric approach and believes that the more you understand about your issue, the more informed your decisions will be. Ultimately your treatments and his recommendations will be based on proper communications, proper understanding, and shared decision making principles --- all geared to improve your quality of life. Please read our Disclaimer

105 comments on “Tennis Elbow and (avoiding) Cortisone Injections

  1. Hi Dr.Luks. I have a terribly sore left arm, it aches, I have trouble sleeping and it feels weak. The doctros that I have seen suspect osteoarthritis of the glenohumeral joint- likely due to crunching my left shoulder whilst kayaking….I went for a cortisone injection into the joint yesterday….this has helped alot- on average, for more or loess how long should a cortsone shot to a glenohumeral joint keep the pain away? I really need to know because x-mas is fast approaching and doctors aren’t usually available during this period.

  2. I have “tennis elbow” been off work for a month… been doing some strength training as recommended. saw my specialist today to get my MRI results and i was told the lateral epicondyle “tennis elbow” is what i have.

    It’s been 5 hours since I had the cortisone shot and it feels worse then ever!!!!!!! Elbow is killing me and I’m in so much pain it’s almost unbearable now. Right arm is having a shooting like pain and very weak… Extreme pain and a Percocet did nothing. Am I having a bad reaction or something? Should I be experiencing this much pain after the injection? I would have never gotten a cortisone injection into my elbow if I would have known this is the pain afterwards. I want to chop off my arm ..any suggestions at all? Please help
    Thanks in advanced.

  3. I have an employee with Tennis Elbow. He had a cortisone shot. He now has a painful serious boil at the point of injection. He also now has a lessor but increasing infection in his wrist where another injection of cortisone.

    The doctor has prescribed to antibiotics and heating pads. Says in 7 days if not sufficiently improved surgery.

    He is scared. What else should he do?

    1. Infection is a very rare, but known risk of injections. If the infection does not respond to antibiotics then surgery to clean the area out might be needed.

  4. HI. been suffering with Tennis elbow for about 3 months. did 2 months of therapy did not help. Cortisone shot about a week ago had the flare and everything but now it barely helped me still have a sharp pain in my elbow. idk what to do next i have my DR appt next week. I’m assuming surgery is next? please contact me back thanks

    1. Hi Sam… If the diagnosis is correct, then you may find that a Flex Bar from Theraband will help significantly. With the use of a Flex Bar and PRP injections, the number of surgeries I perform on tennis elbow have dropped significantly.
      But again… all this assumes the diagnosis — based on physical exam, not just an MRI — is correct.
      Howard Luks

  5. Ok Thanks for the response. MRI came back with a partial tear. Im just super shocked that the cortisone shot gave 0 relief to my arm, when all i saw online was pure pain relief and people were able to get back to full duty.
    thanks again

    1. Many reasons for that Sam… sometimes the injections miss their intended targets… and sometimes.. despite what an MRI shows, the diagnosis is wrong.

  6. I am up at 1:00 am with severe pain mostly in my forearm after a cortisone injection to my elbow about 12 hours ago. The pain is almost unbearable. Prior to the injection the pain was mild to moderate. The doctor diagnosed it as tennis elbow today without an MRI. He had a xray taken but never looked at it, at least while I was there. Is this normal practice to diagnose and treat with cortisone without an MRI? Wondering how long I should expect pain to be this excruciating….

    1. An MRI is not necessary to diagnose tennis elbow. Some patients will experience a flare after the injection. It tends to fade within a day or two.

      Good Luck

  7. I agree with Julia, same scenario with me. I had an injection yesterday Sept 29th in the eve. The pain kept me up all night. I feel worse now than before the injection ! The pain is excruciating ! Any suggestions ?

  8. My left elbow is killing me. I am losing strength It.as been a month and I Have been doing everything possible not to use my arm. I had a tear on my right elbow and I had surgery is it possibles that the same thing could happen to my left arm. And would you recommend a cortisone shot to help relieve this pain. It is so bad it wakes me up at night.

    1. It could be the same problem… that is not unusual. But you need an exam by your doc to know for sure.

      Good Luck

  9. Hi Dr. Luks,
    I am so perplexed. I suffered ALL spring and summer with severe tennis elbow. I saw a sports medicine physician who diagnosed me and sent me straight to PT. I did that for 6+ weeks – to no avail and no relief.

    I then sought the intervention/treatment of a chiropractor. He performed Graston and Acupuncture. No relief from either…

    I babied my elbow, used my left arm/hand for anything I could. I also bought a brace.

    Finally, after 4 months of misery, I received a Cortisone shot in elbow and POOF – the pain was GONE. I was so thrilled. I could actually be active again.

    2 months later (present day), I am beginning to feel the tennis elbow slowly return. I can’t start my car, pick up my purse, etc.

    HELP!!!!!!!!! These diagnoses not only cause physical pain and debility, but they cause psychological anguish as well.

    1. Sorry you are in so much pain… there are further alternatives available … Time to do your research and talk with your doctor. Possibilities include purchasing a FlexBar from Theraband, PRP, Tenex procedure or a traditional surgery. All have been shown to help people. Good Luck to you.
      Howard Luks

  10. I have had pain in elbow for 3 months finally went to Dr. on Nov. 12 The 5 shots itself didn’t hurt but when i got home the main was HORRIBLE. i couldn’t use my arm at all for 2 days. On the 3rd day after 2 days of rest i have movemnt in my fingers so I will still take it easy. I am so glad I took care of this before the Holidays.
    If you do what the Dr. says and rest and no use of arm for a couple days then you sould be good today within a week.

  11. Dr. Luks – I have tennis elbow (and golfer’s elbow) in both arms. I tried the Flex Bar from Theraband and felt worse. Is that possible? Maybe I overdid it? Should I try it again? Thanks!

    1. Hard to say Brad .. many variables involved. IS the Are the diagnoses correct — it is very rare to have both conditions, in both elbows at the same time. Second … many people use the Flex Bar improperly … perhaps watching the vids and trying again. If all else fails, seek another opinion.

  12. Please please help me out. I have a long history of pain in BOTH arms and Im at my wits end with what is going on. My orthopedic doctor isnt sure either but he is involved/concerned about what the issue is.
    Basically over a year and half ago (yes, they have been in horrible pain for that amount of time) I was remodeling my home on my own and my arms started to hurt. Against my doctors advice, because I had to finish the house, I bound my arms up really tight and continued to work through extreme pain for another couple months. After that I started therapy. I did physical therapy for a few months and then oral steroids. X-rays showed nothing. Then I received cortisone injections, which were horrible but it did help the pain mildly so I didnt have to take the pain medication so much. I was convinced it was a nerve issue. I was sent to another location and received a nerve study….NOTHING showed up as irregular. I was in shock, I was so sure that was it. So then I go to the tendons, because that HAS to be the issue. I received MRIs on both arms and today in the doctors office after I received a second round of cortisone injections, when he told me there was so inflammation located or seen on the MRI, I almost started crying….Its been a year and 7 months now, with debilitating pain. Im so exhausted with having to take pain medication to lift cups or open doors, I cant even put my hair back in a pony tail without tears if I dont take medicine….He put in a consult for a neck MRI to see if there is something going on there, but I am just at a loss of what could possibly be wrong….Please offer *something* in the manner of advice.

    1. Colleen .. i’m sorry to hear you are suffering so much. As you know there is little to suggest as I can not offer treatment advice and have not examined you.

      In general, an exam gives you the diagnosis and and MRI or EMG is only used to confirm suspicions. Possible causes of arm pain include tennis elbow, radial tunnel syndrome (nerve tests frequently normal at first), neck issues, brachial plexus pain (nerves as they cross your axilla), and on and on. There are a multitude of reasons people have pain in their arms. A good exam in the key… key trying upper extremity trained Orthopedic Surgeons until you find someone who nails down the diagnosis. I truly wish you the best of luck in your search.

      Howard Luks

    2. Hi Colleen,

      After reading your story, all I can say; is: Wow, can I relate!! I have suffered with tennis elbow in my right (dominant arm) for 2 and a half years now and just had open/release surgery on 12/19/14. As of today I am exactly 6 wks post-surgery and am having more problems and pain then ever! I am a healthy 39 yr old woman. There should be no reason. Today I am suffering with NEW tennis elbow pain in my left elbow, and also chronic snapping and clucking in my right surgery wrist. Not to mention on-going tennis elbow pain in my surgery arm. Still unable to use scissors, spray windex or lift anything over two lbs…..even with PT twice weekly. Please feel free to contact me with any questions….I strongly discourage surgery.

      * (Had 6 cortizone shots prior to surgery)

      Karen

      1. Karen and Colleen,
        After the failure of treatments including a Flex Bar, PT, heat, etc … surgery may prove the be an option for some. The success rate in the literature… and to be honest in my own hands has been very good. The KEY issue is having the right diagnosis. A well preformed procedure for the wrong diagnosis is a common reason for failure. There are many other issues that can cause pain on the outer aspect of the elbow and forearm and can easily be mistaken as tennis elbow. This is one of the more common reasons why second opinions become so important before opting for surgery. Asking your surgeon how sure they are about the diagnosis and how many of these procedures they perform is very important.

        I’m sorry you are both suffering… consider second opinions.
        Good Luck
        Howard Luks

  13. Hello Dr. Luks,
    If PRP and Tenex procedure are not options, what is your opinion on having traditional surgery to correct Tennis Elbow?
    Thank you,
    Preston

  14. Hi Dr Howard, So i have been suffering with tennis elbow for the past 6-7 months have done therapy/ cortisone shots and about a month ago I’ve done a PRP injection. and the pain is still there. My elbow/forearm is swollen and i have constant pain when trying 2 lift or extend my arm. have a few more weeks of therapy and then back to seeing my doctor. I’m assuming surgery is next ?

    1. I don’t know Sam… has your doctor mentioned a Flex Bar, made by Theraband? They work very well for many people. But all this assumes your diagnosis is correct. Perhaps a second opinion is a worthwhile pursuit?

  15. I can sympathize with the others about the excruciating pain post injection. Had it today in left elbow and pain is quite unbearable…cannot even type with left fingers. I had no idea it would hurt this much! I would have opted out had I known, and I would never get another one.

  16. I had prp to treat tennis elbow six weeks ago. Is it common to still experience dull pain in your forearm after the injection. How long should you give this procedure to see results? When can I resume tennis? I am experiencing a different kind of pain since taking the prp. Is that normal?

    1. This is not uncommon Helen … some people respond partially to a single injection, while some do not respond at all.

  17. Dr Luks,
    I had a cortisone injection Nov 2013 for tennis elbow and of course the first couple of days was horrible but after that I had no more pain. I was so relieved at how much better my elbow felt but within a month I lost the fat tissue and pigment of my skin color around my elbow. I went back to the doctor and the PA just brushed it off like it was no big deal. I thought, well if I had to live with the “divot” and a constant band aide to cover the bony area of my elbow to keep skin on it at least my elbow wasn’t hurting anymore. For about one year I was pain feel, then I weeded my yard over a weekend and the next weekend spent many hours on the computer doing some research and my pain came back triple fold. It has been 2 months now. I have tried to rest it, ice it, etc. but just seems to be getting worse and now is radiating shoulder pain and down to the hand.
    My question is, after reading your comments about cortisone injections, could my pain be worse due to tendon degeneration or could it be because the injection was not injected properly? And if there is tendon degeneration can the Flex Bar and/or PRP injections help?
    Thank you.

    1. HI Cary … skin color changes and atrophy of the fat can occur if the injection isn’t deep enough. It’s hard to avoid in some very thin individuals. That being said, there’s little harm in trying the Flex Bar. Most of my patients do very well with it. PRP is an option too.
      Good Luck

  18. Dr Luks ,
    i have had tennis elbow release , revision , then another for scar tissue to be removed and my Dr. says now i have scar tissue around the radial nerve , other then having scar tissue removed ,what other alternatives do i have for getting rid of the pain once and for all ? i have thought about having the nerve burnt . Going on 3 + years in pain . and yes it is bilateral and seams to be turning into golfers elbow , My Dr. also says that pain is from where i am learning my body not to hurt the upper tendon . injections have not helped me . I first noticed the lower tendon pain after wearing tennis elbow braces . any suggestions how the pain can be gone forever ?

    1. Jeanie …
      Many times, when faced with this situation it pays to have another Upper Extremity surgeon take a look at you. The diagnosis may have been wrong, or you may have had something else wrong in addition to tennis elbow. A certain number of patients will have PIN syndrome, radial nerve entrapment or radial tunnel syndrome (all involve the radial nerve) either in addition to tennis elbow, or this may have been the problem all along. Something to look into at least.
      Good Luck.
      Howard Luks

  19. Hello, I have delt with tennis elbow in both arms for years from my tournament bass fishing. It has been a little over a year since the standard surgery in my left arm. Although the it took 6 to 9 months it is now 100%. I had the tenex procedure in my right arm back in Oct and loved it as there was little to no pain. However now it feels like I had nothing done to it and pain is back so I am very disappointed. Go back to my doc next week but would you have any explanation why I am still having pain in my right elbow again? Pretty disappointed that I may have to get the traditional surgery if this in fact did not work after reading about how great tenex procedure has been. Thank you

    1. The Tenex procedure is great…. or at least it seems so from the reports I read. It can be tricky though. You need to have a doc who is very very good at. They need to be good at ultrasound, and have a clear picture of the tissue they are removing.

      Good Luck to you… no easy choices ahead.

  20. Hi Dr. Luks,

    I was diagnosed with tennis elbow in October of 2014. I’ve gone through physical therapy and oral steroid treatment which improved my symptoms. After stopping the steroid and continuing my exercises at home, my elbow seemed to get a little worse again. Two days ago, I woke up with excruciating pain in my elbow, it is also red and inflamed. I saw an orthopedic doctor who suggested a cortisone injection but due to the fact that my elbow was red, inflamed and warm to the touch he said he couldn’t do the injection. I am very hesitant to even have a cortisone injection into my elbow. I’ve had a history of calcific tendinitis in both shoulders but he assured me this was rare in the elbow and that I just had tennis elbow. I’m just wondering why it has suddenly gotten so worse overnight, I didn’t injure my elbow or use it in excess so I’m just wondering could it be something other than tennis elbow? They took X-rays and did see calcium formation near my tendons. Is this normal for tennis elbow? I greatly appreciate any insight, thanks so much.

    1. Hi Brandy … an elbow with tennis elbow is almost never swollen or red. Those are hallmarks of infection or gout. The calcification can be seen with tennis elbow, or many other conditions … including gout. I would seek out another opinion.
      Good Luck

  21. Dr. Luks,
    My apologies if this has been answered already. I was wondering if cortisone injections in the rotator cuff might produce similar results? Also, how long will increased serum glucose levels following cortisone injections typically last? Thank you!

    1. Blood glucose levels in diabetics can stay elevated for a day or two. Injections into any tendon can produce significant pain and further degeneration.

  22. Glad I found this site. I’ve had tennis elbow on and off for a number of years, usually subsided after CI. A year ago it started to bother me, finally saw my Dr and had another shot….3 months later it was getting a lot worse. To the pont I could barely even left my arm and sleeping was getting interrupted. I’ve done the PT, acupuncture, tens and today. I finally saw an orthopaedic Dr. He gave me no other option than another shot, and if there’s no relief in a month get back in touch and possible surgery. Following this injection I’ve been in agony, I can’t move my fingers and the pain is making me feel sick, narcotics not touching it. I’m reading where others had similar reaction, wondering how they are now and did they need further treatment, and at what point do you say this is enough?

    1. Hi Pauline … You have had enough injections. More than one injection risks further tendon injury. Have you tried a Flex Bar from Theraband? Have you investigated PRP injections? You can also look for someone accomplished in the Tenex procedure which is truly minimally invasive. A little more research while you try the Flex Bar… Good Luck !

  23. I am 62 and have had many cortisone injections in my right elbow over the years.The last cortisone injection was in December/2014. In the last few months I have developed a large”crater” at the previous site of injection. The epicondyle brace doesn’t help much with the pain and mobility. I will have an MRI tomorrow to determine the nature of a possible tear in the tendon.I presently have a tear in the cartilage over the radial ulnar area and am wearing a custom wrist brace.
    Do you think that plasma injections might help with the atrophy in my elbow? Do you know if they are available in Canada? Any suggestions would be greatly appreciated.
    Thank-you.

    1. The PRP can help alleviate your pain, but it will not change the appearance of the crater. If steroids are injected under the skin they will dissolve the fat and can also cause skin discoloration.

  24. I have suffered from tennis elbow for years, but last year it became much worse. I never treated it before (wasn’t even sure what it was). Last year I tried physical therapy – but it was too painful. I ended up getting a CI in October of 2014 and the relief was amazing. The pain is now back with a vengeance and much worse than before. The pain is also now extending down into my forearm (I assume this is because I am avoiding the elbow and therefore putting strain on the forearm). I am hesitant to go for another CI, and am wondering if flexbar exercises are advised when the pain is already at a very high level. Simple activities that were not painful previously are quite painful now. Also – if the flexbar is indicated, is there a risk of doing it “wrong” and making things worse?
    Thank you for any input you can provide.

    1. Hi Karen … Yes, the Flexbar can be very useful. Just start with the lowest resistance and follow the videos closely :-). I would avoid another cortisone injection since they can worsen the tendon degeneration. A PRP injection can be considered too.

      Good Luck
      Howard Luks

  25. I have been dealing with tennis elbow for about 9 months. Had a cortisone shot in Sept and did physical therapy. It did not get better, but in fact got worse. To the point where I was not sleeping and could barely do every day activities because of the pain. Recently had an MRI and have about a 8mm common extensor tendon tear. Had another cortisone shot yesterday and was told to wait 4 weeks to try therapy again….BECAUSE I WANT TO AVOID SURGERY AT ALL COSTS. Suggestions on things I can try?

    1. I would strongly consider not getting any more cortisone injections… they can worsen the tendon degeneration. Not all tears require surgery. Many people will get better with a Flexbar … many people! PRP is also an option.

      Good Luck

  26. I have also suffered from elbow pain and have been diagnosed with Tennis Elbow. I am not about to ask the Dr. A question because he is going to suggest PRP…

  27. I have had tennis elbow for about a year it was better for 6 months but returned in in Jan 2015.After going for treatment and with no improvement an MRI was done.Now there is mild tendinosis and a bone spur at the triceps insertion and the extensor tendon is torn 50%. Surgery has been advised because i am a brick and block mason and they told me i could tear it all the way through and that i would be screwed. The pain is low to moderate.it does increase sometimes while working. I was thinking of going for a second opinion.How long is the recovery from surgery until i would be able to work?Any thoughts or advice would be appreciated.
    Thank You
    Dan

    1. Hi Dan … Surgery is indicated to improve your quality of life. It is not done to try and prevent a complete tear — which by the way is still repairable. PRP injections and a Tenex procedure can be very effective as well with a minimal of downtime.

  28. Hi I am a 57 year old man who has been affected by tennis elbow for about 4 years,. I have had cortisone injections from my last 2 GP’s and neither of those Doctors seemed to inject the cortisone correctly. Sometimes the injections would help for a week or so but the pain always came back fairly soon. About 2 months ago I ended up going to see a Orthopedic guy who gave me the same thing ( lidocaine in one syringe and then the cortisone.in the other) This orthopedic guy pushed the needle with the cortisone in and out several times saying “This is to aggravate the bone or tendon” ( I forgot exactly ) but immediately I felt relief from the numbing agent but then upon waking the next morning I was in TERRIBLE pain. This man HURT me. I was sore for several days but low and behold after 2 or 3 days there was no more pain. NONE. I at first was afraid to do any push ups or weight training ( which I do moderately) for exercise but now I can and pain free ! I do not know what this guy did that was so different from my GP Doctors except injecting into several areas of the bone but it has been 2 months or so and I fell GREAT. !

    1. Gary … by moving the needle around a lot we are hoping to upset the degenerative tissue responsible for your pain. That in turn can help the tendon heal. I’m glad it worked out well for you.

  29. Dear Dr. Luks,
    I was diagnosed with Tennis elbow in my right arm in August 2014 (after playing tennis nonstop for about 3 hrs). My doctor (Orthopedic Surgeon) did X-ray and suggested me to do a few exercises and also advised to wear a brace. I did not get any relief with icing, exercise, and use of brace. After three weeks, when I went back to his office for the same problem, I met with another Doctor, who gave a cortisone shot and recommended physiotherapy. After 3 weeks of physiotherapy, I felt worst and went back to my Doctor. MRI was done and showed a tear at the origin. I was given second Cortisone injection in October and felt almost normal after two days. However, when I resumed playing 3 weeks after enjoying painless elbow, I was in pain and my Doctor gave me third Cortisone injection. I felt better, in fact, I had no pain with normal use of my arm/elbow but did not play tennis for the following four months. I started playing Tennis again about a month ago and unfortunately, I experienced the same problem. I stopped playing but the pain did not go away. Finally, this afternoon, I went to see my same Orthopedic Surgeon, he gave me fourth Cortisone injection and recommended for surgery if this problem comes back. Currently, I am having unbearable pain, never had that much pain before and I understand it may take a couple of days to get relief. Thank you for reading my long history of tennis elbow.
    My questions for you are;

    1) Is it OK to have four cortisone injections in a period of nine months?
    2) Can cortisone injections be given (or are generally given) by using a guiding device (like ultrasound) in order to hit the target?
    3) Should I consider going for surgery or do you recommend using Flexbar and/or PRP injection (as suggested above) in my case before considering the surgery.
    4) My doctor also told me that even after surgery there is a chance to have this condition back. So, should I stop playing Tennis if there is no hope of getting relief from this problem?

    Best Regards,

    1. Shoney …
      Multiple injections are frowned upon and not a wise idea. They can make the tendon degeneration worse.
      The FlexBar generally works very well… even in people with tears of the tendon. PRP can be useful too.
      The surgery is usually very successful, and recurrence is rare. A relatively new procedure called a Tenex procedure has shown significant promise. It’s just difficult to find people with enough experience with it.

      Good Luck to you … no more injections please.

  30. Hello Dr.,

    I have been suffering with tennis elbow for approximately nine months. In the last six months I have had seven cortisone injections. The pain has been just awful. What kind of damage will all those injections cause? I have asked my Dr., every time if it’s ok to have this many injections he has always assured me it’s fine. I will be asking him about the flexbar and PCB blood inj.

    Thank you,
    Karyn

    1. Too many injections can cause further tendon degeneration. Many will suggest no more than two. A flexbar can be purchased online and is worth a try.

  31. I had very painful tennis elbow. I would wake up at night when I rolled over because I could not pick up my arm so I would have to use the other one to pick it up and take it with me as I changed positions. Needless to say I did not sleep well for almost a year. I went to a specialist and had an MRI and was diagnosed with tennis elbow. Had cortisone injection. The side effect was that it crystalized or something called a flare and felt like my arm was hit with a sledge hammer! Well less than a day later I was back to the same pain I had before. Then the day after that I was pretty much pain free and have been for almost 2.5 years! I guess it can work for some.

  32. ive had tennis elbow for about 5 months now i got a cortisone injection last month and the doctor give me 2 days off work the pain is more intense now so he gave me another injection yesterday with 3 days off work my job involves heavy lifting and everyone told me that i should at lease have 10 days off to rest it is this true the doctor told me after this the only option is an operation

    1. There are a few other options … Physical therapy, purchase a FlexBar, (watch their videos), PRP injections and a very small procedure called a Tenex procedure.
      Anyway… most obtain relief with the Flexbar. Also… if you do not respond to the injections there is always a chance that the diagnosis is wrong… you can ask a second opinion.

  33. thank you for your advice i will go for a second opinion as i want to be 100% as to what is going on with me THANK YOU once again

  34. I have been experiencing tennis elbow for a awhile, using a elbow brace, and was able to continue playing tennis. History experienced tennis elbow March 21st, took a cortisone March 23, tried PT for a couple weeks, even tried acupuncture. Played tennis April 15th, framed a shot, felt a snap in my elbow. Got an MRI April 27th, results from the MRI and appointment with surgeon at Kaiser as follows: Musculoskeletal: tender over right lateral epicondyle. Elbow range of motion is full. Resisted wrist and finger extension provokes pain. Elbow stress ligament in intact with intact lateral collateral ligaments. NV ok. Data Review: Secondary review of image: fluoro; negative of elbow.
    MRI: rupture of common extensor origin. RIGHT LATERAL EPICONDYLITIS (primary encounter diagnosis) Advised to have surgery. Put of surgery for a month. Emailed doctor after to see if there was any other options besides surgery. Response from doctor is there is a tenex procedure that is not offered at Kaiser.

    After doing some online research on tenex procedure; Actually met with doctor and I am considering the tenex procedure? I have a call into the doctor who does the tenex procedure as follows: “It I want to play tennis regularly is the tenex going to provide goo strength return if my tendon is ruptured, actually torn fully off the bone?”
    Have posed this question with tenix doc and waiting for for call back?

    Question: What do you advise??

  35. Dr. Luks, I already had a cortisone shot and yes felt great for a month or so. I started playing table tennis and the 3rd time I played it act up. Next day my elbow has blue/black bruise. Can I still use Flex bar and see if it will help? is PRP will work after cortisone. What is Tenex procedure? does it work for tennis elbow? Many thanks in advance.

    1. PRP can still work if you wait a few months. Yes.. the FlexBar should have been your first line treatment and might still be effective. The tenex procedure involves using an ultrasound to find the diseased tendon, then putting in a small probe to remove the diseased tendon.

  36. Thanks Dr. Luks. I have received the Flexbar – should I wait to start working with it or can start right away. My elbow is in really bad shape and the exercise it shows do create discomfort and pain for few seconds. Is that normal. You have been very kind and many thanks.

  37. I have suffered with tennis elbow for over 25 years. Stopped playing competitive tennis because of it. However now in my retirement at 60 I have returned to coaching tennis and playing. The soreness has returned. One steriod injection did nothing. I can squeeze 15 lbs on my right hand and 85 on the healthy hand. My doc wants to do surgery. I used the thera band for four weeks and it made it worse. Should I proceed with surgery?

    1. Hard to say Mike … since the inclusion of the FlexBar and PRP injections in the treatment of tennis elbow, it is very very rare that I need to consider surgery.
      In the right hands surgery is a reasonable option if your quality of life dictates it is necessary. Another potential option is to find someone comfortable and experienced with the Tenex procedure.

      Good Luck

      1. After some looking I found someone local who can do the Tenex. It will be their third case, though trained at the Mayo. I am not happy about the lack of experience – but my research suggests it isn’t that difficult a procedure? Do you agree?
        What I like is the recovery period is shortened, improved outcomes and the ability to go back to standard surgery if it doesn’t work. He did a pre-op sonogram and there was a large field of degenerative tissue.

      2. Hello again. Well I am 6 weeks post op (Tenex) and very encouraged! There was no post op pain, nothing! I was able to return to restricted activity quickly and now have already begun to lift weights again. No tennis yet, but soon. I could but being cautious. My doctor has performed three more since mine and is impressed as well. Anyone that doesn’t respond to non-invasive procedures should research this approach. After decades of suffering with this, I have some hope.

  38. I’ve had tennis elbow for more than 2 years. I’ve had 3 injection, normal after 6 months between. I’ve noticed pain starting normally after 4 months and it starts swelling and bursing until I get another one. What is causing the bursing several months after the injection? The doctor did say surgery was something to start considering.

    1. Tennis elbow is a degenerative tendinopathy… that means that your tendon is getting worn out. injections do not cure it… and sometimes make the issue worse.

  39. Hi, I was wondering if you ever see patients with tennis elbow who have tendinitis in the shoulder as well (and if they are related)? I’m 34, been suffering from tennis elbow for over two years now. Initially I did physical therapy for 6 months along with dry needling. This helped but the pain never went completely away. I did purchase a FlexBar but it never seemed to help, either. I refused injections because of the things I had read about them online.

    I started having pain in my shoulder about a year after the tennis elbow pain started, and two months ago had rotator cuff surgery to excise a large calcium deposit. Now that I am doing strengthening exercises in PT my tennis elbow is worse than ever, and I’ve scheduled traditional open surgery for next week. I’ve had second (and third) opinions, and I greatly respect my current ortho surgeon who did the shoulder surgery and will be doing the tennis elbow surgery, but he tells me that the tendinitis in both places is not related. I find this hard to believe. Since the tennis elbow started first I am inclined to think that was at least a catalyst for my shoulder calcium, but maybe I am just looking for a reason for something that is just unfortunate luck (as my surgeon thinks).

    1. We do not know why calcific tendonitis occurs. Some people are more predisposed than others to developing tendinopathy — or degenerative changes in their tendons. So… at some level they may be related. But more than likely through your DNA and genetic makeup than anything else.
      Good Luck

  40. There’s hope:)
    I had a cortisone shot in my right elbow and it helped, but I had a tear in my right on the medial side. After months of pt and cortisone I had surgery, talk about a hard recovery. However when I developed both golfers and tennis at the same time in my left elbow I opted for PRP and stem cell injection! It’s been 4 years and they are holding strong! It’s a GREAT option!

  41. Thank you for the comments and feedback. I have been suffering with tennis elbow for 5 months. I have had 2 prolotherapy treatments from 1 Dr and it didn’t help so went to my favorite PRP Dr and have had 2 treatments. The last was 3 weeks ago. I’m barely noticing much improvement. I started physical therapy and she advised 3 stretching exercises only. I have had great experience with prp in my back and shoulder. I’m debating on a third prp injection but the pain is excruciating after the treatments. It feels worse after treatments it seems. Is this to be expected? How many prp treatments would you expect are needed? What would be another next step? Thank you!

  42. I had PRP five days ago, day three felt as though I was getting better but now into day five I feel as though I’m getting worse. Is this typical for the first few weeks or should I be concerned? I’m not sleeping at all with the dull pain. My physio suggested wearing a wrist strap to isolate my movements but feel it isn’t helping.

  43. Dear Dr. Luks,

    In Nov 2014 I had very mild pain in my triceps muscle. I did an MRI that showed no pathology in any of the tendons around the elbow. I saw a doctor who injected my common extensor origin, claiming that I might have tennis elbow and that it could be causing the pain in the triceps. After the injection, I experienced severe pain in the lateral region of my elbow. I got another MRI shortly after and it showed that I have a lateral tear in the common extensor tendon which I didn’t have before the shot. Could the cortisone cause damage if it was injected into a healthy tendon? Or could it have been the needle itself that caused the damage? it’s been more than a year and so far no doctor has been able to diagnose my condition and my arm is not improving and I wonder what the shot did to the tendon!!

    I am in NY for this week and I called your office to get an appointment this week because I am leaving on Friday. Unfortunately you’re all booked and I was wondering if you can make an exception and see me this week for PRP evaluation before I travel.

  44. Hi….
    Am suffering from tennis elbow on my right hand. Physiotherapy didn’t help. My ortho gave me steroids DEPOMEDROL 40 MG.I am feeling better now. He asked me to cum back after 3 weeks. Should I start exerciseing after the pain is completely gone? Will it ever be completely fine.?
    I am feeling as if my left hand is also showing the same initial symptoms. Or should I start exerciseing my left hand.? Thanx
    Please help

  45. In Feb 2015, I injured my elbow weight lifting which left me with tennis elbow symptoms. It basically eliminated my ability to use dumbbells for curling and other types of lifts that i like to do regularly that puts pressure on my forearm and elbow. After 6 months of avoiding lifts that cause discomfort, which include most arm exercises, I purchased the flex bars but had little success with them. I visited my doctor and tried the cortisone injection which worked great for about 12 weeks and I was able to return to full workouts including curling. The pain returned along with some arm extension issue discomfort so i had to stop again. I kept working with the flex bars to little success and decided to risk another CI.Once again, it worked marvelously but now after 3 months I can feel the pain start to return. I’m not sure what to do next if the pain starts to interfere again with my training. The injections work so well that I feel that a 3rd injection is a viable option but I dont want to cause damage. I am reading about the PRP and tenex solutions and am wondering whether I should go that route and how common they are. Unfortunately, it seems that a lot of physicians are not that well versed in tennis elbow treatments because most of the knowledge I have came from my own research and these options have never been brought up to me. CI is the the most common treatment that has been offered in my experience.
    Any advice would be appreciated.

    1. HI Charlie…
      The most recent thoughts regards management of lateral epicondylitis is to simply let it run its course. Tennis elbow typically occurs in folks between 35-50. It is self limiting and usually goes away within 12 months. Steroid injections should b avoided due to the harm they can cause to the tendon. PRP injections, Tenex and open surgery all have sparse literature to support its use — however — as mentioned, many of us try to get folks to wait it out since it does resolve in nearly everyone within 12 months and the research shows that nothing else is 100% effective in treating it.

  46. Well I am now nearly 10 months post Tenex procedure. I am completely pain free! I play tennis hard (5.0 level) with no symptoms. I highly recommend this simple, mildly invasive procedure. I can’t believe that after 3 decades of pain a 20 min procedure cured me. Wonderful stuff.

    1. Hi Mike –

      I’ve been suffering with TE for 13 months with significant discomfort. I’ve tried PT, Cortisone shots, Stretching, Flexbar, all with limited success. I’d love to hear a bit more about the Tenex procedure you had. How did you come to finally seek an “invasive” technique.

      Thanks,
      Jeff

  47. I’ve been suffering from Tennis Elbow since April 2016. I did chiropractic treatment for 3 weeks, I got some pain relief, however still had sever pain when I worked on day on computers. So took Cortisone shot which made matters worse, did not get any pain relief and on top of that my hand and middle and ring fingers feels stiff in the morning. Due to continuing my work, my wrist began to hurt, at this point (September 2016) I started looking into alternative treatments and exercises and found this article from NY Times published in 2009 – http://well.blogs.nytimes.com/2009/08/25/phys-ed-an-easy-fix-for-tennis-elbow/?_r=0; I bought the Thera-Band Flexbar from amazon. com and have been using it since then, my pain is relieved by 80%, still my hand is not as strong as before, but I am not miserable anymore. I first started with 1 set of 15 – 3 times a day and then gradually increased to 3 sets of 15 – 3 times a day. After exercise, ice pack helps relieve the soreness.

    I had read this article when I was looking for treatments and felt the same pain as many others suffering and had promised myself to come back and share my experience if I ever get any relief from my pain. I hope this helps!

  48. I had a fall cleaning my shower,and my left arm broke my fall. After a month in pain,my doctor sent me for an xray and ultrasound. It showed Common extensor tendon tendinopathy and an interstitial tear. Im in awful pain, and my doctor said a cortisone injection is what he recommends. After reading about cortisone, Im very nervous. Can u help me please. Do I have Tennis Elbow? Kind Regards.

    1. Sounds like it… but I can’t tell without examining you. Injections into tendons, in general, are frowned upon.

  49. Hi, after a session of lifting weights (bicep curls) I noticed pain and stiffness in my wrist, forearm and elbow. I experience a lot of pain in my wrist especially lifting something heavy. My elbow is also constantly cracking. Does this sound like tennis elbow? Thank you for your help

  50. Hi Dr. Luks,
    Love the scientific nature of your blog post. I hurt h elbow about 3 months ago, rest has helped a bit, physio did not help much, so I think it’s time to try the flex bar. I have a couple of questions regarding tennis elbow:
    1. I have used a compression brace with some success, but is a sleeve better for this injury?
    2. My pain has migrated mostly to above my elbow, along the back of my arm. Any ideas why, and is this common?
    3. Is Graston a good technique for tennis elbow? How about ultrasound or electrical stimulation?
    4. Is there any literature on ways to shift the collagen III to I ratio back to a healthy level through exercises?

    Thanks so much.

  51. This website is very helpful, thanks Dr. Luks. It appears to me that Tennis Elbow could be Tendon/Muscle Tear or Inflammation or both, which may require different medical treatments? (An engineering analysis)

    1. True Abraham… there are different causes of tendinopathy. Reactive: say you shoveled snow for 3 hours, Degenerative: chronic use and age. Different causes can lead to different recommendations. For the vast, vast majority of people, waiting it out will result in pain relief, although it can take up to one year.

  52. Hello Dr. Luks, I found your site researching the drawbacks of steroid injections. I recently was diagnosed via MRI with a partially torn common extensor tendon. I have gone through almost three months of physical therapy with no success. Earlier this week I saw my Orthopedic Surgeon for the first time and after he reviewed my MRI and did a brief exam he recommended a steroid injection for my tennis elbow. I asked many questions and my doctor said that the steroid injections (no more than 3 a year) wouldn’t be that detrimental to my health….I guess everyone has an opinion…but I also know many medical procedures and medications have unwanted drawbacks and side effects. It’s now been four days since my steroid injection and my tennis elbow symptoms have all but disappeared. I’m still very cautious using my arm but so far I’m happy with the results and just hoping that when the steroid injection dissipates that my symptoms are not worse. As for the PRP Treatment for tennis elbow, my surgeon discussed that procedure with me…but even in the Pacific Northwest where doctors usually are at the forefront of medical innovations, the PRP procedure is still a new and relatively untested procedure with little data…and not covered by most medical insurance companies. By the way….I’m going to get a Flexbar and start working with it to hopefully help.

    1. Good luck Joe…
      The research on steroid injections for tennis elbow shows that it can make the degeneration in the tendon worse. There are no magic number of injections allowed. The fewer the better.
      Good luck.

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