Tennis 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 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
A 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.
Mike
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.
Howard J. Luks, MD
awesome feedback.
Jeff
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
Sharon
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!
Cig
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.
Howard J. Luks, MD
Sounds like it… but I can’t tell without examining you. Injections into tendons, in general, are frowned upon.
Timothy
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
AB
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.