Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
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 health care provider, this is an inflammation of the tendon attachment (the Extensor Carpi Radialis Brevis) at the outside bony prominence of the elbow, the lateral epicondyle. Whatever it is called, your elbow hurts.
As your elbow continues to hurt, you maybe researching for more aggressive treatments than the ones you have been prescribed, you may even be exploring surgery. In this article we will discuss why your Tennis Elbow problem has become chronic, problematic, and difficult to treat. We will also offer possible treatment solutions utilizing regenerative medicine injections such as Prolotherapy and Platelet Rich Plasma injections. In this article we will also discuss when these treatments may not be as effective as hoped and how they may work better in your next treatment.
“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.
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 racquet ball, 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.
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?
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 and in respect to each other. 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 one of our clinic, curious about this talk of elbow ligament injury and it 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, to the forearm bone, 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 ligaments 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 are 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 unntural stress on the other side.
Did anyone discuss the ligaments of the the elbow in treatment options for your Tennis Elbow?
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 Californa 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.(1)
- “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 over 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 a last resort.
A lifetime of braces, sleeves, tapes and elbow bands – treatments that do not repair degenerative, difficult to treat tennis elbow
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, (2) 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 untaped condition.
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.”
To be fair, other researchers have supported the short-term use of kinesiotaping for tennis elbow patients. These are patients however who have newly diagnosed or onset of tennis elbow of less than 12 weeks. In January 2019 a study from Marmara University School of Medicine in Turkey published in the journal PM & R : the journal of injury, function, and rehabilitation, (3) 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.
Arthroscopic tennis elbow surgery for the most difficult cases
Possible over-excitement in recommending arthroscopic tennis elbow or an elbow tendonitis surgery procedure
Recently, a lot of research has centered on arthroscopic tennis elbow surgery. However, the American Academy of Orthopedic Surgeons suggests that up to 95% of tennis elbow will resolve without surgery.
Why so much research if the surgery is recommended to only 5% of people? This odd circumstance may be explained by a study lead by the University of Ottawa which questioned a possible over-excitement by doctors in recommending arthroscopic tennis elbow or an elbow tendonitis surgery procedure. In an ongoing study, the research team is comparing arthroscopic surgery for tennis elbow vs a sham or fake surgery.
Here is what the researchers wrote at the US National Institutes of Health Clinical Trial website:
“Chronic tennis elbow can be treated surgically, with arthroscopy gaining popularity in recent years as it presents a less invasive option, allows for direct visualization of the elbow joint for other pathology and has a faster return-to-work time compared to other surgical procedures. Despite its promise there have been no high quality studies evaluating the efficacy of arthroscopic tennis elbow release, bringing the actual efficacy of this procedure into question. We propose a randomized, double-blind controlled trial comparing arthroscopic release with arthroscopic debridement for the management of chronic tennis elbow in an effort to definitively answer this question and provide better recommendations for the use of this procedure.”(4)
Two clinical tests confirm that recalcitrant lateral elbow pain (Tennis Elbow) is from ligament laxity causing elbow joint instability
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-five years ago when Ross Hauser, MD, took over the practice, that message never changed.
Here is what the researchers said in the the journal Musculoskeletal surgery.(5)
- The presence of intra-articular findings (problems within the elbow) that may complement the extra-articular pathology (problems from around the elbow) in lateral epicondilytis 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 investigate their diagnostic performance.
- Ten patients suffering of 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. PEPPER test was sensible, specific and accurate in the detection of radial head chondropathy (bones problems).
Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition.
Caring Medical research on elbow ligament damage and elbow instability
The problem of joint instability and in this case elbow instability is a problem of the elbow ligaments. In 2014 we published our article “Structural Basis of Joint Instability as Cause for Chronic Musculoskeletal Pain and Its Successful Treatment with Regenerative Injection Therapy (Prolotherapy)”(6) In that article our research team wrote:
“Ligaments are specialized dense bands of tough, fibrous collagenous connective tissue bundles that attach one bone to another. Ligaments function to hold bones in approximation, assist joint proprioception (keeping the joint where it should be and not hyperextended) and provide mechanical support and stability.”
The keyword is stability. The excitement exhibited by the above research about instability is something that Prolotherapists have discussed for decades. Weak ligaments lead to joint instability and tendinopathy, strong ligaments lead to pain-free joint stability and healed tendons.
Tennis Elbow Treatments
Prolotherapy for Tennis Elbow
David Rabago, M.D., and researchers from the University of Wisconsin published a wonderful study in the American Journal of Physical Medicine & Rehabilitation (7) 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.”
More Caring Medical research
Our research results for treating tennis elbow at a Prolotherapy charity clinic were analyzed and reported. In this study, patients were treated with dextrose Prolotherapy.
- The results of this retrospective, uncontrolled, observational study show that prolotherapy helps decrease pain and stiffness and improve the quality of life in patients with unresolved elbow
pain. The Hackett-Hemwall dextrose prolotherapy gave 64% percent of patients greater than 75% pain relief with 94% of them having 50% or more of their pain relieved. One hundred percent of the patients stated their pain and their life was better after 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.(8)
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.(9)
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 saline injection with the same number of needle punctures and volume (91% versus 33%). In addition, extension strength and grip strength was markedly improved in the treatment group as well.(10)
- 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.(11)
- Another study from Korena university researchers achieved a significant reduction in pain with VAS from baseline patients with lateral epicondylosis as well with the treatment of the lateral epicondyle with 15% dextrose. Evidence of tendon healing was observed via ultrasound imaging.(12)
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.
Platelet Rich Plasma Therapy and Cortisone for Tennis Elbow
Platelet Rich Plasma Therapy utilizes growth factors from your own blood, injected into the elbow to stimulate healing.
The idea behind Platelet Rich Plasma Therapy (PRP) in treating tennis elbow is initiating the inflammatory response. Tendons throughout the body, including those implicated in lateral epicondylitis such as the ECRB (Extensor Carpi Radialis Brevis), heal more slowly than most other types of tissues partly due to a poor blood supply. The inflammatory response brings blood.
Cortisone research – disappointing for Tennis Elbow
In research from doctors at Massachusetts General Hospital-Harvard Medical School, research showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection into the ECRB (Extensor Carpi Radialis Brevis). The weight of evidence suggests that corticosteroid injections are neither meaningfully palliative nor disease-modifying when used to treat Extensor Carpi Radialis Brevis damage.(13)
In a study published in 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 autologous blood or polidocanol
- Corticosteroid injection produced 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 corticosteroid cannot be recommended over polidocanol or autologous blood.(14)
Like autologous blood injection, PRP is prepared using a sample of the patient’s own blood. This is why patients may refer to PRP as “tennis elbow blood injections.” This blood is then centrifuged to separate the liquid and solid components of the whole blood. PRP contains 3 to 10 times higher concentrations of platelets in comparison to autologous whole blood.
While several major clinical studies have promise in the treatment of difficult to treat tennis elbow, a major limitation in the evaluation of the efficacy of PRP in the treatment of lateral epicondylitis and other musculoskeletal diseases is the way with which PRP is prepared and administrated.(15) 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 disabilities scores.
- However, autologous blood injection had the highest risk of adverse effects (injection site pain and skin reaction).(16)
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 as a superior treatment option to cortisone in cases of tennis elbow.(17)
Doctors in Pakistan have shown the effectiveness of platelets rich plasma versus corticosteroids or the “tennis elbow steroid injection.”
The doctors looked at 102 patients in the study and divided them into two groups of 51(50%) each.
- 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 corticosteroid in the treatment of lateral epicondylitis (tennis elbow).(18)
Below is a brief review of the seemingly overwhelming evidence that PRP is a superior treatment.
- Doctors from the United Kingdom, writing in the Journal of Hand and Microsurgery reviewed nine studies to determine 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.”(19)
- 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 the surgery.(20)
In March 2017, doctors in China published more positive results for platelet rich plasma vs steroid for lateral epicondylitis. Their research showed:
- Treatment of patients with lateral epicondylitis by steroid 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.(21)
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 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 placebo.(22)
That is a lot of research.
If this article has helped you understand the problems of Tennis Elbow and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
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