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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 tennis elbow
• 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.
• Research questions the “tennis elbow” diagnosis: Orthopedic surgeons say they are besieged by myths that guide surgical treatment.
• Why has nothing helped? Have you had the right problem treated with an appropriate treatment? If you have chronic pain, probably not.
• Perhaps your elbow problems started as a fraying and weakening of the ligaments.
  • 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.
  • Research: People like to be taped up – Placebo tape works just as well.
  • “Our results showed that both taping sessions (Kinesio taping and “Sham” taping) produced significant improvement in pain.”
• Research: Which is better? Ultrasound therapy, extracorporeal shock wave therapy, or kinesiotaping.
• Which is better? A Counterforce brace or physical therapy?
• 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.
• Cutting away at the extensor carpi radialis brevis. Surgeons say this procedure does not help patients any more than placebo surgery.
• Surgeons question the validity of tennis elbow surgery recommendations.
• 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.
• Acknowledging that elbow instability does play a role in the cause of “tennis elbow.
• Research on elbow ligament damage and elbow instability.
• Prolotherapy for Tennis Elbow.
• Splinting and three injection therapies (corticosteroid, autologous blood, and prolotherapy).
• Other research supports the use of Prolotherapy treatments.
• Cortisone injections: Study: A sham or “nothing treatment” works just as well as cortisone
• Research: Prolotherapy is superior to cortisone injections in the treatment of tennis elbow.
• Prolotherapy compared to Hyaluronic acid injection.
• Platelet Rich Plasma Therapy and Cortisone for Tennis Elbow – Initiating the inflammatory response.
• PRP vs Cortisone research in the treatment of tennis elbow.
• A brief review of the evidence that PRP can be a helpful tennis elbow treatment.
• PRP therapy for tennis elbow is not without its controversy.
• Bone Marrow Aspirate Concentrate – Bone Marrow Prolotherapy – Bone Marrow stem cell therapy for tennis elbow.

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 was told that my surgery was essentially a gamble, it will either work very well or it will not work at all. It has been 6 months after surgery. I lost the gamble it did not work at all, the pain has returned, and the loss of function is back,  I was told I should consider some cortisone injections.  I did try some Arnica (a homeopathic or herbal anti-inflammatory cream or application.)  After surgery, I do not think this is a long-term solution.

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

• I am thinking about the surgery because this has gone on for years, I have worn splints, I have gone to a lot of physical therapy, I bought myself a TENS unit (electro-stimulation). I have done all the resting, icing, taping, and bracing that I think I want to do at this point.  The cortisone injections work great for 2 – 3 weeks then the pain comes back. 

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.

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 the 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.

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:

• “As orthopaedic surgeons, we are besieged by myths that guide our treatment of lateral epicondylitis, or “tennis elbow.” This extends from the term used to describe the condition to the nonoperative and operative treatments as well. The term epicondylitis suggests an inflammatory cause; however, in all but 1 publication examining pathologic specimens of patients operated on for this condition, no evidence of acute or chronic inflammation is found. Numerous nonoperative modalities have been described for the treatment of lateral tennis elbow. Most are lacking in sound scientific rationale.”(1)

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.

Ultrasound documentation of lateral elbow instability

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 is 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 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:

• Fifty patients were enrolled in the study.
• The average age of patients was about 45 years old.
• Almost 3 out of 4 patients were female.
• Half of the patients were active and the majority of them (60%) worked in a traditional office environment.
• The right elbow was most affected (78% of cases).
• The average duration of symptoms was just about 15 months.
• Clinical examination showed tendon damage in the lateral epicondyle in 96% of cases.
• All patients received painkillers
  • 84% of patients received non-steroidal anti-inflammatory drugs,
  • only 8 patients received corticosteroid injections.
  • One patient underwent surgery after therapeutic failure.
• Ninety-two percent of patients were scheduled for physical therapy.

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

• Total improvement was noted in 42% of patients, 46% reported transient improvement and 12% progressed to chronicity (non-responsive to treatment).

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

 

 

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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 elbow’s radial collateral ligament supports the outside of the elbow. It holds the upper arm bone, the humerus, the forearm bone, and the radius. The ligament attaches at the lateral epicondyle (YES, that bony notch on the outside of your elbow) of the humerus to the head of the radius.
  • This ligament’s main function is to prevent the elbow from suffering from excessive varus (hyper-extension). What if this ligament is damaged? In its weakened state can it prevent hyper-extension? Can it help the tendons not be stressed?
• The radial collateral ligament also supports the elbow’s annular ligament which encircles and keeps the radius bone in place as you rotate your forearm. If either of these ligaments is weakened or damaged they impact each other and do not protect the elbow from excessive and unnatural movement. This creates stress in the whole elbow.
• The most famous ligament of the elbow sits on the inner side, the “Tommy John Surgery,” ligament the ulnar collateral ligament. If this ligament is damaged, it too can create unnatural stress on the other side.

“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)

• “Although most cases are self-limiting over several years, controversy exists regarding the best treatment strategy for chronic Lateral epicondylitis.”
• Conservative Care: “Nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), shockwave therapy, and injections with corticosteroids or biologics are all conservative treatment options for Lateral epicondylitis.”
• For more difficult cases, surgery: “Surgical options include open, arthroscopic, and percutaneous (needle puncture) techniques.”

The findings of this study:

• “The data demonstrate that NSAIDs, physical therapy, bracing, and shockwave therapy provide limited benefit for treating Lateral epicondylitis.
• Biologics such as platelet-rich plasma and autologous whole-blood injections may be superior to steroid injections in the long-term management of Lateral epicondylitis. Although the initial results are promising, larger comparative studies on stem cell injections are needed.
• For refractory (difficult to treat)  Lateral epicondylitis, open, arthroscopic, and percutaneous techniques are all highly effective, with no method seemingly superior to another. Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work.” For some surgery may be an option, but this is the last resort.

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

A March 2021 study (47) 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:

• Improvements in pain and disability scores were statistically significant in all groups at the end of the second week.
• At the end of the fourth week, there was also a statistically significant improvement in all three groups, but these improvements were not as high as they were in the first 2 weeks.
• There was a slight deterioration in the functional scores in the rest-and-medication group and corticosteroid injection groups, while the improvement in the Kinesio tape group continued.
• Conclusions: Corticosteroid,  Kinesio tape, and rest-and-medication treatments were all effective in terms of pain reduction and functional scores at the end of week 2, and the only treatment that continued to be effective in the final week was Kinesio tape.

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:

• facilitatory kinesiotaping,
• inhibitory kinesiotaping,
• sham kinesiotaping,
• and untapped conditions.

After the taping, the researchers measured:

• pain intensity, pain-free grip strength, maximal grip strength, and electromyographic activity of wrist extensor muscles.

The disappointing results were:

• No significant differences in the pain intensity
• No significant differences in pain-free grip strength
• No significant differences in maximal grip strength

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, 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 (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 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.

• “Our results showed that both taping sessions (Kinesio taping and “Sham” taping) produced significant improvement in pain experienced during resisted wrist extension and pain-free grip strength. “
• However, kinesiotaping was superior to “Sham” taping in reducing pain elicited by resisted wrist extension, Our results supported the use of kinesiotaping as temporary pain management for lateral epicondylitis.

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 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, (6) found that:

• “Kinesiotaping in addition to exercises is more effective than sham taping and exercises only in improving pain in daily activities and arm disability due to lateral epicondylitis.”
  • In other words, as a tape and brace, it helped people with symptoms, BUT, kinesiotaping does not reverse or regenerate soft tissue damage in the elbow. Eventually taping, and for that matter braces, bands, and sleeves, will not help at all. This is when surgery is typically explored.

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:

• Thirteen had an ultrasound.
• Fourteen had extracorporeal shock wave therapy.
• Thirteen had kinesiotaping.

Results:

• Pain scores significantly decreased in all groups.
• Grip strength significantly increased after eight weeks in only the kinesiotaping group
• The Patient-Rated Tennis Elbow Evaluation Scale scores significantly decreased after two weeks and after eight weeks in the ultrasound and extracorporeal shock wave therapy groups and after eight weeks in the Kinesio taping group

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.

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 (45) 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.

• Group 1 was given Kinesio taping and exercise.
• Group 2 was given dry needling and exercise, and
• Group 3 was given exercise alone.

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 at the 6th month.

• Kinesio taping and dry needling were found to be effective in the short and long term in terms of pain, functional status, muscle strength, and tendon thickness.
• In intergroup evaluations, improvement in Kinesio taping and dry needling groups was superior to the control group in all parameters. In comparison to Kinesio taping and dry needling, the improvements in the clinical parameters and tendon thickness were significantly better in the dry needling group in the short and long term.
• The ultrasound outcomes in our study objectively demonstrated that although dry needling in general is superior in the treatment of lateral epicondylitis, Kinesio taping treatment is also effective.

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:

• A small improvement in pain over the short term and a moderate-to-large improvement in pain in subjects 45 years or younger in favor of the brace versus physiotherapy interventions were found.
• In contrast, long-term physiotherapy interventions, wrist splints, and laser therapy had better effects on pain improvement versus the brace.

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

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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 surgery for tennis elbow vs a sham or fake surgery.

Here is what the researchers wrote on 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)

Cutting away at the extensor carpi radialis brevis. Surgeons say this procedure does not help patients any more 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 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:

• Both procedures improved patient-rated pain frequency and severity, elbow stiffness, difficulty with picking up objects, difficulty with twisting motions, and overall elbow rating of more than 6 months and at 2.5 years.
• With the number of available participants, this study failed to show the additional benefit of the surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow.

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) 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 (40) questioned the validity of tennis elbow surgery recommendations, suggesting a degree of overzealousness. Here are the study learning points:

• Surgeons often recommend surgery if symptoms persist despite nonsurgical management, but operations for tennis elbow are inconsistent in their effectiveness, and what we know about those operations often derives from observational studies that assume the condition does not continue to improve over time (without surgery). This assumption (that the tennis elbow pain will not improve without surgical intervention) is largely untested, and it may not be true; analyzing results from the control arms of tennis elbow studies can help us to evaluate this premise, but to our knowledge, this has not been done.

The results

• “Based on the placebo or no-treatment control arms of randomized trials, about 90% of people with untreated tennis elbow achieve symptom resolution at one year. The probability of resolution appears to remain constant throughout the first year of follow-up and does not depend on previous symptom duration (how long the patient had persistent elbow pain did not seem to matter), undermining the rationale that surgery is appropriate if symptoms persist beyond a certain point of time. We recommend that clinicians inform people who are frustrated with persisting symptoms that this is not a cause for apprehension, given that spontaneous improvement is about as likely during the subsequent few months as it was early after the symptoms first appeared. Because of the high likelihood of spontaneous recovery, any active (surgical) intervention needs to be justified by high levels of early efficacy and little or no risk to outperform watchful waiting. “

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)

• The presence of intra-articular findings (problems within the elbow) that may complement the extra-articular pathology (problems from around the elbow) in lateral epicondylitis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated.
  • (Our note: This paper is acknowledging that elbow instability does play a role in the cause of “tennis elbow”.)

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 investigating their diagnostic performance.

• Ten patients suffering from atraumatic lateral elbow pain unresponsive to conservative treatment were considered in this study.
• Two clinical tests were developed and administrated prior to arthroscopy:
  • Supination and Antero-Lateral pain Test (SALT);
  • Posterior Elbow Pain by Palpation-Extension of the radiocapitellar joint (PEPPER).
• SALT moves the elbow around trying to get the “jump” or pain response
• PEPPER palpates the elbow – presses down on spots looking for the jump response

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)”(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, 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:

• When patients have chronic elbow pain whether this pain comes from playing tennis or golf or work-related repetitive injury, and this injury does not heal or resolve in a few weeks and seems to ” never get better,” we have to suspect what is happening is that the tendons of the elbow are suffering from tendinosis, or degeneration, of that tendon. This is elbow pain and loss of function usually without any inflammation. (Tendinosis – pain without inflammation).

Treatments that do not help:

• Patients with chronic elbow pain, whether it is Tennis Elbow or Golfer’s Elbow will often try programs of ice, anti-inflammatory medications, KT Tape or Kinesio tape on it, physical therapy, rest, and the whole gamut of conservative care options. This is when these people come to see us. When everything else has not worked or even helped and they are looking for another option of an alternative to help their chronic elbow pain.

Injections beyond cortisone

• Prolotherapy or proliferation therapy is an injection technique that can work to regenerate the degenerated tendon. The injection of simple dextrose initiates a signaling response that recreates and mimics a natural healing response. The injections stimulate healing growth factors and repair platelets from the blood and immune response that makes healthy new tissue.

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

• There are times when the degenerative tendon disease in the elbow has progressed to micro-tearing or more substantial tearing. In some cases, we may use an ultrasound machine instead of sending patients for MRIs to determine the extent of the tendon damage. If it is fraying or micro-tearing, then we can guide our treatments one way. If a more substantial tear is present, then we can guide our treatments another way. This is done in our office and upon completion of the ultrasound examination, we can start treatment immediately with this new information.

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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.

• This patient came to see us for chronic lateral elbow pain. His pain had been previously diagnosed as tennis elbow. His complaints were elbow pain when playing hockey and lifting weights. After these activities, he would notice that his elbow would swell and get warm and the pain would take a couple of days to calm down.
• The patient told us that he tried pain management and cortisone injections, but neither seemed to help him so he came to our office to see if Prolotherapy would help with his pain.
• After examination, we determined that he was a good candidate for treatment.
• Initially, we treated him with standard dextrose Prolotherapy treatment. The Prolotherapy treatment’s healing did not respond as quickly as we hoped so, at the next treatment, Platelet Rich Plasma PRP was added as a more aggressive option to the treatment plan.  The PRP treatment did not replace the Prolotherapy treatment, they were done simultaneously.
• In the video, the clear solution is the Prolotherapy being injected.
• In the combined treatment the Prolotherapy injections are given at the lateral epicondyle,  the head, and neck of the radius, the annular ligament, the radial collateral ligament, the common extensor muscle origins, and the common extensor tendon, making sure we treat all of these in a comprehensive manner.
• Notice that the patient is not sedated for all these injections. He did take pain medication ahead of time to help him kind of get through the treatment but no intravenous sedation or anything like that. Most patients tolerate the treatment really well even though it is a lot of shots. When the PRP is injected we may or will numb the area ahead of time just because the PRP solution is thicker than the normal Prolotherapy solution.

Tennis Elbow Treatments

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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 (14) evaluating 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:

• Ultrasound-guided Prolotherapy with dextrose solution,
• Ultrasound-guided Prolotherapy with dextrose-morrhuate sodium solution (sodium salts and fatty acids of Cod Liver Oil).
• or watchful waiting (“wait and see”).

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) 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.

• Using a single-blinded randomized clinical trial design, 120 participants with lateral epicondylalgia of at least 6 weeks duration were randomly assigned to prolotherapy (4 sessions, monthly intervals), physiotherapy (weekly for 4 sessions), or combined (prolotherapy+physiotherapy).
• The Patient-Rated Tennis Elbow Evaluation (PRTEE) and participant global impression of change scores were assessed by blinded evaluators at baseline, 6, 12, 26, and 52 weeks.
• The success rate was defined as the percentage of participants indicating elbow condition was either ‘much improved’ or ‘completely recovered.

Eighty-eight percent completed the 12-month assessment.

• At 52 weeks, there were substantial, significant improvements compared with baseline status for all outcomes and groups. Prolotherapy alone, physiotherapy alone, and Prolotherapy and physiotherapy in combination.

A December 2020 (43) 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 US-guided prolotherapy, following which the pain disappeared and the tendon was restored. Three treatments were necessary.

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 (42) 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.

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

• The study is of 36 patients who were treated with Prolotherapy for their elbow pain. On average each patient received four different treatments. Injections focused on the medial elbow and the lateral elbow.
  • Most of the patients were middle-aged women, they had elbow pain for about four years. They saw several physicians before Prolotherapy treatments. Most of these patients were on pharmaceutical drugs for the pain. Fifteen of the patients were told by their doctors that there was no treatment available that was going to get rid of their pain.
• The patients were questioned at least 31 months after their last Prolotherapy session. So a question that could be answered here in these 36 patients was, “did the results of Prolotherapy treatment last?”

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.

• The average pain level on a scale of 0 – 10 before Prolotherapy treatments was about 5.0 after treatment some patients report the pain had reduced to 1 out of 10. The patients who were told there was no other treatment option experience significant pain relief.
• Before the Prolotherapy treatment, only thirty-three percent of these patients could exercise for over 30 minutes, After Prolotherapy treatments 86% could exercise for more than 30 minutes.

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

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

In June 2022 (49) 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

• A total of 120 patients (43 males, 77 females; average age: about 46 years old. The oldest person in the group was 65, and the youngest was 18) all diagnosed with lateral epicondylitis.
  • The first group was administered 20 mg methylprednisolone acetate + 2 mL 2% prilocaine (Corticosteroid group)
  • In the second group 2 mL venous blood + 0.5 mL prilocaine, (the autologous blood group)
  • The third group 2 mL 30% dextrose + 0.5 mL prilocaine injections. (The Prolotherapy group). A second injection was administered to the Prolotherapy group one month later.
  • The fourth group was recommended to use only a wrist splint.

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 (42) 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.

• Patients received an average of 4.3 Prolotherapy treatments per elbow.
• The average time of follow-up after their last Prolotherapy session was 31 months.
• Patients were asked to rate their pain and stiffness levels on a scale of 1 to 10, with 1 being no pain/stiffness and 10 being severe crippling pain/stiffness.
• The 36 patients had an average starting pain level of 5.1 and stiffness of 3.9.
• Their ending pain and stiffness levels were 1.6 and 1.4 respectively.
• Sixty-one percent had a starting pain level of 6 or greater, while only 11% had a starting pain level of three or less whereas, after Prolotherapy, only 5% had a pain level of 6 or greater and 94% had a pain level of three or less.
• One hundred percent of patients stated that the pain and stiffness in their elbows were better after Prolotherapy. Over 78% said the improvements in their pain and stiffness since their last Prolotherapy session have continued 100%.

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

• In the Clinical Journal of Sports Medicine, doctors from the Department of Family Medicine, University of Wisconsin-Madison found that their Prolotherapy treatment group showed significant improvement in pain levels compared with patients given a saline injection with the same number of needle punctures and volume (91% versus 33%). In addition, extension strength and grip strength were markedly improved in the treatment group as well. (18)
• Korean doctors published research that studied 84 patients with lateral epicondylitis who were treated with dextrose prolotherapy. Dextrose prolotherapy decreased VAS (Visual analog pain score) from 6.79 to 2.95, which reached statistical significance. (19)
• In another study, researchers achieved a significant reduction in pain with VAS from baseline patients with lateral epicondylosis as well as with the treatment of the lateral epicondyle with 15% dextrose. Evidence of tendon healing was observed via ultrasound imaging. (20)
• A September 2020 study in the Journal of Alternative and Complementary Medicine (21) found that dextrose Prolotherapy offered significant benefits as compared to saline injections in function and pain scores.

Cortisone injections: Study: A sham or “nothing treatment” 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.

• Corticosteroid injections and dry needling are utilized options in the treatment of tennis elbow.
• The question of which one is better has not been thoroughly researched.
• A total of 108 patients with tennis elbow whose pain was not relieved by 3 weeks of first-line treatment (those treatments mentioned above) were included in a randomized study manner 54 patients were treated with corticosteroid injections and 54 patients were treated with dry needling. The minimum follow-up duration was 6 months.

After treatment

• Dry needling patients showed better improvement than corticosteroid injection-treated patients.
• Both treatments were effective but at assessments at 3 weeks and 6 months post-treatment, treatment gains diminished.
  Four of the corticosteroid injection-treated patients developed skin atrophy and whitening.

Conclusion

• Dry needling and Corticosteroid injections afforded significant improvements during the 6 months of follow-up. However, compared to Corticosteroid injections injection, Dry needling was more effective.

A September 2022 paper in The archives of bone and joint surgery (50) “Corticosteroid injection provides false hope, which ultimately may decrease the patients 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.”

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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 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, (24) compared the effects of hyaluronic acid and dextrose Prolotherapy injections in patients with chronic lateral epicondylalgia.

• Thirty-two patients with at least 6 months of signs and symptoms of lateral epicondylalgia were randomly allocated into two groups:
  • a hyaluronic acid group (16 patients) and a dextrose prolotherapy group (16 patients).
  • Hyaluronic acid injections were performed as a single dose of 30 mg/2 mL 1500 kDa high-molecular-weight preparation (baseline).
  • Dextrose Prolotherapy injections were administered with 15% dextrose solution in three doses (baseline, third week, and sixth week).

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:

• Prolotherapy was favored over hyaluronic acid for improvements from 0 to 12 weeks for:
  • pain with activity
  • pain at night
  • and pain at rest
  • Q-DASH scores improved significantly more from 0 to 12 weeks in the Prolotherapy group
• Conclusions: Hyaluronic acid injection and Prolotherapy injections were both effective in reducing pain and increasing grip strength and function in patients with chronic lateral epicondylalgia. Prolotherapy injection was more effective in the short term than Hyaluronic acid injection, in terms of pain relief and functional outcome.

A February 2022 study in the Archives of Physical Medicine and Rehabilitation (44) 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 (46) 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.

• Dextrose prolotherapy, ESWT, PRP, and botulinum toxin A  outperformed placebo for short-term pain relief
• Dextrose prolotherapy was ranked as the most optimal short-term and medium-term pain reliever
• ESWT was ranked as the most optimal short-term and medium-term grip strength recovery.
• Corticosteroids were not recommended.

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 (25) 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 is appearing 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).

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, (26) the documented:

• 31 patients who had failed conservative management of their elbow problems.
• Average 5.2 years follow up
• 87.1% of the patients exhibited minimum clinically important differences. Two patients had a repeat injection and six underwent open release surgery.

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 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 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. (28)

A 2017 paper (48) 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-month duration.

• Results: Overall, 49 females and 31 males were included with thirty elbows in each group.
• Both the PRP and triamcinolone groups had better pain relief at 3 and 6 months as compared to the normal saline group, but at 6 months follow-up, the PRP group had statistically significantly better pain relief than the triamcinolone group. In the triamcinolone group, 13 patients had injection site hypopigmentation and 3 patients had subdermal atrophy.

In December 2018 in the journal Current Reviews in Musculoskeletal Medicine,(27) 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.”

In a 2017 study (29) 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:

• Complete recovery or much improvement was greater for corticosteroid injection than autologous blood and polidocanol at 4 weeks
• In contrast, at 26 weeks corticosteroid patients were significantly worse than polidocanol.
• Recurrence of pain and symptoms after corticosteroid injection was significantly higher than in autologous blood or polidocanol
• Corticosteroid injection produced a greater reduction in tendon thickness and vascularity than autologous blood at 4 weeks only.
• Compared to autologous blood, polidocanol reduced tendon thickness at 4 and 12 weeks.
• Conclusion: Injections of corticosteroids cannot be recommended over polidocanol or autologous blood.

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. (30) You 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:

• PRP injection was the best treatment for reducing pain after 2 months whereas autologous blood was the best treatment for improving disability scores.
  • However, autologous blood injection had the highest risk of adverse effects (injection site pain and skin reaction). (31)

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

• The results (of our study) revealed that the long-term efficacy of PRP treatment is better. Therefore, we concluded PRP is a superior treatment option to cortisone in cases of tennis elbow. (32)

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.

• In the patients in the cortisone group 53% improvement
• In the patients in the PRP group 82%

Their conclusion: PRP is an effective alternative to corticosteroids in the treatment of lateral epicondylitis (tennis elbow). (33)

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

• Doctors from the United Kingdom, writing in the Journal of Hand and Microsurgery reviewed  nine studies to determine the effectiveness of Platelet Rich Plasma Therapy treatment for tennis elbow and found that PRP worked – “PRP injections have an important and effective role in the treatment of this debilitating condition.”(34)

• Doctors in Turkey found that in comparing the treatment of chronic elbow tendinosis with platelet-rich plasma (PRP) or Nirschl surgical technique (tendon release). PRP seems to be better for pain relief and functionality and had more success than surgery. (35)

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

• Treatment of patients with lateral epicondylitis by steroids could slightly relieve pain and significantly improve the function of the elbow in the short term (2 to 4 weeks, 6 to 8 weeks).
• PRP appears to be more effective in relieving pain and improving function in the intermediate-term (12 weeks) and long-term (half year and one year).
• Considering the long-term effectiveness of PRP, we recommend PRP as the preferred option for lateral epicondylitis. (36)

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:

• Glucocorticoid injection was no more effective than a placebo.
• Although botulinum toxin showed marginal benefit it caused temporary paresis of finger extension, and all trials were at high risk of bias. (The studies were biased in favor of botulinum toxin.)
• Prolotherapy and hyaluronic acid were both more efficacious than placebo. But between the two – only Prolotherapy met the criteria for low risk of bias.
• Polidocanol and glycosaminoglycan showed no effect compared with the placebo. (37)

In December 2019, orthopedic surgeons in China published their findings in The American Journal of Sports Medicine (38) 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.”

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:

• The patient was not a good candidate.
• The patient did not get enough treatment. PRP is not a “one-shot wonder.” Rarely will one shot of PRP provide significant pain relief and improvement in joint function.

An August 2020 study in Clinical rheumatology (39) made this observation in the use of PRP versus placebo for the treatment of tennis elbow.

• The goal of this study was “to compare the effects of platelet-rich plasma (PRP) injection versus placebo (saline injection) on pain and joint function in lateral epicondylitis in randomized placebo.
• Five trials involving a total of 276 individuals were included.
• PRP injection was not superior to placebo for relieving pain and joint functionality in chronic lateral epicondylitis. However, patients reported improvement after both interventions.

The pratfalls of research like this are 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.

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, (41) 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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