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

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

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 the patient who suffered from other past traumatic elbow injury. 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, 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 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?

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, providing there is not a complete ligament rupture.

The elbow replacement option

We do not offer surgery at our center, we offer regenerative medicine injections. We have been doing this work for 28 years now. However, 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. Here is December 2019 paper published in the journal Clinics in Orthopedic Surgery. (1) Let’s let the 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 the 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, 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, 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, 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.

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, this 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 (2) 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 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 (3) 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 a 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, 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 the 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 

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)”(4) 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, (5) 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. (6)

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, 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 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

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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1 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]
2 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]
3 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]
4 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]
5 Hauser R, Hauser M, Hollan P. Hackett-Hemwall dextrose prolotherapy for unresolved elbow pain. Practical Pain Management. October 2009;14-26.
6 Hauser RA, Hauser MA, Hollan P, Hackett-Hemwall Dextrose Prolotherapy for Unresolved Elbow Pain. Practical Pain Management. October 2009;14-26. [Google Scholar]


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