Non-Surgical treatment of elbow osteoarthritis – alternatives to elbow replacement

Ross Hauser, MD.

At our center, we see patients with elbow osteoarthritis who have been through years of treatments for tennis elbow or golfer’s elbow, and their elbow pain has progressed to a more painful, less functional situation with a significant loss of range of motion. This of course does not mean that people with elbow osteoarthritis are only people who played tennis or golf. We see the people who never played golf or tennis but do physically demanding work. They were told by their doctors that they had tennis elbow-like symptoms and it has now progressed to degenerative elbow disease. We may also see the old baseball player who now has a loose elbow from years of throwing. We may also see the patient who may have had a terrible triad elbow injury, (dislocation, radial head fracture, and a coronoid process fracture) that despite pins and plates is still weak and unstable. We may see a patient who suffered from other past traumatic elbow injuries. The typical story we hear goes something like this:

I have bone-on-bone arthritis in my elbow. It was diagnosed as tennis elbow, and then, golfer’s elbow. I never played either game. Diagnosed with both tennis and golfers elbow though I never played either. I was on a wide range of anti-inflammatories, I wore elbow braces, and I had cortisone. My orthopedist tells me that I am running out of conservative care options.

If you are reading this article, these treatments probably have not been effective long-term treatments for you either.

Conservative Care Failures and Surgery

For many people, conservative care treatments for their elbow pain worked very well. For some patients, whose elbow pain has become chronic and life-altering, where the conservative care options stopped working, surgery was performed and it worked very well for them.

The conservative care and surgical success people are not the people we see at our center. We see the people for whom conservative care and surgery did not help and in some cases made the patient worse or at best, didn’t help at all. These people are now exploring, in many cases, last-ditch efforts to avoid an elbow replacement surgery or second elbow surgery that they do not have the utmost confidence in.

We understand that many people have severe elbow pain and they have to do something, many of these people have already made up their minds that they will proceed with surgery and for them, this is probably a good choice. The people we see, and perhaps yourself, someone who is continuing to read this article, may not be confident or have concerns about elbow replacement. This article presents information on options. If you have elbow replacement surgery the odds are you will have a good outcome.

Is your elbow ever too far gone?

To be able to avoid surgery and use non-surgical methods to alleviate your elbow pain you have to have a realistic outlook on what surgery can do and what non-surgical methods can do. Later in this article, we will explore various types of regenerative tissue-building injection therapies. For non-surgical options to work in getting you back to work or sport, you have to have a careful examination of the range of motion in your elbow. If you have bony overgrowth and bone spurs in the elbow joint that prevents you from going through various ranges of motions or if the elbow joint is frozen or locked up, you may be too far gone. You can use the contact us an email at the end of this article to ask us about your case. Bone spurs are Nature’s last resort in protecting your elbow by preventing you from the bending and rotating that caused your problems in the first place. Your body is saying, “don’t bend your elbow anymore, I can’t fix it.”

What are we seeing in this image?

The caption reads “Clinical stages of posterolateral instability of the elbow.” The image is explained below.

Look at the top row of elbow joint pictures as a type of computer image x-ray. Look at the bottom pictures of the elbow joint as a computer-type image MRI. Combined we are presenting a graphic image of how elbow osteoarthritis can develop and we will introduce the idea that the elbow ligaments play a key role in the prevention or development of elbow osteoarthritis. We will also suggest briefly and cover this more thoroughly later in this article that by repairing the elbow ligaments, there can be a realistic expectation that elbow replacement surgery can be avoided in many cases.

In this image we start with a normal elbow, then we move through a progression of a mild elbow instability problem of supination.

Supination – the second images

Vagus rotation

You will see in the corresponding image below, more ligament damage is demonstrated. The strong ligament bands are no longer in optimal condition to hold the elbow together.


When we reach the point where the radius forearm bone is dislodged, in a state of subluxation (partial dislocation), or dislocated over the ulna, the person begins a more urgent assessment of elbow replacement surgery because of pain, stress, and instability at the elbow joint. In this final phase, elbow function may be significantly compromised.

As mentioned above, if the elbow has yet to be engulfed in bone spurs and bony overgrowth, there is a realistic expectation that the ligament damage and tear can be non-surgical repaired, provided there is not a complete ligament rupture.

Elbow stiffness and loss of function and range of motion

In December 2021, Dr. Joaquin Sanchez-Sotelo, Chair of the Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic published an intensive review of the problems of elbow osteoarthritis and stiffness in the Journal of Experimental Orthopaedics (1). These are some brief summary points of that review.

Dr. Sanchez-Sotelo writes:

“For orthopedic surgeons, elbow stiffness implies that the elbow joint has lost motion in one or more directions (flexion, extension, pronation, and/or supination). Several factors may contribute to loss of motion, including fibrosis Tissue, scar tissue overgrowth impeding movement), osteophytes (bone spurs), ectopic bone formation (bone is forming in soft tissue where it does not belong, typical of surgical complication or traumatic injury), and changes to the joint articular surface (the smooth cartilage at the joint that allows for gliding motion has now been damaged and is causing impediment of movement).”

“Whereas conservative treatment may improve motion to some degree in patients recovering from a traumatic injury, oftentimes elbow motion can only be improved with surgery. Fortunately, arthroscopic elbow techniques have been refined to allow successful surgical management of the majority of stiff elbows.”

From here Dr. Sanchez-Sotelo describes various orthopedic options for elbow pain and stiffness. They include:

In his paper, Dr. Sanchez-Sotelo summarizes: “Arthroscopic contracture release (removal of bone and tissue causing elbow problems), typically combined with in situ decompression of the ulnar nerve (removing tissue that may be pressing on the ulnar nerve), has become the procedure of choice for the majority of elbows with primary, posttraumatic, and inflammatory arthritis. Staged surgery (as it sounds surgery in different stages at different times) is commonly considered for neurogenic contractures. Surgeons with advanced arthroscopic skills may be able to tackle more complex procedures, such as arthroscopic removal of ectopic bone, the release of forearm rotation contractures, and even osteoid osteoma removal (small tumors that develop in the bone).”

The elbow replacement option

We do not offer surgery at our center, we offer regenerative medicine injections. We have been doing this work for 29 years now. Elbow replacement is usually reserved for patients who suffered a severe traumatic injury to the arm that made an elbow repair impossible. It is also offered to patients who have had numerous arthroscopic surgeries, as outlined above, where failed surgery and complication offered the patient little to no option. It can also be offered to patients with inflammatory arthritis or degenerative arthritis in which case the elbow would be seen as the knee or hip that is considered “too far gone.” Later in this article, we will discuss whether “too far gone” is an accurate portrayal of the patient’s elbow.

Now when discussing any joint replacement, it is always best to bring in orthopedic surgeons to have them help us explain the reasons for recommending a total elbow replacement to patients.

In this October 2021 paper published in the journal Shoulder and Elbow, (3) researchers in the United Kingdom offered this assessment of elbow replacement.

How was the study conducted? The researchers examined previously published research, 12 studies in total, that compiled data on 815 patients who had a total elbow replacement.

Conclusion of the researchers: “This is the largest systematic review of the complications of total elbow replacement. Surgeons should be aware of different complications related to their implant of choice, each having its own specific complication. Trauma as an indication appears to have an increased complication rate compared to inflammatory (joint disease). There is a lack of literature regarding the independent results of osteoarthritis as a specific indication for total elbow replacement.”

The last sentence on the lack of data on the “independent results of osteoarthritis as a specific indication for total elbow replacement” is also indicative of research surrounding other non-surgical forms of treatment as we will see below.

Here is December 2019 paper published in the journal Clinics in Orthopedic Surgery. (4) Let’s let these orthopedists discuss the surgery.

“Total elbow arthroplasty (replacement) is a common surgical procedure used in the management of advanced rheumatoid arthritis, post-traumatic arthritis, osteoarthritis, and unfixable fracture in elderly patients. Total elbow prostheses have evolved over the years and now include linked, unlinked, and convertible types. However, long-term complications, including infection, aseptic loosening, instability, and periprosthetic fracture, remain a challenge.”

The common problems of joint replacement

Let’s point out that many people have very successful elbow replacement surgeries. The challenges pointed out by the surgeons “infection, aseptic loosening, instability, and periprosthetic fracture” are however common problems of all types of joint replacements. Let the authors of this study help us understand more.

“Because it is a relatively rare procedure, most surgeons have less experience with total elbow arthroplasty than hip and knee arthroplasty, and few long-term outcome data are available. Therefore, to avoid iatrogenic errors (these would be surgical errors that would make the patient’s condition worse following the surgery), surgeons should carefully review the previous literature on total elbow arthroplasty.”

In this study, the authors set out to help their fellow orthopedic surgeons by laying out the information at hand to help the surgeons have better outcomes. Here are some of the suggestions:

An unlinked total elbow arthroplasty

The linked total elbow arthroplasty

The convertible total elbow arthroplasty

What the authors say here, are points of interest to our practice and the types of patients we see. Let’s go to the bullet points for emphasis:

The reality is if you are a manual laborer, a throwing athlete, or a wheelchair-assisted individual, the chances are that you will wear out this replacement or cause hardware failure.

Finally, the problems with elbow replacement and degenerative arthritis.

The study authors suggest: “Because the elbow is not a weight-bearing joint, the incidence of primary osteoarthritis is rarer than that in other joints. The incidence is higher in the overused upper extremities (in manual laborers, throwing athletes, and wheelchair-assisted individuals). Patients with primary osteoarthritis typically have higher functional demands and capabilities than those with inflammatory arthritis.) Thus, it is critical to communicate with the patient regarding postoperative management, with the surgeon stressing that the risk of complications could increase if the patient continues to have the same habitual pattern of elbow use.”

The reality is if you are a manual laborer, a throwing athlete, or a wheelchair-assisted individual, the chances are that you will wear out this replacement or cause hardware failure.

Again we point out that people do have success with elbow replacement surgery.

Interposition arthroplasty for post-traumatic elbow osteoarthritis

Surgeons at the University Hospital Cologne, Germany reviewed research on interposition (a tendon or other soft tissue is used to separate and provide a cushion between the bones of the elbow) arthroplasty for post-traumatic osteoarthritis of the elbow. The study was published in November 2022 in the journal International Orthopaedics (10). The researchers write: “Interposition arthroplasty for the post-traumatic osteoarthritic elbow is a salvage procedure used in young and active patients and remains a rare and unexplored therapeutic option.” The purpose then of their study was to see if this option was a good one. They assessed this by functional patient outcomes, revision surgery frequencies, complication and subsequent surgery rates among patients with surviving grafts.”

The researchers examined the data from five previously published studies comprising 67 patients. The average age of the study patients was 40 years old, 68% were male, average follow-up was 61 months after the surgery. Eleven patients (16.4%) were treated with fascia lata (deep thigh tissue) autografts, and 56 patients (83.6%) were treated with Achilles tendon allografts.

Conclusion: “Given graft survival, this systematic review demonstrated satisfactory functional outcomes following interposition arthroplasty of the post-traumatic osteoarthritic elbow, however, associated with a cumulative complication and subsequent operative treatment rate of 44.8%. In addition, a revision rate of 20.9% needs to be expected.”

What are we seeing in this image?

The vagus rotation or hypermobility of the elbow joint causes compressive and stress forces on the elbow. This can lead to the development, as demonstrated in item three of this image, of the compression and degeneration of the radiohumeral joint and the development of bone-on-bone osteoarthritis. In item four we see compression of the olecranon in the fossa, which is a notch in the upper arm bone that allows the elbow the ability to bend. If this area develops bone spurs, bending the elbow will be extremely problematic and a surgical suggestion may be offered.

The long-term success of elbow replacement

A January 2021 study in the Journal of Shoulder and Elbow Surgery (5) evaluated the long-term success of elbow replacement. Here the researchers examined the results of 23 previously published studies that included 1429 elbows (60.4% were the linked elbow replacement type).

Of the patients in this study:

Discussion and conclusion: (The authors say) “Our systematic review established that total elbow arthroplasty offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short- and medium-term.”

But what about the 36.7% who still had pain?

Revision of Total Elbow Replacement – That is three surgeries on the same elbow

A November 2020 study in the Journal of Shoulder and Elbow Surgery (6) looked at 14 patients who had a revision of revision surgery after failed total elbow replacement.

The average age of these 14 patients was 73 with the youngest being 57 and the oldest being 83. They were assessed two to seven years following the final surgery.

These patients had an average of three major complications that necessitated the need for two more surgeries following the total elbow replacement:

At the final clinical assessment:

Conclusions: “Revision surgery of revision surgery after failed total elbow replacement is a satisfactory treatment option in these complex cases with good short to mid-term survival rates but with a relatively high complication rate.”

There are more studies on the challenges and complications of elbow replacement surgery, but the point has been made. Let’s now look at non-surgical options.

Prolotherapy Specialist Danielle R. Steilen-Matias, MMS, PA-C gives a brief introduction to our treatment protocols for healing chronic elbow pain

Above we spoke about the possibility that regenerative medicine injections may help a person with elbow osteoarthritis avoid elbow surgery. In this video and the summary explanation below, Prolotherapy Specialist Danielle R. Steilen-Matias, MMS, PA-C gives us an introduction.

Summary transcript and learning points:

Ligaments and tendons

Above we spoke about damaged ligaments’ inability to hold the radius and ulna bones together. When these bones move out of position, they can cause the tendons to stretch as well. Let’s point out that the run-up to elbow osteoarthritis is a stretching and tearing of the soft tissue of the elbow including the ligaments and tendons.

What are we seeing in this image?

When you have tendon breakdown, it takes the elbow ligaments with it. When you have an elbow ligament breakdown it takes the elbow tendons with it. Here we have a situation of tendinosis, pain in the elbow where the body has given up trying to heal it. The “osis” part is pain without inflammation. If your body was trying to heal the elbow it would be an “itis,” pain with inflammation.

Back to Prolotherapy Specialist Danielle R. Steilen-Matias, MMS, PA-C’s video summary:

Treatments that do not help:

Injections beyond cortisone

Prolotherapy is the simple injection of dextrose (sugar) into the shoulder joint. Many studies have documented Prolotherapy treatment’s effectiveness in treating the problems of chronic pain.

In this video Ross Hauser, MD and Prolotherapy clinician student demonstrates Prolotherapy medial elbow treatment

The treatment begins at 1:12 

Ross Hauser, MD discusses the Prolotherapy treatment results that were published a few years ago as part of our article series on the use of Hackett-Hemwall dextrose Prolotherapy, as well as shows a treatment demonstration from a Prolotherapy symposium he taught in 2021.

Caring Medical research on elbow ligament damage and elbow instability

The problem of joint instability and in this case elbow instability is a problem of the elbow ligaments. In 2014 we published our article “Structural Basis of Joint Instability as Cause for Chronic Musculoskeletal Pain and Its Successful Treatment with Regenerative Injection Therapy (Prolotherapy)”(7) In that article our research team wrote:

“Ligaments are specialized dense bands of tough, fibrous collagenous connective tissue bundles that attach one bone to another. Ligaments function to hold bones in approximation, assist joint proprioception (keeping the joint where it should be and not hyperextended) and provide mechanical support and stability.”

The keyword is stability. The excitement exhibited by the above research about instability is something that Prolotherapists have discussed for decades. Weak ligaments lead to joint instability and tendinopathy, strong ligaments lead to pain-free joint stability and healed tendons.

In our published research in the medical journal Practical Pain Management, (8) our Caring Medical team found that:

Our research results for treating tennis elbow at a Prolotherapy charity clinic were analyzed and reported. In this study, patients were treated with dextrose Prolotherapy.

These results were reported as part of our larger study “Evidence-Based use of dextrose Prolotherapy for musculoskeletal pain: a scientific literature review.” Published in the Journal of Prolotherapy 2011. (9)

While the normal proliferant used in prolotherapy is dextrose-based, PRP Prolotherapy (Platelet Rich Plasma as demonstrated in the video below) is gaining in popularity. In PRP Prolotherapy, a concentrated amount of one’s own platelets which contain growth factors are injected into the injured tissue to promote and speed up the body’s natural healing process.

Prolotherapy and PRP injections for Tennis Elbow. The treatment here is explained by Danielle R. Steilen-Matias, MMS, PA-C, who is also performing the treatment on the patient.

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, and reliable alternative to surgical and non-effective conservative care treatments.

This is a transcript summary of the above video.

Summary and contact us. Can we help you?

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your elbow problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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1 Sanchez-Sotelo J. Arthroscopic management of elbow stiffness. Journal of Experimental Orthopaedics. 2021 Dec;8(1):1-0. [Google Scholar]
2 Agarwal S, Loder S, Cholok D, Li J, Breuler C, Drake J, Brownley C, Peterson J, Li S, Levi B. Surgical excision of heterotopic ossification leads to re‐emergence of mesenchymal stem cell populations responsible for recurrence. Stem cells translational medicine. 2017 Mar;6(3):799-806. [Google Scholar]
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4 Kwak JM, Koh KH, Jeon IH. Total elbow arthroplasty: clinical outcomes, complications, and revision surgery. Clinics in Orthopedic Surgery. 2019 Dec;11(4):369. [Google Scholar]
5 Davey MS, Hurley ET, Gaafar M, Molony D, Mullett H, Pauzenberger L. Long-Term Outcomes of Total Elbow Arthroplasty-A Systematic Review of Studies at 10-Year Follow-Up. Journal of Shoulder and Elbow Surgery. 2021 Jan 5. [Google Scholar]
6 Domos P, Chelli M, Papanna MC, Gokaraju K, Stanley D, Ali AA. Outcomes Following Revision of the Revision Total Elbow Arthroplasty. Journal of Shoulder and Elbow Surgery. 2020 Nov 19. [Google Scholar]
7 Hauser RA, Blakemore PJ, Wang J, Steilen D. Structural basis of joint instability as cause for chronic musculoskeletal pain and its successful treatment with regenerative injection therapy (prolotherapy). The Open Pain Journal. 2014 Sep 9;7(1). [Google Scholar]
8 Hauser R, Hauser M, Hollan P. Hackett-Hemwall dextrose prolotherapy for unresolved elbow pain. Practical Pain Management. October 2009;14-26.
9 Hauser RA, Hauser MA, Hollan P, Hackett-Hemwall Dextrose Prolotherapy for Unresolved Elbow Pain. Practical Pain Management. October 2009;14-26. [Google Scholar]
10 Lanzerath F, Hackl M, Pucher CJ, Leschinger T, Uschok S, Müller LP, Wegmann K. Interposition arthroplasty for post-traumatic osteoarthritis of the elbow: a systematic review. International Orthopaedics. 2022 Aug 30:1-8. [Google Scholar]

This page was updated October 24, 2022

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