Marc Darrow, MD, JD.
Many times when a patient is diagnosed with “tennis elbow” and elbow tendon damage the first thing that they will say to their doctor is “but I don’t play tennis.” In this article we will talk about tennis elbow treatments, elbow, arm and hand pain, the problem of tendonitis. Tendonitis is inflammation of the elbow tendons.
Tennis elbow symptoms
Tennis elbow (lateral epicondylitis) is a term for elbow tendinitis, an inflammation, soreness, or pain on the outside (lateral) part of the upper arm near the elbow. The cause of tennis elbow symptoms is usually common extensor tendinosis or a partial tear in the tendon fibers, which connect muscle to the bone. 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 that plague the patient include elbow pain that gradually worsens and can radiate outside of the elbow to the forearm and the back of the hand. Although termed “tennis elbow,” anyone can experience this painful tendon condition that results from overuse of the tendon, such as in keyboarding.
Tennis elbow treatments
Typically surgery is not recommended to relieve tennis elbow pain. While some may go on to have a surgery, and even a successful surgery, tennis elbow surgery itself can offer complications that can worsen the patient’s condition. Most visit me for options of avoiding surgery with our injection treatments.
Injections for tennis elbow
Patients with tennis elbow may not respond to the conventional tennis elbow treatments for tendon overuse of “wait, rest, and medicate for pain relief.” For many patients, this slow track to tendon healing is not on their schedule nor does it relieve their elbow pain in a timely manner. Most patients prefer getting on with their lives by fast-forwarding the tendon healing process. More recently, PRP injections for tennis elbow has become more popular. So, does PRP injections work for tendon damage and treating lateral epicondylitis or treating tennis elbow? The treatments can help. Sometimes however the success of the treatments is dependent on the experience of the doctor performing the treatments. A doctor who offers a single jab, like cortisone, may not be able generate healing needed to relieve the patient’s tennis elbow pain.
The challenges of treatment for the non responsive tennis elbow
An August 2021 paper (1) outlines the difficulties in treating the difficult to treat tennis and golfer’s elbow tendon injury. “Most medial and lateral epicondylitis patients respond well to conservative management. Some may take 12 months to improve. The etiology is degenerative and associated with repetitive overuse in the background of tendinopathy. Although NSAIDs and local corticosteroid injections may give short term symptomatic relief however, long term benefit is uncertain. Definitive evidence is lacking for other types of injections. Most tendinopathies are self-limiting. Surgery can be offered when non-operative management fails after 6–12 months of treatment. Most (surgeons) recommend open resection of diseased part and repair, although patients must be informed about the risk of infection with open techniques. Arthroscopic techniques have shown lower infection with similar functional recovery to open techniques, but risk of neurovascular injuries have been noted, in particular in patients with previous surgeries e.g. ulnar nerve transposition or other intra-articular procedures.”
The side-effects and challenges of surgery are noted.
PRP therapy for Tennis Elbow
Short-term vs. Long term PRP injections vs. Cortisone injections in elbow tendon repair
Doctors use cortisone injections on patient a to help reduce inflammation and relieve relieve tendon pressure off the nerves that are producing the pain. As we will see in the research below, cortisone injections can provide effective short-term patient pain relief. However it is not a reparative treatment, meaning that it does not heal the underlying tendon damage the patient suffers from. Symptoms are not relieved in the long-term.
Injections for tennis elbow
Platelet-Rich Plasma Therapy injections extracts the healing platelets from the patient’s blood and then re-injects the platelet-rich plasma into the injured elbow tendon. I find that injecting the joint at the same time also speeds healing. In a comparison of PRP injections and cortisone injections, in a 2015 paper doctors found PRP injections to be a superior treatment option over the long term.(2)
- In a 2019 study (3) researchers found that “Local corticosteroid injections demonstrated favorable outcomes compared with those of local PRP treatments for lateral elbow epicondylitis during the short-term follow-up period (4 weeks and 8 weeks post-treatment). Otherwise, at the long-term follow-up (24 weeks post-treatment), PRP injections had improved pain and function more effectively than corticosteroid injections.”
In another comparison study, doctors examined treatment with autologous blood injections verses painkillers, cortisone, and PRP. Of these three options, PRP injections were found to improve pain with a lower risk of complications.(4)
Recent research in the American Journal of Sports Medicine documented the positive effects of PRP on tennis elbow. Patients treated with PRP had significantly less pain and greater function, exceeding the effect of corticosteroid injection, even after a follow-up of two years.(5)
Research in the British Journal of Sports Medicine states that cortisone should never be used, and that injection therapies such as PRP and simple dextrose prolotherapy injections can be effective and excellent treatments for tennis elbow.(6)
In addition, research published in the Journal of Hand and Microsurgery examined the effectiveness of PRP injections. It was found that PRP injections have an important and effective role in the treatment of elbow instability.(7)
In this study above prolotherapy is mentioned. Prolotherapy was a forerunner treatment to PRP. It is offered as a treatment for ligament damage in the joints. As a pain syndrome treatment it can be used to help people avoid surgery for arthritis. Where PRP uses platelets, prolotherapy uses dextrose.
Tennis elbow injection comparison: Corticosteroid and PRP for tennis elbow pain
Cortisone causes secondary tendon tears
A 2018 study comparison (8) of PRP treatments to cortisone for tennis elbow demonstrated that PRP seems to be a more favorable treatment when compared to steroid injection for pain management. The paper also noted that PRP injection does not seem to have the potential complications associated with a steroid injection such as “skin atrophy, discoloration, and secondary tendon tears.”
PRP appears more effective in treating tendon damage
A 2017 paper found steroid injections could slightly relieve pain and significantly improve function of elbow in the short-term (2 to 4 weeks, 6 to 8 weeks), however 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). The researchers recommend PRP injections as the preferred injections option for tennis elbow and tendon inflammation.(9)
A June 2021 study (10) reviewed the current evidence for PRP use over corticosteroid injections for tennis elbow. The results were: Corticosteroid injections were more effective for short-term pain relief, and PRP injections were more effective for long-term pain relief and improved function. Here again the doctor has a choice in what to offer his/her patients to relieve their elbow pain. Cortisone, surgery or PRP. I would suggest the PRP.
In the journal BioMed Research International, doctors reviewing the medical literature found that the first studies on Stem Cell Therapy injections showed promising results for elbow pain. That same research showed that patients who had received a series of three separate Prolotherapy injections over a period of 8 weeks had significantly improved pain scores and isometric strength at 16 weeks compared to a placebo.(11)
In several failed cases I have seen, the doctor removed the extensor tendon from the bone was performed, and resutured to the bone. I honestly am not sure why this procedure is ever done. These patients present to me with a prominent scar. In all cases to date, regenerative medicine helped achieve the patient’s goals.
A 2022 review study writes (12) : “PRP therapy offers significant pain relief compared to saline control (placebo) when employed in the management lateral epicondylitis. However, we did not note similar improvement in functional outcomes measures. With the available low-quality evidence, PRP is ranked to be the most promising therapy that needs further exploration. Further high-quality (studies) are needed to explore its usefulness in lateral epicondylitis.”
The difference between Blood injections and PRP Injections for tennis elbow
Some people will contact me with the story of a very painful patient experience getting “blood injections” into their elbow. In autologous blood injection, blood is taken from your arm and then the doctor puts the blood injections into the elbow. The difference between this injection and PRP injections is that the PRP injections is concentrated down and the healing growth factors separated out. It is not the simple reinjection of blood into the elbow and inflamed tendon.
There was initial enthusiasm for this treatment as an alternative for cortisone. This was demonstrated in a 2014 study (15) : “Autologous blood injection was more effective over the follow-up period than corticosteroid injection in improving pain, function, and grip strength. It is recommended as a first-line injection treatment because it is simple, cheap, and effective.”
Bone Marrow Aspirate Injections for tennis elbow
Bone marrow aspirate injections are more commonly known as bone marrow stem cell therapy. In this procedure a small sample of your own bone marrow is used in concentrated form and injected into the elbow. A paper published in the Journal of natural science, biology, and medicine (13) suggested that “treatment of tennis elbow patients with single injection of bone marrow aspirate showed a significant improvement in short to medium term follow-up. In 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.” This stuyd is suggesting the treatment can help avoid surgery.
Is PRP tennis elbow injections the right treatment for you?
We have treated many people with elbow, tendon and ligament problems over the years. In many cases patients can achieve the goal of the treatment, tendon repair to alleviate pain and restore function. While some doctors have found the results controversial, as outline above, many research studies demonstrate a clear long-term benefit of PRP injections over cortisone injections and suggest use of the treatment in the well qualified patient. The need for alternatives to cortisone injections and surgery have been long documented by unwanted side-effects including the further degeneration of the elbow tendons and possible ligament damage.
A January 2022 case history published by Turkish doctors (14) describes possible patient cortisone injections side-effects in this way. The patient was initially considered very responsive to the treatment, but she was overtreated: “Corticosteroid injection for the treatment of lateral epicondylitis is a frequently used method of conservative management. A 43-year-old woman was referred to our clinic with a 6-month history of pain along the lateral side of her right and left elbow. She had been treated with 20 mg (corticosteroid) to the right and left elbow for lateral epicondylitis with the resistance of pain. After 3 weeks of the injection, the pain was completely relieved. The patient was able to move easily her elbow within normal limit. Examination also revealed depigmentation of the patient’s skin and atrophy of subcutaneous fat over the lateral epicondyle of both elbows. In the treatment of lateral epicondylitis, corticosteroid injection can be used for alternative conservative treatment in the right patient . Depigmentation or subcutaneous tissue atrophy may occur inappropriate technique or excessive cortisone dose.”
Platelet Rich Plasma Tennis Elbow Treatments vs. Tennis Elbow Surgery: A comparison study
A February 2022 study (16) wrotre: “Although surgical treatment is considered reliable for lateral elbow tendinosis, local injection therapy may be preferable, as it avoids surgery. Among a number of local injections, platelet-rich plasma has been used successfully to treat lateral elbow tendinosis.”
The researchers looked at patients suffering from tennis elbow pain and divided them into two groups. Patients treated with either platelet-rich plasma injections or tennis elbow surgery for lateral elbow tendinosis.
What they found was: “Local platelet-rich plasma injections and surgical treatment produced equivalent pain scores and functional outcomes in patients with lateral elbow tendinosis. Thus, platelet-rich plasma injections may represent a reasonable alternative treatment for patients who are apprehensive to proceed with surgery or for poor surgical candidates.”
For patients with tennis elbow symptoms, PRP worked just as well as tennis elbow surgery.
Thank you for reading this article on PRP injections for elbow tendon damage and inflammation. You can use the form below to reach out to me with your questions about PRP treatment for your elbow pain or other musculoskeletal or arthritis problems, or questions about avoiding surgery or to inquire about being a patient.
References for this article:
1 Kheiran A, Pandey A, Pandey R. Common tendinopathies around the elbow; what does current evidence say?. Journal of Clinical Orthopaedics and Trauma. 2021 May 21.
2 Yadav R, Kothari SY, Borah D. Comparison of local injection of platelet-rich plasma and corticosteroids in the treatment of lateral epicondylitis of humerus. J Clin Diagn Res. 2015 Jul;9(7):RC05-7. doi: 10.7860/JCDR/2015/14087.6213.
3 Li A, Wang H, Yu Z, Zhang G, Feng S, Liu L, Gao Y. Platelet-rich plasma vs corticosteroids for elbow epicondylitis: a systematic review and meta-analysis. Medicine. 2019 Dec;98(51).
4 Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2015 Sep 11.
5 Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011 Jun;39(6):1200-8. Epub 2011 Mar 21.
6 Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, Kong FL, Welle K,Jiang ZC, Kabir K. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med. 2015 Sep 21. pii: bjsports-2014-094387. doi: 10.1136/bjsports-2014-094387.
7 Murray DJ, Javed S, Jain N, Kemp S, Watts AC. Platelet-rich-plasma injections in treating lateral epicondylosis: a review of the recent evidence. J Hand Microsurg. 2015 Dec;7(2):320-5. doi: 10.1007/s12593-015-0193-3. Epub 2015 Jul 8.
8 Kwapisz A, Prabhakar S, Compagnoni R, Sibilska A, Randelli P. Platelet-Rich Plasma for Elbow Pathologies: a Descriptive Review of Current Literature. Current reviews in musculoskeletal medicine. 2018 Sep 25:1-9.
9 Mi B, Liu G, Zhou W, Lv H, Liu Y, Wu Q, Liu J. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. The Physician and Sportsmedicine. 2017 Apr 3;45(2):97-104.
10 Kemp JA, Olson MA, Tao MA, Burcal CJ. Platelet-Rich Plasma versus Corticosteroid Injection for the Treatment of Lateral Epicondylitis: A Systematic Review of Systematic Reviews. International Journal of Sports Physical Therapy. 2021;16(3):597.
11 Kahlenberg CA, Knesek M, Terry MA. New developments in the use of biologics and other modalities in the management of lateral epicondylitis. BioMed Res Int. Volume 2015 (2015), Article ID 439309. http://dx.doi. org/10.1155/2015/439309
12 Muthu S, Patel S, Gobbur A, Patil SC, Ks KH, Yadav V, Jeyaraman M. Platelet-Rich Plasma Therapy Ensures Pain Reduction in the Management of Lateral Epicondylitis – A PRISMA-compliant Network Meta-Analysis of Randomised Controlled Trials. Expert Opin Biol Ther. 2022 Jan 25. doi: 10.1080/14712598.2022.2032638. Epub ahead of print. PMID: 35078375.
13 Singh A, Gangwar DS, Singh S. Bone marrow injection: A novel treatment for tennis elbow. Journal of natural science, biology, and medicine. 2014 Jul;5(2):389.
14 Yıldırım MA, Öneş K, Gökşenoğlu G. Skin depigmentation and subcutaneous fat atrophy after corticosteroid injection for lateral epicondylitis in two elbow. Agri: Agri (Algoloji) Dernegi’nin Yayin Organidir= The Journal of the Turkish Society of Algology. 2022 Jan 1;34(1):60-2.
15 Arik HO, Kose O, Guler F, Deniz G, Egerci OF, Ucar M. Injection of autologous blood versus corticosteroid for lateral epicondylitis: a randomised controlled study. Journal of Orthopaedic Surgery. 2014 Dec;22(3):333-7.
16 Kim CH, Park YB, Lee JS, Jung HS. Platelet-rich plasma injection vs. operative treatment for lateral elbow tendinosis: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2021 Oct 14.