Tennis Elbow Pain Treatments – Conservative Care, Injections, Surgery

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

Tennis Elbow Pain Treatments – Conservative Care, Injections, Surgery

If you are reading this article, it is very likely that you have a difficult-to-treat tennis elbow (lateral epicondylitis). As you have probably been told by your healthcare provider, this is an inflammation of the tendon attachment (the Extensor Carpi Radialis Brevis) at the outside bony prominence of the elbow commonly known as the lateral epicondyle. Whatever it is called, your elbow hurts.

As your elbow continues to hurt, you may be researching for more aggressive treatments than the ones you have been prescribed, you may even be exploring surgery. In this article, we will discuss why your Tennis Elbow problem has become chronic, problematic, and difficult to treat. We will also offer possible treatment solutions utilizing regenerative medicine injections such as Prolotherapy and Platelet Rich Plasma injections. In this article, we will also discuss when these treatments may not be as effective as hoped and how they may work better in your next treatment.

Conservative Care and Surgery

For many people, conservative care treatments for their elbow pain work very well. For some patients, whose elbow pain has become chronic and life-altering, surgery has worked for them as well. These are not the people that we see in our clinic. We see the people for whom conservative care and surgery did not help and in some cases made the patient worse. These are some of the things we hear in the examination room:

I was told that my surgery was essentially a gamble

I am thinking about the surgery because this has gone on for years

Why do these people not have success in treatment where others have? Maybe their elbow pain is not “Tennis Elbow,” at all.

“Tennis elbow” is a common condition, however as a diagnostic reason for elbow pain, the term “Tennis elbow” is often overused and can cause confusion in treatment, and, if you are a patient with chronic elbow pain, and the treatments are not working, you will likely be confused about why they are not.

There is no confusion to you that you have pain in your elbow. If you have pain on the outside of the elbow, and you tell your health care provider that you routinely use tools that require grip and force, such as a hammer, or you do a lot of typing at a keyboard, or you do actually play tennis, or racquetball, or do a lot of weight training, a likely diagnosis of “tennis elbow” will be immediately suggested.

What will also be immediately suggested is the standard course of conservative care treatments. Rest, ice, Anti-inflammatories, elbow brace, etc. If you are reading this article, these treatments probably have not been effective long-term treatments for you.

Research questions the “tennis elbow” diagnosis: “As orthopedic surgeons, we are besieged by myths that guide our treatment of lateral epicondylitis, or “tennis elbow.”

In 1999, doctors at the Department of Orthopaedic Surgery, Washington University School of Medicine warned about calling “Tennis Elbow,” a problem of inflammation in the Journal of Shoulder and Elbow Surgery:

Twenty years later, in 2018 the confusion continues. So you go to your health care provider with a history of “outside elbow pain.” What type of treatments might you get? Anti-inflammatory, maybe a cortisone injection. In our opinion, as we will document below, these treatments will make your elbow worse.

Why has nothing helped? Have you had the right problem treated with an appropriate treatment? If you have chronic pain, probably not.

Let’s think about this. You went to your health care provider with your elbow complaint. The health care provider sees this as being a problem of degenerative tendon tearing and focuses on the tendon attachment to the bone. That is what you may have been told needs to be fixed. But clearly, if you are reading this article, you have already tried many ways to fix this and it is still not fixed. What else can be wrong?

No therapeutic option seems clearly superior to the other.

Here are the findings published in an August 2020 study (2) where the researchers had to conclude that: “No Therapeutic Option Seems Clearly Superior to the Other.”

Here are the learning points:

How successful were the non-steroidal anti-inflammatory drugs? The cortisone injections? The physical therapy?

Conclusion: “no therapeutic option seems clearly superior to the other.”


In this illustration we see that the problems of tendinosis or tendinopathy occurs when the elbow is "loose" or "wobbly," from problems of ligament damage or injury. This is a whole elbow problem as demonstrated by the damage or tendinosis at the wrist flexor origin point in the elbow from medial elbow instability coming from a damaged or injured ulnar collateral ligament injury. As will be explained later in this article, Prolotherapy injections into this damaged area will help repair the tendons and the ligaments.

In this illustration, we see that the problems of tendinosis or tendinopathy occur when the elbow is “loose” or “wobbly,” from problems of ligament damage or injury. This is a whole elbow problem as demonstrated by the damage or tendinosis at the wrist flexor origin point in the elbow from medial elbow instability coming from a damaged or injured ulnar collateral ligament injury. As will be explained later in this article, Prolotherapy injections into this damaged area will help repair the tendons and the ligaments.


Perhaps your elbow problems started as a fraying and weakening of the ligaments.

What if your elbow pain was more a problem of the elbow ligaments than the elbow tendons? Perhaps your elbow problems even started as a fraying and weakening of the elbow ligaments.

The elbow ligaments hold the bones in place with respect to each other, allowing for a strong, stable base for which the muscles can contract and move the joint.  What if the loose ligaments caused the strain on the tendon by allowing excessive elbow instability? The tendons, trying to hold the muscle to the bone would be put under stress and begin fraying. Has anyone addressed the ligament problem?

Many times a patient will come into Caring Medical, curious about this talk of elbow ligament injury and its being a possible solution to their elbow problems. When we ask them, has anyone talked ligaments to you? A great deal of the time they report, NO.

This is unfortunate because the elbow ligaments provide structural stability to the elbow.

“The data demonstrate that NSAIDs, physical therapy, bracing, and shockwave therapy provide limited benefit for treating Lateral epicondylitis.”

Let’s highlight some of the discussions of researchers and surgeons from the David Geffen School of Medicine at UCLA, the Rothman Institute, and the Department of Orthopaedic Surgery at the University of California at Irvine. All leading and well-respected centers for excellence in research. They are discussing treatment options for Tennis Elbow in the October 2018 Open Access Journal of Sports Medicine. (3)

The findings of this study:

Researchers say: A lifetime of braces, sleeves, tapes, and elbow bands may be a waste of money and prevent you from getting treatments that may help

There is a great debate going on on the effectiveness of kinesiotaping, forearm bands, and elbow sleeves in helping patients with tennis elbow problems. Part of the debate is at what point do these things help and at what point do they not help.

One study in the journal, Physiotherapy Theory, and Practice, (4) from the Hong Kong Polytechnic University was very strong in its assessment that elbow kinesiotaping was not effective at all for tennis elbow patients.

In this study 4 groups of patients were randomized to get:

After the taping, the researchers measured:

The disappointing results were:

Conclusion: “Neither facilitatory nor inhibitory effects were observed between different application techniques of kinesiotaping in patients with lateral epicondylitis. Hence, alternative intervention should be used to manage lateral epicondylitis.”

Research: People like to be taped up – Placebo tape works just as well

Over many years, we have seen patients with varying elbow problems and an equal number of varying tapes, bandages, sleeves, etc. When we ask the patients if their tape, sleeve, or brace is helping, they say “I don’t know.” When we ask them then, why do they continue to use the tape, sleeve, or brace? The answer, “because I think it helps. ”

People do think it helps. That’s okay too, whatever is needed to help reduce pain and fear of more pain is okay. But tape, sleeve, or brace should not be considered a long-term solution.

A 2018 study in the journal BioMed Central Musculoskeletal Disorders (5) compared the effects of Kinesio taping and “sham” or placebo taping on pain relief by measuring pain parameters (scores) in patients with lateral epicondylitis. The “Sham” taping was done in such a way that it could not provide pain relief. So the researchers thought. Here is what they wrote:

“Lateral epicondylitis is frequently seen in racquet sport players and the treatments are usually symptomatic rather than curative. Taping therapy is cheap and easy to apply in the sports field. In this study, we valued the effectiveness of Kinesio taping (KT) on immediate pain control for patients with chronic lateral epicondylitis.”

In the study, the researchers conducted a randomized, double-blinded, cross-over study with 15 patients with chronic lateral epicondylitis. All participants received two taping sessions in random order with a 3-day interval in between: one with Kinesio taping and the other with sham taping (a placebo). Pain perceived during resisted wrist extension and at rest using a numeric rating scale (NRS), the pain-free grip strength, and the pressure pain threshold were measured before and 15 min after the tape was applied.

Results: A significant reduction was found on a numeric rating scale with both the  Kinesio taping and the placebo taping indicating that both taping sessions produced immediate pain relief for resisted wrist extension. Both taping sessions significantly improved the pain-free grip strength. Compared with placebo, Kinesio taping exhibited superiority in controlling pain experienced during resisted wrist extension.

“Our results showed that both taping sessions (kinesio taping and “Sham” taping) produced significant improvement in pain”

Conclusions: Taping produced unneglectable placebo effects on pain relief and pain-free grip strength for patients with lateral epicondylitis, and Kinesio taping seemed to have additional effects on controlling pain that was elicited by resisted wrist extension.

Conclusion: “Taping produced unneglectable placebo effects (you cannot ignore that the benefit may be coming from the Placebo effect) on pain relief and pain-free grip for patients with lateral epicondylitis, and kinesiotaping seemed to have additional effects on controlling pain that was elicited by resisted wrist extension.”

In the short term, kinesiotaping can help with pain related to wrist extension.

Other researchers have supported the short-term use of kinesiotaping for tennis elbow patients. These are patients however who have newly diagnosed or onset of tennis elbow of less than 12 weeks. In January 2019 a study from Marmara University School of Medicine in Turkey published in the journal PM & R: The Journal of Injury, Function, and Rehabilitation, (6) found that:

Research: Which is better? Ultrasound therapy, extracorporeal shock wave therapy, or kinesiotaping.

A July 2020 study published in the Turkish Journal of Medical Sciences, (7) compared the clinical and sonographic effects of ultrasound therapy, extracorporeal shock wave therapy, and kinesiotaping in patients with lateral epicondylitis. There were a total of 40 patients in the study:

Results:

Conclusion: Ultrasound therapy, extracorporeal shock wave therapy, and kinesiotaping are effective in reducing pain and improving functionality. However, none of these treatment methods were found to be superior to the others in reducing the pain and improving functionality.

For some people, these treatments may be very effective. We usually do not see the people for whom these treatments worked. We see the people for whom these treatments did not provide long-term pain reduction and improved functionality and for whom surgery is now being recommended.

Which is better? A Counterforce brace or physical therapy?

A July 2020 study in the journal Prosthetics and Orthotics International (8) examined the popular counterforce brace in people with problems of lateral elbow tendinopathy. In this study, the researchers explored the outcomes of seventeen studies with a total of 1145 participants.

Findings:

Conclusion: The results indicated that physiotherapy interventions compared to counterforce braces have better effects, especially over the long term. However, counterforce braces may have better effects on pain in younger people ( less than 45 years old) over the short term (less than 6 weeks).

For some people, these treatments may be very effective. We usually do not see the people for whom these treatments worked. We see the people for whom these treatments did not provide long-term pain reduction and improved functionality and for whom surgery is now being recommended.

Arthroscopic tennis elbow surgery for the most difficult cases


Researchers say: There is a possible over-excitement in recommending arthroscopic tennis elbow or an elbow tendonitis surgery procedure. People may get the surgery they did not need.

Recently, a lot of research has centered on arthroscopic tennis elbow surgery. However, the American Academy of Orthopedic Surgeons suggests that up to 95% of tennis elbow will resolve without surgery.

Why so much research if the surgery is recommended to only 5% of people? This odd circumstance may be explained by a study led by the University of Ottawa which questioned a possible over-excitement by doctors in recommending arthroscopic tennis elbow or an elbow tendonitis surgery procedure. In an ongoing study, the research team is comparing arthroscopic surgery for tennis elbow vs a sham or fake surgery.

Here is what the researchers wrote at the US National Institutes of Health Clinical Trial website:

“Chronic tennis elbow can be treated surgically, with arthroscopy gaining popularity in recent years as it presents a less invasive option, allows for direct visualization of the elbow joint for other pathology, and has a faster return-to-work time compared to other surgical procedures. Despite its promise, there have been no high-quality studies evaluating the efficacy of arthroscopic tennis elbow release, bringing the actual efficacy of this procedure into question. We propose a randomized, double-blind controlled trial comparing arthroscopic release with arthroscopic debridement for the management of chronic tennis elbow in an effort to definitively answer this question and provide better recommendations for the use of this procedure.”(9)

Lateral collateral ligament complex

The radial collateral ligament (RCL), also called the lateral collateral ligament (LCL), or external lateral ligament or collectively as the lateral collateral ligament complex. This image demonstrates where multiple injections can be given as in Prolotherapy treatments.

Cutting away at the extensor carpi radialis brevis. Surgeons say this procedure does not help patients anymore than a placebo surgery

An April 2018 paper published in The American journal of sports medicine (10) investigated surgical removal of the degenerated portion of the extensor carpi radialis brevis as compared with skin incision and exposure of the extensor carpi radialis brevis alone to treat patients who had tennis elbow for more than 6 months and had failed at least 2 nonsurgical modalities.

The researchers measured the success or non-success of each procedure as: “as patient-rated frequency of elbow pain with activity at six months after surgery. Secondary outcome measures included patient-rated pain and functional outcomes, range of motion, epicondyle tenderness, and strength at six months and 2.5 years.”

Findings:

In April 2020, one of the study authors, Dr. George A C Murrell co-authored an editorial in the British Journal of Sports Medicine (11) titled: “Time to put down the scalpel?” Here he and his co-authors wrote:

“Our published review highlighted the importance of sham surgery in randomized controlled surgical trials including those in tendinopathy. Compared with using a non-surgical control group, sham surgery equalizes the placebo effect of surgery and gives more realistic insights into the effectiveness of the actual surgical procedure in question.

The exact mechanisms of how surgery (corrective of sham) lead to improvement of outcomes in tendinopathy remain unclear and highlight the distinct possibility that postsurgical loading regimes (physical therapy and exercise) may play a role and also that ‘passage of time’ is important.

Further noted is the common knowledge that physical therapy and exercise can fail a patient and this may uninterntionally steer doctors more quickly to the surgical recommendation.

Two clinical tests confirm that recalcitrant lateral elbow pain (Tennis Elbow) is from ligament laxity causing elbow joint instability – this is why many conservative treatments and surgery may not work. Wrong treatment – wrong problem.

Now we are going to talk about the ligaments.

The importance of ligament strength and flexibility in elbow instability cannot be overstated.

In August 2017, University medical researchers in Italy published their findings under the title: “It’s time to change perspective! New diagnostic tools for lateral elbow pain.”

What they are suggesting is what our practice has discussed with our patients since the days of Dr. Hemwall almost 70 years ago, tennis elbow (or elbow pain as it was known back then) is a whole joint disease caused by instability, you must treat the whole elbow. Twenty-six years ago when Ross Hauser, MD, took over the practice, that message never changed.

Here is what the researchers said in the journal Musculoskeletal Surgery. (12)

This paper is acknowledging that elbow instability does play a role in the cause of “tennis elbow”

So the Italian team devised two new tests aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance.

In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity (ligament laxity of weakness) or intra-articular abnormal findings had a positive response to at least one of the two tests.

SALT proved to have a high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis. PEPPER test was sensible, specific, and accurate in the detection of radial head chondropathy (bone problems).

Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition. 

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)”(13) In the 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.

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

Summary transcript and learning points:

Treatments that do not help:

Injections beyond cortisone

In-office ultrasound as compared to MRI for determining tendon tears in the elbow


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.

Tennis Elbow Treatments


Prolotherapy for Tennis Elbow

Prolotherapy is an injection of a simple dextrose-based solution, with other ingredients such as fatty acids, minerals, or even a person’s own repair cells (PRP or stem cells) added in for strengthening the solutions, as warranted by the injury. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.

David Rabago, M.D., and researchers from the University of Wisconsin published a study in the American Journal of Physical Medicine & Rehabilitation (14evaluating the use of Prolotherapy for tennis elbow.

Twenty-six adults (32 elbows) suffering from chronic lateral epicondylosis for three months or longer were randomized to:

The participants receiving Prolotherapy with dextrose and Prolotherapy with dextrose-morrhuate reported improvement at 4, 8, and/or 16 weeks compared with those in the wait-and-see group

The grip strength of the participants receiving Prolotherapy with dextrose exceeded that of the Prolotherapy with dextrose-morrhuate and the wait and see at 8 and 16 weeks. Satisfaction was high; there were no adverse events.

The authors concluded, “Prolotherapy resulted in safe, significant improvement of elbow pain and function compared with baseline status and follow-up data and the wait-and-see control group. This pilot study suggests the need for a definitive trial.”

A November 2019 study (15)  lead by Dr. Michael Yelland with Dr.Rabago compared Prolotherapy with a physiotherapist-guided manual therapy/exercise program used singly and in combination with physiotherapy.

Eighty-eight percent completed the 12-month assessment.

More Caring Medical research

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. (16)

In the medical journal Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, we updated our research by publishing: A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. (17)

Other research supporting the use of Prolotherapy treatments

Cortisone injections: Study: Nothing works just as well as cortisone

A September 2020 study in the Journal of shoulder and elbow surgery (22) tested the idea that if you injected a tennis elbow patient with cortisone into their elbow or you just stuck a needle into the elbow and injected nothing, nothing would work just as well as cortisone.

Here are the research’s learning points.

After treatment

Conclusion


Research: Prolotherapy superior to cortisone injections

A November 2019 study in the journal Orthopedic Research and Reviews (23) compared the effectiveness of Prolotherapy to corticosteroid injections. This is what the researchers wrote:

“This investigation showed that both corticosteroid injection and dextrose prolotherapy efficiently improved pain and function in patients with chronic lateral epicondylitis. In the Prolotherapy group, this improvement persisted even after 1-month follow-up and the results after one injection were still improvable, whereas, in the parallel group, steroids only provided a short-term improvement. This finding proved that dextrose prolotherapy had better and longer effects in treating chronic tennis elbow.”

Prolotherapy works on a simple concept: reignite the immune system to heal by causing targeted inflammation (the natural healing process) at the spot of the injury. This is achieved by, in most cases, injecting a simple sugar (dextrose) at the pain-generating “trigger points,” in the elbow. Strengthen ligaments and tendons, stabilize the elbow, strengthen the elbow, and end the elbow pain. The pain-alleviating aspect of Prolotherapy is also well documented.

Prolotherapy compared to Hyaluronic acid injection

September 2020 study in The Journal of Alternative and Complementary Medicine, (24) compared the effects of hyaluronic acid and dextrose Prolotherapy injections in patients with chronic lateral epicondylalgia.

The severity of pain using the visual analog scale score, grip strength with a hand dynamometer, and physical function as determined by the Quick-Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score was determined.

Results:


Platelet Rich Plasma Therapy and Cortisone for Tennis Elbow

Platelet Rich Plasma Therapy utilizes growth factors from your own blood, injected into the elbow to stimulate healing.

The idea behind Platelet Rich Plasma Therapy (PRP) in treating tennis elbow is initiating the inflammatory response. Tendons throughout the body, including those implicated in lateral epicondylitis such as the ECRB (Extensor Carpi Radialis Brevis), heal more slowly than most other types of tissues partly due to a poor blood supply. The inflammatory response brings blood.

In August 2019, doctors at the Department of Orthopaedics, Royal Lancaster Infirmary, in the United Kingdom published their data on the long-term effects in patients receiving Platelet Rich Plasma injections for their tennis elbow problems. Publishing in the Journal of Orthopaedics, (25) the documented:

They concluded: “PRP is successful in treating refractory LE (difficult to treat tennis elbow) in most patients and avoiding surgery.

PRP vs Cortisone research

In December 2018 in the journal Current Reviews in Musculoskeletal Medicine,(26) research lead by doctors at the Medical University of Lodz in Poland and the Department of Orthopedics Post Graduate Institute of Medical Education and Research in India offered this assessment of PRP treatments for various elbow problems:

“The response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis. PRP injection does not seem to have the potential complications associated with a steroid injection such as skin atrophy, discoloration, and secondary tendon tears. . . Regarding elbow pathologies, PRP injections in tennis elbow seems to be the best-studied intervention.”

In research from doctors at Massachusetts General Hospital-Harvard Medical School, research showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection into the ECRB (Extensor Carpi Radialis Brevis). The weight of evidence suggests that corticosteroid injections are neither meaningfully palliative nor disease-modifying when used to treat Extensor Carpi Radialis Brevis damage. (27)

In a study published in the Journal of Science and Medicine in Sports, doctors looked at Autologous blood injection, a treatment where a patient’s own blood is injected into the site of injury to get the blood platelets at the wound in comparison to cortisone.

Autologous blood injection differs from Platelet Rich Plasma. In PRP the blood platelets are separated out in an attempt to give a more effective treatment by making the plasma “platelet-rich.” Autologous blood injection is considered by many a less effective form of PRP. The doctors also compared polidocanol, an injection treatment that is often given to irritate the immune system to repair varicose veins. Polidocanol belongs to the field of Sclerotherapy, “irritation medicine.” Prolotherapy is also part of the field of “irritation medicine,” and at one time Prolotherapy was called Sclerotherapy.

So it can be said in this study we have a less effective means of PRP and Prolotherapy being compared to cortisone injections.

Here are the results:

Like autologous blood injection, PRP is prepared using a sample of the patient’s own blood. This is why patients may refer to PRP as “tennis elbow blood injections.” This blood is then centrifuged to separate the liquid and solid components of the whole blood. PRP contains 3 to 10 times higher concentrations of platelets in comparison to autologous whole blood.

While several major clinical studies have promise in the treatment of difficult to treat tennis elbow, a major limitation in the evaluation of the efficacy of PRP in the treatment of lateral epicondylitis and other musculoskeletal diseases is the way with which PRP is prepared and administrated. (29You have to go to a doctor who knows how to use PRP. It is much more than a simple “blood injection”.

In a direct comparison of autologous blood injections, platelet-rich plasma injections, and cortisone, doctors wrote in the Journal of Orthopaedics and Traumatology:

Based on the evidence presented, it can be concluded that when comparing three active treatments:

In the Journal of Clinical and Diagnostic Research doctors wrote simply: 

Doctors in Pakistan have shown the effectiveness of platelets rich plasma versus corticosteroids or the “tennis elbow steroid injection.”

The doctors looked at 102 patients in the study and divided them into two groups of 51(50%) each.

Their conclusion: PRP is an effective alternative to corticosteroid in the treatment of lateral epicondylitis (tennis elbow). (32)

Below is a brief review of the evidence that PRP can be a helpful treatment

In March 2017, doctors in China published more positive results for platelet-rich plasma vs steroids for lateral epicondylitis. Their research showed:

Danish researchers writing in the American Journal of Sports Medicine presented a summary of which tennis elbow injections work best? They found:

“[Therapies studied included] glucocorticoid, botulinum toxin, autologous blood, platelet-rich plasma, polidocanol, glycosaminoglycan [hyaluronic acid is part of this family], Prolotherapy, and hyaluronic acid.

After compiling and comparing the research they found that the medical literature suggested that beyond eight weeks:

In December 2019, orthopedic surgeons in China published their findings in The American Journal of Sports Medicine (37) of the superiority of PRP treatment against cortisone. They reviewed 20 medical studies that examined the comparative effects of PRP and cortisone in over 1,200 patients. Their simple findings were: “The use of PRP yields statistically and clinically better improvement in long-term pain than does corticosteroid in the treatment of elbow epicondylitis.”

PRP therapy is not without its controversy

Often we will hear from people asking for more information on the use of Platelet rich Plasma therapy for their elbow pain. They ask because they were told by their doctor or orthopedist that PRP does not work. In some people PRP may not work. It is our belief that this evaluation should come at the consult.

PRP therapy will fail for various reasons. The main two:

An August 2020 study in the Clinical rheumatology (x) made these observation in the use of PRP versus placebo for the treatment of tennis elbow.

The pratfalls of research like this is that it compares a single injection of PRP to a single injection of placebo. At our center PRP is not a single injection treatment. It is part of a more comprehensive approach. When you doctor says one shot of PRP probably won’t work. The likelihood is that he/she is correct.


If this article has helped you understand the problems of Tennis Elbow and you would like to explore Prolotherapy and PRP as a possible remedy, ask for help and information from our specialists

1 Boyer MI. Lateral tennis elbow:” Is there any science out there?.”Journal of Shoulder and Elbow Surgery. 1999;8(5):481-91. [Google Scholar]
2 Sghir M, Elhersi T, Abdallah A, Salah AH, Khemiri NE, Dammak N, Kessomtini W. Epidemiological profile of lateral epicondylitis in rehabilitation department. The Pan African Medical Journal. 2020 Aug 11;36:265-. [Google Scholar]
3 Lai WC, Erickson BJ, Mlynarek RA, Wang D. Chronic lateral epicondylitis: challenges and solutions. Open access journal of sports medicine. 2018;9:243. [Google Scholar]
4 Au IP, Fan PC, Lee WY, Leong MW, Tang OY, An WW, Cheung RT. Effects of Kinesio tape in individuals with lateral epicondylitis: a deceptive crossover trial. Physiotherapy theory and practice. 2017 Dec 2;33(12):914-9. [Google Scholar]
5 Cho YT, Hsu WY, Lin LF, Lin YN. Kinesio taping reduces elbow pain during resisted wrist extension in patients with chronic lateral epicondylitis: a randomized, double-blinded, cross-over study. BMC musculoskeletal disorders. 2018 Dec;19(1):193. [Google Scholar]
6 Giray E, Bingul DK, Akyuz G. The effectiveness of kinesiotaping, sham taping or exercises only in treatment of lateral epicondylitis: A randomized controlled study. PM&R. 2019 Jan 4.  [Google Scholar]
7  Özmen T, Koparal SS, KarataŞ Ö, Eser F, Özkurt B, GafuroĞlu TÜ. COMPARISON OF THE CLINICAL AND SONOGRAPHIC EFFECTS OF ULTRASOUND THERAPY, EXTRACORPOREAL SHOCK WAVE THERAPY AND KINESIO TAPING IN LATERAL EPICONDYLITIS [published online ahead of print, 2020 Jul 19]. Turk J Med Sci. 2020;10.3906/sag-2001-79. doi:10.3906/sag-2001-79
8 Shahabi S, Bagheri Lankarani K, Heydari ST, Jalali M, Ghahramani S, Kamyab M, Tabrizi R, Hosseinabadi M. The effects of counterforce brace on pain in subjects with lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials. Prosthetics and Orthotics International. 2020 Jul 8:0309364620930618. [Google Scholar]
9 Matache BA, Berdusco R, Momoli F, Lapner PLC, Pollock JW. A randomized, double-blind sham-controlled trial on the efficacy of arthroscopic tennis elbow release for the management of chronic lateral epicondylitis. BMC Musculoskeletal Disorders. 2016;17:239. doi:10.1186/s12891-016-1093-9.[Google Scholar]
10 Kroslak M, Murrell GAC. Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial. Am J Sports Med. 2018 Mar 1:363546517753385. doi: 10.1177/0363546517753385. [Google Scholar]
11 Millar NL, Murrell GA, Kirwan P. Time to put down the scalpel? The role of surgery in tendinopathy. [Google Scholar]
12 Arrigoni P, Cucchi D, Menon A, Randelli P. It’s time to change perspective! New diagnostic tools for lateral elbow pain. Musculoskeletal surgery. 2017 Aug 2:1-5. [Google Scholar]
13 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]
14 Rabago D, Lee KS, Ryan M, Chourasia AO, Sesto ME, Zgierska A, Kijowski R, Grettie J, Wilson J, Miller D. Hypertonic Dextrose and Morrhuate Sodium Injections (Prolotherapy) for Lateral Epicondylosis (Tennis Elbow): Results of a Single-blind, Pilot-Level, Randomized Controlled Trial. Am J Phys Med Rehabil. 2013 Jan 3.  [Google Scholar]
15 Yelland M, Rabago D, Ryan M, Ng SK, Vithanachchi D, Manickaraj N, Bisset L. Prolotherapy injections and physiotherapy used singly and in combination for lateral epicondylalgia: a single-blinded randomised clinical trial. BMC musculoskeletal disorders. 2019 Dec 1;20(1):509.  [Google Scholar]
16 Hauser RA, Hauser MA, Baird NM. Evidence-Based use of dextrose Prolotherapy for musculoskeletal pain: a scientific literature review. Journal of Prolotherapy. 2011;3(4):765-789. [Google Scholar]
17 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2016 Jan;9:CMAMD-S39160. [Google Scholar]
18 Scarpone M, Rabago DP, Zgierska A, Arbogast G, Snell E. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008;18(3):248–54. [Google Scholar]
19 Shin J, Seo K-M, Kim D-K, Kim B-K, Kang SH. The effect of prolotherapy on lateral epicondylitis of elbow. J Korean Acad Rehabil Med. 2002;26:764–8. [Google Scholar]
20 Park JH, Song IS, Lee JB, et al. Ultrasonographic findings of healing of torn tendon in the patients with lateral epicondylitis after prolotherapy. J Korean Soc Med Ultrasound. 2003;22(3):177–83. [Google Scholar]
21 Akcay S, Gurel Kandemir N, Kaya T, Dogan N, Eren M. Dextrose Prolotherapy Versus Normal Saline Injection for the Treatment of Lateral Epicondylopathy: A Randomized Controlled Trial. The Journal of Alternative and Complementary Medicine. 2020 Sep 28. [Google Scholar]
22 Uygur E, AktaŞ B, Yilmazoglu EG. The use of dry needling versus corticosteroid injection to treat lateral epicondylitis: a prospective, randomized, controlled study. Journal of Shoulder and Elbow Surgery. 2020 Sep 17. [Google Scholar]
23 Bayat M, Raeissadat SA, Babaki MM, Rahimi-Dehgolan S. Is Dextrose Prolotherapy Superior To Corticosteroid Injection In Patients With Chronic Lateral Epicondylitis?: A Randomized Clinical Trial. Orthopedic Research and Reviews. 2019;11:167.
24 Apaydin H, Bazancir Z, Altay Z. Injection Therapy in Patients with Lateral Epicondylalgia: Hyaluronic Acid or Dextrose Prolotherapy? A Single-Blind, Randomized Clinical Trial [published online ahead of print, 2020 Sep 15]. J Altern Complement Med. 2020;10.1089/acm.2020.0188. doi:10.1089/acm.2020.0188 [Google Scholar]


25 Brkljac M, Conville J, Sonar U, Kumar S. Long-term follow-up of platelet-rich plasma injections for refractory lateral epicondylitis. J Orthop. 2019 Aug 14;16(6):496-499. doi: 10.1016/j.jor.2019.08.023. PMID: 31680739; PMCID: PMC6818374. [Google Scholar]
26 Kwapisz A, Prabhakar S, Compagnoni R, Sibilska A, Randelli P. Platelet-Rich Plasma for Elbow Pathologies: a Descriptive Review of Current Literature. Current reviews in musculoskeletal medicine. 2018 Dec 1;11(4):598-606. [Google Scholar]
27 Claessen FM, Heesters BA, Chan JJ, Kachooei AR, Ring D. A Meta-Analysis of the Effect of Corticosteroid Injection for Enthesopathy of the Extensor Carpi Radialis Brevis Origin. J Hand Surg Am. 2016 Aug 18. pii: S0363-5023(16)30379-3. [Google Scholar]
28 Branson R, Naidu K, du Toit C, Rotstein AH, Kiss R, McMillan D, Fooks L, Coombes BK, Vicenzino B. Comparison of corticosteroid, autologous blood or sclerosant injections for chronic tennis elbow. J Sci Med Sport. 2016 Oct 29. pii: S1440-2440(16)30226-2.  [Google Scholar]
29 Kahlenberg CA, Knesek M, Terry MA. New developments in the use of biologics and other modalities in the management of lateral epicondylitis. BioMed research international. 2015 May 31;2015. [Google Scholar]
30 Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2015 Sep 11.[Google Scholar]
31 Yadav R, Kothari SY, Borah D.  Comparison of Local Injection of Platelet Rich Plasma and Corticosteroids in the Treatment of Lateral Epicondylitis of Humerus. J Clin Diagn Res. 2015 Jul;9(7):RC05-7. doi: 10.7860/JCDR/2015/14087.6213. Epub 2015 Jul 1. [Google Scholar]
32 Khaliq A, Khan I, Inam M, Saeed M, Khan H, Iqbal MJ. Effectiveness of platelets rich plasma versus corticosteroids in lateral epicondylitis. J Pak Med Assoc. 2015 Nov;65(11 Suppl 3):S100-4. [Google Scholar]
33 Murray DJ, Javed S, Jain N, Kemp S, Watts AC. Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence. J Hand Microsurg. 2015 Dec;7(2):320-325. Epub 2015 Jul 8. [Google Scholar]
34 Karaduman M, Okkaoglu MC, Sesen H, Taskesen A, Ozdemir M, Altay M. Platelet-rich plasma versus open surgical release in chronic tennis elbow: A retrospective comparative study. J Orthop. 2016 Jan 22;13(1):10-4. doi: 10.1016/j.jor.2015.12.005. eCollection 2016 Mar. [Google Scholar]
35 Mi B, Liu G, Zhou W, Lv H, Liu Y, Wu Q, Liu J. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. Phys Sportsmed. 2017 Mar 3:1-8. doi: 10.1080/00913847.2017.1297670. [Google Scholar]
36 Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, Bliddal H, Christensen R. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. The American journal of sports medicine. 2013 Jun;41(6):1435-46. [Google Scholar]
37 Huang K, Giddins G, Wu LD. Platelet-Rich Plasma Versus Corticosteroid Injections in the Management of Elbow Epicondylitis and Plantar Fasciitis: An Updated Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2019 Dec 10:0363546519888450. [Google Scholar]

8305
8688

6 Seetharamaiah VB, Gantaguru A, Basavarajanna S. A comparative study to evaluate the efficacy of platelet-rich plasma and triamcinolone to treat tennis elbow. Indian journal of orthopaedics. 2017 May;51(3):304.
7 Mi B, Liu G, Zhou W, Lv H, Liu Y, Wu Q, Liu J. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. The Physician and Sportsmedicine. 2017 Apr 3;45(2):97-104.
9 Tang S, Wang X, Wu P, Wu P, Yang J, Du Z, Liu S, Wei F. Platelet-rich plasma versus autologous blood versus corticosteroid injections in the treatment of lateral epicondylitis: a systematic review, pairwise and network meta-analysis of randomized controlled trials. PM R. 2019 Nov 17. doi: 10.1002/pmrj.12287. [Epub ahead of print]
10 Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011 Jun;39(6):1200-8. Epub 2011 Mar 21.
11 Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, Kong FL, Welle K, Jiang ZC, Kabir K. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med. 2015 Sep 21. pii: bjsports-2014-094387. doi: 10.1136/bjsports-2014-094387.
12 Kemp JA, Olson MA, Tao MA, Burcal CJ. Platelet-Rich Plasma versus Corticosteroid Injection for the Treatment of Lateral Epicondylitis: A Systematic Review of Systematic Reviews. International Journal of Sports Physical Therapy. 2021;16(3):597.
13 Murray DJ, Javed S, Jain N, Kemp S, Watts AC. Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence. J Hand Microsurg. 2015 Dec;7(2):320-5. doi: 10.1007/s12593-015-0193-3. Epub 2015 Jul 8.
14 Hastie G, Soufi M, Wilson J, Roy B. Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention. Journal of orthopaedics. 2018 Mar 1;15(1):239-41.
15 Kholinne E, Liu H, Kim H, Kwak JM, Koh KH, Jeon IH. Systematic Review of Elbow Instability in Association With Refractory Lateral Epicondylitis: Myth or Fact?. The American Journal of Sports Medicine.:0363546520980133.
16 Moon YL, Jo SH, Song CH, Park G, Lee HJ, Jang SJ. Autologous bone marrow plasma injection after arthroscopic debridement for elbow tendinosis. Annals Academy of Medicine Singapore. 2008 Jul 1;37(7):559.
17 Singh, A., Gangwar, D. S., & Singh, S. (2014). Bone marrow injection: A novel treatment for tennis elbow. Journal of Natural Science, Biology, and Medicine5(2), 389–391. http://doi.org/10.4103/0976-9668.136198
18 Tarpada SP, Morris MT, Lian J, Rashidi S. Current advances in the treatment of medial and lateral epicondylitis. J Orthop. 2018 Feb 2;15(1):107-110. doi: 10.1016/j.jor.2018.01.040. PMID: 29657450; PMCID: PMC5895908.
19 Cho WS, Chung SG, Kim W, Jo CH, Lee SU, Lee SY. Mesenchymal Stem Cells Use in the Treatment of Tendon Disorders: A Systematic Review and Meta-Analysis of Prospective Clinical Studies. Ann Rehabil Med. 2021 Aug;45(4):274-283. doi: 10.5535/arm.21078. Epub 2021 Aug 30. PMID: 34496470.

 

Make an Appointment |

Subscribe to E-Newsletter |

Print Friendly, PDF & Email
SEARCH
for your symptoms
Prolotherapy, an alternative to surgery
Were you recommended SURGERY?
Get a 2nd opinion now!
WHY TO AVOID:
★ ★ ★ ★ ★We pride ourselves on 5-Star Patient Service!See why patients travel from all
over the world to visit our center.
Current Patients
Become a New Patient

Caring Medical Florida
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax Fort Myers, FL Office
We are an out-of-network provider. Treatments discussed on this site may or may not work for your specific condition.
© 2021 | All Rights Reserved | Disclaimer