We will often see patients who have lingering elbow pain. They continue to receive and remedy themselves with traditional “conservative” treatments that include resting, icing, anti-inflammatory medications, Kinesio tape and various other health care provided treatments including physical therapy, massage, cortisone injections and even acupuncture. While some will respond to these treatments the patients who come into our office have not. They have been scheduled for one of the many surgical procedures often suggested for treatment of lateral epicondylitis. Most will be recommended to a debridement, the removal of tissue “too far gone,” to be saved. For many, removing tissue may not be their optimal way way to go. These people will reach out to us to discuss the realistic surgical alternatives we can offer. In this report we will discuss PRP and stem cell treatments as well as look at some new research on tennis elbow surgery.
Tennis elbow in office workers and laborers
There is a great probability that the people reading this article have been diagnosed with tennis elbow that have never played tennis in their life. We have seen patients with tennis elbow who were carpenters, rock climbers, office workers, landscapers, golfers, and more. Many never having picked up a racquet.
- Tennis Elbow (lateral epicondylitis) is a term for severe elbow tendonitis, or an inflammation, soreness, or pain on the outside (lateral) part of the upper arm near the elbow.
- The cause is usually common extensor tendinosis or a partial tear in the tendon fibers, which connect muscle to the bone. Of the tendinopathies, the traditional term tendinitis refers to the acute (recent) inflammatory stage of tendon injury, while the new term, tendinosis refers to the chronic injury when inflammatory cells are no longer seen, but the tendon is worn.
- Symptoms include elbow pain that gradually worsens and radiates outside of the elbow to the forearm and to the back of the hand.
While many of these people have never picked up a racquet, they usually have picked up a shopping cart filled with elbow tapes, braces, and sleeves that they hope will help them.
Patients with tennis elbow may not respond to the conventional treatments of “wait, rest, and medicate for pain relief.” For many patients, this slow track to healing is not on their schedule. Most patients prefer getting on with their lives by fast-forwarding the healing process. So they try many things. Some work. Some don’t.
Why tape, sleeves and physical therapy did not help your tennis elbow pain
Some people find great comfort in taping up their elbow or getting elbow sleeves. If it helps, then it is a good thing. For many however, sleeves, kinesiotaping, and ace bandages are not really helpful. Some people get great benefit from physical therapy.
A study from July 2019 (1) had three groups of people (10 in each group) with a new onset of elbow pain go to physical therapy. At the physical therapist’s they would receive treatment and taping.
- Ten patients received kinesiotaping plus exercises
- Ten patients received sham taping (Tape that would not help) plus exercises
- Ten patients received exercises only.
- “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, this conservative care option of kinesiotaping did not fix the problem of the elbow degeneration.
But, despite this people still go online and buy expensive elbow braces. Why? As many patients say. “it gives me comfort.”
Cortisone, Kinesiotaping, Rest – According to one study – they are only short term relief remedies
for tennis elbow pain
A March 2021 study (2) compared early results of Kinesio tape as an alternative method for the treatment of lateral epicondylitis with those of corticosteroid injection and the rest-and-medication group. Among the fifty patients (53 elbows), Kinesio tape was applied to 20 patients (21 elbows), and corticosteroid injection was applied to 15 patients (17 elbows).
Fifteen patients were included in the rest-and-medication group. Patients in the rest-and-medication group were informed about their condition, and necessary warnings were given. No oral or topical treatments were recommended. If needed, paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed.
- Improvements in all (pain and function testing) 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.
- However, there was no significant difference between the Kinesio tape, the rest-and-medication group and the corticosteroid groups at the fourth week.
- 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.
Ultrasound (US) therapy, extracorporeal shock wave therapy (ESWT), and Kinesio taping comparison study
A February 2021 study (23) aimed to compare the clinical and sonographic effects of ultrasound (US) therapy, extracorporeal shock wave therapy (ESWT), and Kinesio taping (KT) in the lateral epicondylitis. A total of 40 patients with lateral epicondylitis were included. The patients were randomly assigned to 3 treatment groups: ultrasound (US) therapy, ESWT, and Kinesio taping groups.
Pain scores significantly decreased in all groups. Grip strength significantly increased after eight weeks in only the Kinesio taping (KT). The Patient-Rated Tennis Elbow Evaluation Scale (PRTEE) scores showed significantly elbow pain and disability improvements after 2 weeks and after 8 weeks in the ultrasound (US) therapy group and ESWT groups, and after 8 weeks in the Kinesio taping group. Common extensor tendon (CET) thicknesses significantly decreased after 8 weeks in only the extracorporeal shock wave therapy (ESWT) group.
The study found all three treatments are effective in reducing pain and improving functionality. However, none of these treatment methods were found to be superior to others in reducing the pain and improving functionality.
Why physical therapy may fail
An August 2022 study (26) assessed the effectiveness of physical therapy and therapeutic exercise for rotator cuff-related shoulder pain and lateral elbow tendinopathy. Currently there is, as attested to in this paper, no consensus about the optimal progression type exercise program for these disorders. What the researchers of this study found was general reasons why physical therapy may fail. “Pain was the most frequent benchmark when modulating and progressing the exercises, although other criteria were found such as fatigue or self-perceived ability.” Pain, fatigue, and the patient’s belief in the usefulness of the exercise played a major role in preventing physical therapy from being successful.
Headline: One type of tennis elbow surgery, with a track record of “excellent” results, is found to be no more effective than placebo or sham surgery
When conservative treatments do not respond, often a patient is suggested to surgery. In 2018, Australian surgeons made headlines when they published their study in the American Journal of Sports Medicine (3) comparing tennis elbow surgery to placebo surgery.
Here is what the research team wrote:
“A number of surgical techniques for managing tennis elbow have been described. One of the most frequently performed involves excising (shaving away) the affected portion of the extensor carpi radialis brevis (ECRB, a muscle of the forearm). The results of this technique, as well as most other described surgical techniques for this condition, have been reported as excellent, yet none have been compared with placebo surgery.”
When the surgery was compared to a sham surgery, the doctors concluded: “this study failed to show additional benefit of the surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow.” So the surgical removal of damaged tissue did not help the patient anymore than the conservative treatments. How about regenerative treatments?
A reassessment of tennis elbow surgery
Researchers found that in previously medical studies (21), patients who received a placebo or no-treatment about 90% of them achieved symptom resolution at one year. In this study the researchers noted: “Surgeons often recommend surgery if symptoms persist despite nonsurgical management, but operations for tennis elbow are inconsistent in their efficacy, and what we know about those operations often derives from observational studies that assume the condition does not continue to improve over time. This assumption is largely untested, and it may not be true. ” Their findings followed that people who had no treatment seemed to do very well after one year and that surgical recommendation maybe premature: “The probability of resolution appears to remain constant throughout the first year of follow-up and does not depend on previous symptom duration, 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 intervention needs to be justified by high levels of early efficacy and little or no risk to outperform watchful waiting.”
Approximately 85%-90% of patients respond satisfactorily to conservative treatment, but in resistant patients, surgical treatment is considered
A May 2022 paper (22) wrote: “Approximately 85%-90% of patients respond satisfactorily to conservative treatment, but in resistant patients, surgical treatment is considered. Classic open surgery is successful in between 70% and 97% of patients, similarly to more modern techniques such as arthroscopy. (In this) retrospective study of 47 working-age patients with resistant lateral epicondylitis: 27 underwent arthroscopic surgery and 20 underwent open surgery. ” Between the two procedures, no statistically significant differences were observed between the groups in the reduction in reduced pain or disability socres. The differences in terms of time off were also not statistically significant. The period of work leave corresponded, on average, to 84 days in the arthroscopy group and 90 days in the open surgery group. Conclusions: “Arthroscopic surgery and open surgery provide similar functional results and pain reduction in the treatment of lateral epicondylitis.”
PRP and bone marrow stem cells for tennis elbow – are they realistic treatment options or not?
Platelet Rich Plasma therapy extracts the healing platelets from your blood and then re-injects the Platelet-Rich Plasma into the injured elbow. The research below from leading medical universities and research centers from around the world helps confirm our own observations of these treatments.
PRP is a controversial subject even among the experts who use the treatment.
As discussed throughout this article, PRP treatment for tennis elbow is looked upon even by doctors who use it as a a controversial treatment for elbow pain. A November 2021 study (4) demonstrates this with the results of a survey that was sent to European doctors who use PRP. What they found was the controversy was not so much over if PRP worked, but how it could work better. This survey showed that
“Consensus of agreement (among the doctors who use the treatment) was only reached for 17/40 (42.5%) statements. For statements on PRP formulation, consensus of agreement was reached in 2/6 statements (33%). Only limited consensus on the contraindications, delivery strategy and delivery technique was achieved.”
In this article I am demonstrating research that suggests when PRP would work, when it would not work. Many times that the treatment does not work is not in the treatment itself, but in the application. How was the treatment given, how was the solution prepared.
PRP injections vs. Cortisone
There are many research papers that compare cortisone or steroid injection and PRP treatments.
In December 2018 a multi-national team of doctors wrote in the journal Current reviews in musculoskeletal medicine (5) compared PRP treatments to cortisone for tennis elbow. They wrote that:
“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.” They also noted that in comparison with extracorporeal shockwave, dry needling, or surgical treatments, (PRP injections in tennis elbow seems to be the best-studied intervention.”
- University researchers in India suggest Platelet-rich plasma (PRP) offers a better option for the treatment of lateral epicondylitis. In a comparison of PRP and cortisone injections, the doctors say PRP is a superior treatment option in the long-term. (6)
- A second study published in the Indian journal of orthopaedics compared single injection of platelet-rich plasma for tennis elbow as compared with single injections of triamcinolone (corticosteroid) and placebo (normal saline) over a short term period.
- Both the PRP and triamcinolone groups had better pain relief at 3 and 6 months as compared to normal saline group, but at 6 months followup, the PRP group had statistically significant better pain relief than triamcinolone group.
- In the triamcinolone group, 13 patients had injection site hypopigmentation (loss of skin color) and 3 patients had subdermal (skin and subdermal fat layer) atrophy. (7)
- In the journal The Physician and sports medicine, doctors found steroid could slightly relieve pain and significantly improve function of 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, the researchers recommend PRP as the preferred option for tennis elbow.(8)
- Doctors from teaching universities in Thailand examined injections of cortisone, autologous blood injection (simple blood injection) and PRP. What they found was the blood injection and the PRP injection provided superior results to cortisone for pain reduction and functional improvement. The autologous blood injection had a higher rate of site complication that was significant enough to note.(9)
- A November 2019 study compared the effectiveness of Platelet Rich Plasma injections versus autologous blood injection (blood without making it Platelet Rich), and cortisone. The findings were “PRP was associated with more improvement in pain intensity and 29 function in the long-term than the comparators.”(10)
Long term-benefit of PRP vs Cortisone
- Dutch researchers writing in the American Journal of Sports Therapies documented the positive effects of PRP on tennis elbow. Treatment of patients with PRP reduced elbow pain and increased function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years.”(11)
- British doctors agree – research in the British Journal of Sports Medicine says cortisone should never be used and that injections therapies including PRP can be effective and excellent long-term treatments for elbow pain.(12)
Most recently, a June 2021 study (13) also examined the current evidence for the effectiveness of platelet rich plasma (PRP) injections versus corticosteroid injections as treatment interventions for tennis elbow. In this systematic review the researchers examined previously published papers evaluating PRP vs. corticosteroid injections as treatment methods for tennis elbow. Two independent researchers searched and screened for articles that were systematic reviews that directly compared PRP to corticosteroid injections injections for tennis elbow. The results were: Corticosteroid injections were more efficacious for short-term pain relief, and PRP injections were more efficacious for long-term pain relief and improved function. PRP injections appear to be a more effective long-term treatment option than corticosteroid injections for those with tennis elbows who did not respond to conservative management.
A March 2022 study (24) testing the effectiveness of PRP injections for tennis elbow. This study suggested: “Injection of PRP were, found to be effective in treating tendinopathy and arthritis. . . this “study was conducted to access the functional outcome of PRP injection in tennis elbow patients.” Results “In total, 80 individuals participated in (this) study, of which the average age of the participants was 45-54 There is statistical significance in the difference of means of pain score obtained using both VAS (visual pain score) and MAYO (function ability) score at 12 weeks and 24 weeks. . . In tennis elbow patients, PRP injection shows an effective reduction in pain according to VAS and MAYO score and especially, younger age patients have shown more benefit in terms of pain reduction with PRP treatment.”
Worse pain after corticosteroid injection
A September 2022 paper (27) found a “significant difference in perceived pain VAS (Pain scale of 0 none – 10 worst pain) and disability QuickDASH (11 outcome based questions about physical function and symptoms) between pre-injection and recurrence, showing that the patient’s perceived pain and disability were greater when recurred. (After the initial corticosteroid, if and when pain returned it was felt to be worse by patients). The paper concluded: “Although corticosteroid 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.”
Long term-benefit of PRP vs Physical Therapy
- In some of the more research reported in the surgical journal – Journal of Hand and Microsurgery (14) doctors reviewed and presented their evidence on the effectiveness of PRP injections. They found PRP injections have an important and effective role in the treatment of elbow instability. Here is what they wrote:
- The majority of sufferers recover within 1 year with conservative management which includes physical therapy. The most effective treatment for chronic lateral epicondylitis, however, is argued amongst experts.
- In the opinion of this study, after review of the literature, PRP injections have an important and effective role in the treatment of debilitating tennis elbow pathology, in cases where physical therapy has been unsuccessful.
- Previously, cases that persisted despite physical therapy have been treated with corticosteroid injections. Steroid injections are reported to give short-term pain relief, however the proven recurrence rates and complications (including dermal depigmentation, subcutaneous atrophy, and a theoretical risk of increased tendon rupture) should limit their use.
- PRP has been shown to provide a continuing long-term benefit in cases of chronic lateral epicondylosis, in the recent literature. It is superior to autologous blood injection injections and placebo/dry needling procedures.
PRP can eliminate the need for elbow surgery
A team of researchers in the United Kingdom wrote in the Journal of orthopaedics (15).
- “Our study adds to the evidence that PRP injection for intractable lateral epicondylitis of the elbow is an acceptable and useful treatment with improvement in symptoms in 56 out of 64 patients (87.5%). It adds to the literature in that we have tried to ascertain the effect of PRP on reducing the need for a complex, risk laden, surgical intervention. . .we consider PRP injection, for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms and have shown it has reduced the need for surgical intervention in this difficult cohort of patients.”
Chronic elbow instability causing tennis elbows in people with physically demanding jobs and frequency of cortisone injections.
A study published in January 2021 (16) can offer evidence that strengthening and tightening the ligaments and tendons of the elbow can help with elbow pain. This is what the study said:
“Instability can coexist and may be associated with refractory lateral epicondylitis. The risk factors of instability associated with refractory lateral epicondylitis are heavy labor and multiple steroid injections.”
This is what I see in my patients. A person comes in with a history of elbow pain. They go to a few doctors, get the traditional treatments and do not get pain alleviation. Mostly in part because they continue at a job that is considered “heavy labor.” So they go onto get a few cortisone injections to help them at their jobs. The cortisone injections over time has lead to a wearing down or thinning of the ligaments and tendons of the elbow causing instability. Your bones are floating around in a hypermobile, unstable state and are compressing and impinging on nerves and other soft tissue. This instability is what PRP and stem cell therapy can address. By stabilizing the elbow, the tennis elbow pain can now be managed.
MRI validation of tendon recovery following PRP treatments
We are often asked if we suggest an MRI for patients following treatments. Usually the answer is no. If the treatment works then the evidence is in the patients pain and function improving. An August 2022 paper (25) did do after PRP treatment MRI. The MRI results of patients at 6 follow-up visits over a 2-year period after platelet-rich plasma injection in patients with lateral epicondylitis were assessed.
- Thirty patients who underwent PRP treatment for lateral epicondylitis and sequential MRI evaluation were prospectively enrolled.
- Significant improvements in the MRI scores occurred by 3 months and continued over a period of 24 months.
- Continuous tendon recovery assessed by MRI was found during a 2-year period after PRP treatment. Improvements in the MRI scores followed and continued longer than improvements assessed by the clinical scores.
Bone marrow derived stem cells for the treatment of tennis elbow
In our practice we have found stem cell therapy to be an effective and reliable treatment in certain patients. There are many claims made about the effectiveness of stem cell therapy. When offering this treatment the doctor and the patient need to have a realistic expectation of the effectiveness of the treatment and if it will help the person’s elbow problems. Many people who seek stem cell therapy have already been advised that they should consider surgery. For some of these people surgery will be very effective. But, as with any medical treatment, surgery can have its undesired effects. Even successful surgery can require months of physical therapy and diminished function.
Is there research behind the use of stem cells? Many doctors point to a 2008 paper (17) as one of the earliest suggestions that bone marrow derived stem cells could help people with elbow tendinopathy. In this paper doctors suggested that iliac bone marrow plasma injection after arthroscopic debridement of degenerative tissue( in the elbow) will bring along biological healing. The treatment will not only reduce pain but also improve function in patients with resistant elbow tendonitis.
- Twenty-four patients (26 elbows) with significant persistent pain for an average of 15 months following surgery
- The doctors applied autologous iliac bone marrow plasma injection following arthroscopic debridement.
- All patients in this study noted improvement both in pain and function. No complication occurred in any patient.
- Conclusion: “Biologic treatments in orthopaedics are just beginning to evolve. In the present investigation, the injection of iliac bone marrow plasma after arthroscopic debridement in severe elbow tendinosis demonstrated early recovery of daily activities and clear improvement.”
A study in the Journal of natural science, biology, and medicine (18) found that a bone marrow aspirate (containing plasma rich in growth factors and mesenchymal stem cells) injection was an effective treatment for tennis elbow.
Bone marrow aspirate injections contain plasma rich in growth factors and mesenchymal stem cells
In this research a total of 30 adult patients with previously untreated tennis elbow were administered a single injection of bone marrow aspirate (stem cells and platelets).
- This concentrate was made by centrifugation of iliac crest bone marrow aspirate.
- The researchers concluded: Treatment of tennis elbow patients with single injection of bone marrow aspirate showed a significant improvement in short to medium term follow-up. They suggest that in the future, such growth factors and/or stem cells based injection therapy can be developed as an alternative conservative treatment for patients of tennis elbow, especially who have failed non-operative treatment before surgical intervention is taken.
Let’s point out again bone marrow aspirate contains plasma rich in growth factors and mesenchymal stem cells. No separate PRP treatment was given.
More recently a 2018 study in the Journal of orthopaedics (19) commented on the above study:
“Bone marrow aspirate concentrate (BMAC) is an emerging, novel treatment for various bone and cartilage pathology and injury. Similar to other orthobiologic intra-articular injections like hyaluronic acid and PRP, BMAC gives patients the opportunity to restore the natural microenvironment of their damaged or diseased tissue. Bone marrow concentrate is commonly taken from pelvic bone, and contains mesenchymal and hematopoetic stem cells, platelets, growth factors, cytokines, and anti-inflammatory and immunomodulatory cells. . . Further evaluating the efficacy of bone marrow injections, thirty patients who were untreated for Lateral Epicondylitis were evaluated with the Patient-rated Tennis Elbow Evaluation (PRTEE) prior to and following the treatment of a single administration of Iliac Bone Marrow Aspirate. – This concentrate, composed of iliac bone marrow aspirate. . . was effective in simplicity and safety, avoiding further complications as other modes of treatment. Evaluated at 2, 6, and 12 weeks after administration, these patients showed drastic improvement in the two week evaluations, thus showing the efficacy of this treatment’s recovery time. Although (the authors} explained the limitation of their study in long term treatment, they believe that this treatment, when paired with growth factor and other stem cell treatment, can be an effective alternative in lieu of surgery.”
Finally, a 2021 study (20) suggested that generally, stem cell therapy can have good impact on tendon injury: “Potential evidence has shown that MSC injection improves pain, joint functional, radiological, and arthroscopic parameters in patients with tendon disorders. Although all the included studies had a small sample size, the results clearly presented MSC dose-dependent responses regarding pain relief.”
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