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 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.

Discussion points of this article:

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. 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.

Many causes of chronic elbow pain exist, including tennis elbow (extensor tendonitis), annular ligament sprain, and biceps muscle strain. Since muscle, ligament, or tendon injury can all cause pain, a proper diagnosis is needed to permanently alleviate the pain. Tennis elbow is diagnosed when we observe weakness and pain with wrist extension and tenderness at the elbow where the extensor tendons attach. An annular ligament sprain is diagnosed when we palpate this ligament in the elbow and elicit a positive “jump sign.”

Another source of elbow pain is biceps muscle strain. When the biceps tendon is weak, resisted flexion (resisting the upward movement of the forearm) of the elbow is painful. Since the bicep muscle flexes at the elbow, carrying a box or turning a screwdriver may produce painful symptoms associated with strain or weakness of this muscle. Since the extensor tendons, bicep muscle, and annular ligament all attach to the bone in the elbow, good palpatory skills are necessary for proper diagnosis.

Searching for elbow instability

The caption reads: Stress-motion examination of the elbow searching for joint instability. As the forearm is rotated, the clinician is feeling the elbow joint for cracking, popping, grinding, and all signs of instability.

Stress-motion examination of the elbow searching for joint instability

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

Let’s go back 25 years to demonstrate the confusion and controversies in the problems of tennis elbow and bring this research to 2013. 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:

As we will see, twenty -five years later, in 2023 the confusion continues. Since the publication of that paper a May 2023 paper in the journal Medical Science Monitor (2) noted a trend over the last thirty in how researchers explored treatment options. The “Hot Words” of research include PRP, corticosteroid injections, shockwave therapy, ultrasound, exercise interventions, and manipulative therapy. Surgery is not a hot word. We will explore all these options below.

Ultrasound documentation of lateral elbow instability

Let’s talk about diagnosis. In the image below the “A” image is the elbow at rest. In the “B” image stress is placed on the arm to “stretch” or distract the elbow. When this happens a significant increase in joint space can indicate that the patient’s elbow instability and weakness are being caused by a ligament problem.

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 healthcare 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 (3) 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? 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.”

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. (4)

The findings of this study:

This 2018 paper is cited in many research papers, many listed below.

Comparing Kinesio taping to the more traditional treatments of cortisone and rest

Elbow and arm Kinesiology taping

A March 2021 study (5) wanted to compare the early patient satisfaction returns of Kinesio tape against corticosteroid injection and a rest-and-medication group. The goal was to see if Kinesio’s tape could be presented as a realistic alternative. In the fifty patients of this study, Kinesio tape was applied to 20 patients (21 elbows), and corticosteroid injection was applied to 15 patients (17 elbows).

The researchers found:

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 kinesio taping, 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, (6) from the Hong Kong Polytechnic University was very strong in its assessment that elbow kinesio taping 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 kinesio-taping 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 is “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, sleeves, or braces should not be considered a long-term solution.

A 2018 study in the journal BioMed Central Musculoskeletal Disorders (7) 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 three-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 kinesio taping seemed to have additional effects on controlling pain that was elicited by resisted wrist extension.”

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

Elastic tape may not immediately improve pain-free grip

Citing this research was a 2023 study (8) from Central Queensland University in Australia which suggested: “Tensioned multidirectional elastic tape may not immediately improve pain-free grip strength or pressure pain threshold in our lateral elbow tendinopathy population; however, individual variation may exist.

Other researchers have supported the short-term use of kinesio taping for tennis elbow patients. These are patients however who have newly diagnosed or onset of tennis elbow of fewer 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, (9) found that:

Wrist pain in post-partum women

Wrist pain is a common clinical feature in pregnancy. Post-partum wrist pain as well. A March 2021 paper in the International Journal of Environmental Research and Public Health (10) suggested that wrist stabilization exercise combined with taping is beneficial and effective in managing wrist pain and disability in postpartum women with wrist pain.  Exercises consisted of wrist stabilization exercises for 40 min (once a day, five times a week for eight weeks).

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

Ultrasound therapy, extracorporeal shock wave therapy, or kinesiotaping

A July 2020 study published in the Turkish Journal of Medical Sciences, (11) compared the clinical and sonographic effects of ultrasound therapy, extracorporeal shock wave therapy, and kinesio taping 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 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.

An October 2022 paper published in the journal Lasers in Medical Science (12) compared the effects of extracorporeal shockwave therapy (ESWT) and high-intensity laser therapy on pain, grip strength, and function in patients with lateral epicondylalgia. This study included 42 patients (22 women and 20 men, average age 37) divided into 3 groups.

Short and long-term effects of Kinesio taping  and dry needling on Tennis Elbow

An April 2022 paper in the Journal of Shoulder and Elbow Surgery (13) investigated the short and long-term effects of Kinesio taping and dry needling applications on pain, functionality, and muscle strength in lateral epicondylitis patients.

In this study seventy-eight, patients were randomized into three groups. The groups were given a program that consisted of nine sessions in total, 3 times a week for 3 weeks.

Pain, functional status, grip strength, and the thickness of the common extensor tendon were evaluated before treatment, after treatment (at the end of the 3rd week), and in the 6th month.

Which is better? A Counterforce brace or physical therapy?

A July 2020 study in the journal Prosthetics and Orthotics International (14) 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 elbows 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

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

Questioning surgery: Research from 2018 – 2023

An April 2018 paper published in The American Journal of Sports Medicine (15) 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 by: “the 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 (16) 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) leads 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 the passage of time is important.

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

Surgeons question the validity of tennis elbow surgery recommendations

A December 2021 study by Clinical Orthopaedics and Related Research (17) questioned the validity of tennis elbow surgery recommendations, suggesting a degree of overzealousness. Here are the study learning points:

The results

Do not rush to surgery if conservative care treatments fail at first

A February 2023 paper in The Bone & Joint Journal (18) questions the rush to surgery when conservative care options fail. The authors write: “Surgery is often offered to patients who fail to improve with conservative treatment. However, there is no evidence to support the superiority of surgery over continued nonoperative care or no treatment. New evidence also suggests that the prognosis of tennis elbow is not influenced by the duration of symptoms and that there is a 50% probability of recovery every three to four months. This finding challenges the belief that failed nonoperative care is an indication for surgery.”

Lateral collateral ligament complex

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. Thirty 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. (19)

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

elbow instability

So the Italian team devised two new tests aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigating 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. The 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 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)”(20) 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, and strong ligaments lead to pain-free joint stability and healed tendons.

The elbow ligament mesh

The caption of the image below reads: The elbow ligament mesh. Notice how the elbow ligaments completely surround the bones that make up the elbow joint. This is one of the reasons that Prolotherapy to the elbow joint involves lots of injections to treat as many of the ligament attachments as possible.

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, and 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 (21evaluating 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 (22) led 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.

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.

In 2009 I wrote a paper that was published in the journal Practical Pain Management. I am going to give a video update more than 13 years later. This journal is read by many doctors who practice pain management pain. The paper is cited below.

My study was a retrospective study, meaning it was an accumulation of data after treatments to see what the results were after treatment.

Many of the patients had elbow instability severe enough to cause a myriad of symptoms including elbow tendinitis and tendinosis, tennis elbow, golfer’s elbow,  tendinosis, and it’s notorious for causing ulnar nerve irritation.

At 3:15 of the above video, the treatment begins.

Prolotherapy onto the medial epicondyle of the elbow is done for injuries to the origin of the common wrist/finger flexor tendons.

Prolotherapy onto the medial epicondyle of the elbow

Prolotherapy to the common extensor tendon of the elbow. When doing Prolotherapy, the superficial injections are typically done first.

Prolotherapy to the common extensor tendon of the elbow

More research on Tendon restoration

A December 2020 (23) case history by doctors in Italy described a case of lateral epicondylitis, in a 70-year-old patient diagnosed with clinical and ultrasound examination, where local steroid injections provided relief only for a limited time. They treated the patient with ultrasound-guided prolotherapy, following which the pain disappeared and the tendon was restored. Three treatments were necessary.

Splinting and three injection therapies (corticosteroid, autologous blood, and prolotherapy)

In June 2022 (24) doctors examined the effects of splinting and three injection therapies (corticosteroid, autologous blood, and prolotherapy) on pain, grip strength, and functionality in patients with lateral epicondylitis.

Here are the learning points of this research

In all groups, VAS values (01-0 pain scores reported by the patients) at one and six months after treatment were found to be lower in comparison to baseline.

Except for the splint group, a significant improvement was observed in all three injection groups in terms of grip strength and elbow function values at six months compared to the baseline values.

In the comparison of the groups, no significant difference was observed in terms of improvement in VAS scores and grip strength.  Corticosteroid injection, autologous blood injection, and prolotherapy are effective and safe long-term methods in lateral epicondylitis treatment.

More Caring Medical research

In the October 2009 issue of Practical Pain Management (25), we presented a study on 36 patients with unresolved elbow pain who were treated with dextrose Prolotherapy at a quarterly clinic, which included a sub-group of 15 patients who were told by another practitioner that there was no other option for their pain. The patient’s average age was 53 years old. They reported an average of four years and one month of pain and saw 2.4 MDs before receiving 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. (26)

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. (27)

Other research supporting the use of Prolotherapy treatments

Cortisone injections: Study: A sham or “nothing treatment” works just as well as cortisone

Cortisone injections elbow

A September 2020 study in the Journal of Shoulder and Elbow Surgery (32) 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

Prolotherapy to the elbow under fluoroscopic guidance

Cortisone masks pain. That is how it works. However masking pain can lead to further injury of tissue. A September 2022 paper in The archives of bone and joint surgery (33) “Corticosteroid injection provides false hope, which ultimately may decrease the patient’s health . . . Although Corticosteroid injection seems to relieve or mask the pain in the short term, there is a considerable chance of recurrence, and patients may perceive more significant pain and disability that may lead to subsequent injection or precocious surgery.”

A November 2019 study in the journal Orthopedic Research and Reviews (34) 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 a 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, (35) 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 were determined.

Results:

A February 2022 study in the Archives of Physical Medicine and Rehabilitation (36) comes to us from noted Prolotherapy researchers David Ragabo of Pennsylvania State University and Dean Reeves, MD. In this study, the effectiveness of hypertonic dextrose prolotherapy on pain intensity and physical functioning in patients with lateral elbow tendinosis was compared with other active non-surgical treatments. This research concludes: Conclusions: “hypertonic dextrose prolotherapy is superior to (placebo) at 12 weeks for decreasing pain intensity and functioning by margins that meet criteria for clinical relevance in the treatment of lateral elbow tendinosis. While existing studies are too small to assess rare adverse events, for lateral elbow tendinosis patients, especially those refractory to first-line treatments, hypertonic dextrose prolotherapy can be considered a non-surgical treatment option in carefully selected patients.”

Comparing Extracorporeal Shock Wave Therapy and Prolotherapy for Tennis Elbow

A June 2022 paper in the publication: Arthroscopy: The Journal of Arthroscopic & Related Surgery (37) examined the effectiveness of extracorporeal shock wave therapy (ESWT) and injection therapies by synthesizing direct and indirect evidence for all pairs of competing therapies for lateral epicondylitis. To do this the researchers collected previously published studies assessing the effect of ESWT or injection therapies. The primary outcome was short-term (less than 3 months) and medium-term (more than 3 months but less than 12 months) pain, while the secondary outcomes were grip strength and patient-reported outcome measures.

Extracorporeal shock wave therapy (ESWT) was then compared to five different injection therapies, including corticosteroids, autologous whole blood, platelet-rich plasma (PRP), botulinum toxin A, and dextrose prolotherapy.

Platelet-Rich Plasma Therapy

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

Like many of the treatments outlined in this article, Platelet Rich Plasma therapy is considered a controversial treatment. European and Italian researchers writing in November 2021 in the  Journal of Orthopaedics and Traumatology (38) discussed this controversy in their paper titled: “Even experts cannot agree on the optimal use of platelet-rich plasma in lateral elbow tendinopathy.”

“Platelet-rich plasma (PRP) is widely used in the management of lateral elbow tendinopathy despite conflicting evidence on its effectiveness.” Their study, they write, “aimed to assess consensus amongst experts on Platelet-rich plasma’s (PRP) clinical use.” To do this, they mailed a survey to Elbow/PRP experts asking the experts to agree or disagree with statements about the effectiveness of PRP treatments.

“Consensus of the agreement was only reached for 17/40 (42.5%) statements. For statements on PRP formulation, the consensus of the agreement was reached in 2/6 statements (33%). Only limited consensus on the contraindications, delivery strategy, and delivery technique was achieved.”

What appears out of this survey is that PRP experts have vast differences of opinion on how PRP should be prepared, how often it should be given, and how it should be given (many offer it as one injection as noted throughout this article – we do not agree with that type of treatment).

This was further outlined in a January 2022 paper in the publication BMJ Open Sport and exercise medicine (39) The authors here write: “Platelet-rich plasma (PRP) is a commonly used treatment for tendinopathies such as tennis elbow despite the questionable evidence of its efficacy. A recent Cochrane review suggests that it likely does not provide clinically meaningful benefits in people with tennis elbow.”

We are in agreement with this. PRP is typically treated as a one-shot wonder. On injection and then weeks or months later the effectiveness of that injection is measured by patient survey. It is very likely that many patients will not find benefit in that type of application of PRP. Further, some physicians are rapidly jumping on the PRP bandwagon without having much injection experience or without any knowledge except for a weekend course in the use of PRP. PRP should be part of a more comprehensive treatment plan, as we outline below.

Platelet Rich Plasma Therapy and Cortisone for Tennis Elbow – Initiating the inflammatory response

The idea behind Platelet Rich Plasma Therapy (PRP) in treating tennis elbow is to initiate 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, (40) 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 – a few years of research

In 2016 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 six 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. (41)

A 2017 paper (42) from the Department of Orthopaedics, Victoria Hospital, Bangalore Medical College and Research Institute compared the effectiveness of a single injection of platelet-rich plasma (PRP) for tennis elbow as compared with single injections of triamcinolone and placebo (normal saline) over a short term period.

This study included a total of eighty patients with unilateral or bilateral tennis elbows. The study population included patients between 20 and 40 years of age group belonging to either sex with seventy unilateral and ten bilateral affections for more than 3 months duration.

In December 2018 in the journal Current Reviews in Musculoskeletal Medicine,(43) research led 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 seem to be the best-studied intervention.”

An October 2023 paper (57) from doctors at the Department of Orthopaedics, Jinnah Postgraduate Medical Centre in Pakistan compared the results of local administration of platelet-rich plasma (PRP) with methylprednisolone in the treatment of tennis elbow.

A September 2023 study in the Journal of shoulder and elbow surgery (59) compared local injections of either platelet-rich plasma (PRP) or corticosteroid for the treatment of lateral elbow epicondylitis and found that PRP has no advantage over steroid injections within the first month of treatment, but that it is superior to steroids at both 3 and 6 months. These results also suggest that corticosteroids have a short-term beneficial effect during the early treatment period, although the quality of the available evidence is not very robust in support of this finding.  The study authors cautioned: “However, these findings must all be viewed with caution as the high risk of bias and moderate to low quality of the included studies may not justify a recommendation of one treatment over another.”

A June 2023 study in the journal Clinics in orthopedic surgery (60) compared ultrasound guided PRP versus ultrasound guided steroid injections for Lateral Elbow Tendinopathy. In this research, 64 non-athletes (average age about 40) with Lateral Elbow Tendinopathy who failed conservative treatment that included avoiding strenuous activities, ice treatments, non-steroidal anti-inflammatory drugs, bracing, and physiotherapy for six months.

After two years, the average  Visual Analogue Scale (0 = no pain to 10 = unbearable pain score)  at the latest follow-up of 2 years in the PRP group was 1.25 (very mild pain) and it was significantly better than the score of 3.68 (mild to moderate pain) in the steroid group. The average DASH score (Disabilities of the Arm, Shoulder and Hand survey of thirty questions, scored 0 – 100 with 0 = no disability and 100 = severe disability) at the latest follow-up of two years in the PRP group was 4.00 and it was significantly better than the score of 7.43 in the steroid group.

Conclusions: “Corticosteroid injections alleviated symptoms of Lateral Elbow Tendinopathy over short-term follow-up providing quicker symptomatic relief; however, the effect faded off over the long term. PRP injections provided a more gradual but sustained improvement over the long-term follow-up, indicating the biological healing potential of PRP.

Autologous blood injection differs from Platelet Rich Plasma

In a 2017 study (44) 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.

It is suggested you go to a doctor who knows how to use PRP. It is much more than a simple “blood injection”.

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. (45You 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 platelet-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 corticosteroids in the treatment of lateral epicondylitis (tennis elbow). (48)

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 (53) on 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.”

Again, 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 consultation.

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

An August 2020 study in Clinical rheumatology (54) made this 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 your doctor says one shot of PRP probably won’t work. The likelihood is that he/she is correct.

A May 2023 study from the Department of Orthopedics and Rehabilitation, University of Iowa, published in the Journal of Hand Surgery Global Online (55) assessed the effectiveness of platelet-rich plasma (PRP) injection and ultrasonic tenotomy and debridement for lateral elbow tendinopathy as well as risk factors for each treatment failure. The researchers noted in their comparison study, that “some studies have found PRP to have little advantage over other treatments or even saline, whereas others have found PRP to be an effective treatment for lateral elbow tendinopathy.  Ultrasonic tenotomy and debridement have also been shown as an effective treatment for lateral elbow tendinopathy.”

The risk factors for failure in the PRP group were LCL complex involvement (this includes the lateral ulnar collateral ligament, radial collateral ligament, annular ligament, and LCL complex injection. At this study’s institution, the LCL complex is typically only injected when there is LCL complex tearing or other overt LCL complex involvement. Only one patient received an LCL complex injection without major LCL complex involvement. Based on this, it is likely that LCL complex involvement is the true risk factor for the failure of PRP, with LCL complex injection being a reflection of this variable.” Let’s take a moment here. The reflection of PRP failure is seen in the fact that LCL complex ligaments, the lateral ulnar collateral ligament, radial collateral ligament, and annular ligament were typically not addressed in treatment. When there was not this excessive damage, 84.6% of PRP patients in this study were able to avoid surgery.

A quick note about palpation-guided and ultrasound-guided platelet-rich plasma (PRP) injections

A November 2022 paper published in the Archives of rheumatology (58) examined if there were differences in the effectiveness of palpation-guided and ultrasound (US)-guided platelet-rich plasma (PRP) injections in patients with chronic lateral epicondylitis. In this study, 60 patients diagnosed with chronic lateral epicondylitis were randomly assigned to either the palpation-guided or the US-guided injection group before they received PRP injection. In conclusion, the researchers found “both palpation-guided and US-guided PRP injections were similarly effective in reducing the pain and symptoms and improving the function in the treatment of lateral epicondylitis.

Bone Marrow Aspirate Concentrate – Bone Marrow Prolotherapy – Bone Marrow stem cell therapy

This treatment goes by many names but the concept is the same. Bone Marrow Prolotherapy involves direct bone marrow aspiration (or also concentrated) to get bone marrow-derived stem cells to the damaged area of the elbow.  In our experience, we have discovered that these stem cells act as effective solutions for Prolotherapy.

It is important to note that we do not use stem cell therapy on every patient. In fact, we use stem cell therapy in very few of our patients. The reason? We find that our mainstay treatment, simple dextrose Prolotherapy, administered in the ways documented in the research over 70 years, can in many cases, provide equal and sometimes superior results in some patients.

Not all injuries require stem cells to heal. However, for those cases of advanced arthritis, meniscus tears, labral tears, bone-on-bone, or aggressive injuries, our Prolotherapy practitioners may choose to use stem cell injections to enhance the healing, in combination with dextrose Prolotherapy to strengthen and stabilize the surrounding support structures.

In our research published in The Open Stem Cell Journal, (56) Rationale for Using Direct Bone Marrow Aspirate as a Proliferant for Regenerative Injection Therapy (Prolotherapy). We not only showed the benefit of bone marrow-derived stem cells as a Prolotherapy proliferant solution but also that this exciting field of medicine needs doctors and scientists working together to expand research and technique guidelines.

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

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This article was update October 12, 2023

 

 

 

 

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