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.
Julie
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!
Saskia
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.
Howard J. Luks, MD
not unusual… in some instances it can take up to 6 weeks to feel better.
Mina
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.
Howard J. Luks, MD
I will squeeze you in… please email me at [email protected]
dimple
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
Charlie
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.
Howard J. Luks, MD
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.