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.
Click here to receive our Sports Medicine Blog Updates
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.
Nehal
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.
Mike
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?
Howard J. Luks, MD
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
MIke
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.
Howard J. Luks, MD
Sounds good …
Mike
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.
Howard J. Luks, MD
Excellent… I’m glad you are starting to see a light at the end of the tunnel.
Staci
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.
Howard J. Luks, MD
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.
Camille
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).
Howard J. Luks, MD
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
Patti
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!