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.
Abraham Gale says
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)
Howard J. Luks, MD says
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.
Joe says
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.
Howard J. Luks, MD says
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.
Steve Anderson says
Dr Luka: excellent article, very informative. I’d like to give you my experience with a cortisone injection because it offers a contrarian view to the research results cited in most studies. My experience with one singular cortisone shot for tennis elbow can be best summarized in a word, miraculous. I suffered for 18 months with debilitating TE pain that at times was so bad I dropped a milk carton when pulling it out of out of the fridge. I tried PT exercises using a Flex bar and related stretching for 9 months with little to no improvement. I then received one cortisone shot and 3 days later the swelling and pain was gone and it’s never returned in any form – that was 2 1/2 years ago! I realize people can react differently to different types of therapies and maybe I’m the exception but I thought it was worth noting that for some people the cortisone therapy can have long lasting and truly remarkable results. Best, Steve
Lisa says
Hi Dr Luke.
I have a high grade tear at the origin of the common extensor tendon. But was told not to get surgery and prp was a fad and to get cortisone pills. Will such a tear heal on its own?. It’s been 2 months.
Thank you in advance for any advice.
Howard J. Luks, MD says
That’s a very common finding in tennis elbow. Tennis elbow is a degenerative disorder which usually spontaneously resolves (heals) in nearly 100% of people who suffer from it. It can take 8-10 months to fully resolve in some. Surgery is very rarely necessary, PRP injections can be considered. They “might” help with the healing process.
lisa says
Hi Dr. Luks,
My Tendon completely tore off the bone last week. I am in less pain now. But, The tear is no longer pulling.But, should i be worried about any complications? Is surgery suggested for this now? What would be your advice ?
Thank you so much for all of your help and insight.
Raj says
Hi Dr. Luks,
Thank you for sharing such good information.
I am suffering from tennis elbow in my both the elbows from last 6 months or more. NSAID medicines are not giving relief. As per the doctor’s advise I have taken 3 depo medrol injection (1 in left and 2 in right elbow), now pain is almost gone but the doctor is advising to take 3 more injections (means 3 inj in each elbow) . I am scared of the pain after injection. Its almost unbearable for more than 48 hours.
Is it safe to take 6 injections ? can I go for another 3 injections ? What would be your suggestion ?
Waiting for your reply.
Thanks in advance for your time and suggestion
Raj