What is Tennis Elbow?
Tennis elbow, also known as lateral epicondylitis, is a painful condition affecting the outside of the elbow. The lateral epicondyle is bony prominence on the outside of the elbow to which important ligaments and tendons attach. The most important structures that attach to the lateral epicondyle are the extensor muscles and tendons. These include the extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum which are illustrated below. Tendons attach muscle to bone. Repetitive wrist extension, internal rotation of the forearm and gripping cause inflammation of the extensor tendons. Inflammation of the tendon is known as tendonitis and when it becomes chronic it is called tendinosis. The overall prevalence of lateral epicondylitis is 1-3% (1). The highest incidence is in individuals 40-60 years of age (2).
Classic symptoms include pain with gripping and wrist extension. Reduced grip strength may also be present and the lateral epicondyle may be exquisitely sensitive to touch.
Treatment Options for Tennis Elbow
First and foremost is activity modification with reduced gripping and wrist extension. For tennis players, this may mean playing with a different racket with a larger grip and lower string tension. Physical therapy with myofascial release of the tight extensor muscles can be helpful. Curcumin and fish oil are effective anti-inflammatory agents that can reduce swelling.
Steroid Injections for Tennis Elbow
Steroid injections can actually damage tendon cells and accelerate damage (3). Other adverse effects of steroids include muscle atrophy, escalation in pain and depigmentation. Physical therapy has been shown to be more effective than steroid injections. In a 2002 study, 185 patients with lateral epicondylitis were randomized to 6 weeks of treatment with either steroids or physical therapy. Outcome measures included pain and function which were measured at 3,6,12,26 and 52 weeks. Physical therapy was superior to steroid injections (4)
PRP For Tennis Elbow
PRP, which stands for platelet-rich plasma, is a concentration of platelets and growth factors derived from whole blood. Plasma is the fluid portion of blood. Blood is drawn from a peripheral site most commonly in the arm and then placed into a centrifuge where the platelets are concentrated. Platelets contain important growth factors that are critical to tissue healing and repair which include vascular endothelial growth factor and platelet-derived growth factor.
PRP has been compared with steroids in the treatment of lateral epicondylitis. In a 2015 study, 65 patients with lateral epicondylitis were randomized to receive PRP or steroid injections. Pain, grip strength and function were measured at 15 days, 1 month and 3 months. PRP was the superior treatment at 3 months (5). A randomized control study (RTC) in 2014 established PRP as the best treatment option. In this study, 230 patients with lateral epicondylitis who failed conservative therapy were randomized into two groups( 6). One group received PRP injections whereas the other served as controls and received no PRP. At 24 weeks patients treated with PRP demonstrated significant clinical improvement in comparison to those who did not receive PRP.
Not all PRP is the same, however. Most PRP is processed by a bedside centrifuge which has limited flexibility. At the Centeno-Schultz Clinic, we have extensive experience in the treatment of lateral epicondylitis. We utilize a state of the art cell laboratory which allows for your PRP to be customized for your specific condition, which is not possible with a bedside centrifuge. To better understand the important differences in PRP please click on the video below.
PRP for tennis elbow is most effective when injections are performed under ultrasound guidance to ensure accurate placement of the platelets. Injections without ultrasound are not precise and may miss the areas of injury. To watch an ultrasound-guided injection into the lateral epicondyle please click on the video below.
Tennis elbow also known as lateral epicondylitis is a painful condition that involves the outside portion of the elbow with injury and inflammation of the extensor muscles and tendons. Repetitive wrist extension, gripping and internal rotation of the forearm are common risk factors. Physical activity modification, physical therapy, and anti-inflammatory agents are useful. Steroids injections are associated with complications and are inferior to physical therapy. PRP injections are superior to steroid injections in long term studies in the treatment of lateral epicondylitis and now have become the gold standard.
(1974) Prevalence, Incidence, And Remission Rates of Some Common Rheumatic Diseases Or Syndromes, Scandinavian Journal of Rheumatology, 3:3, 145-153,
2. Olaussen M, Holmedal Ø, Lindbaek M, Brage S. Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: a protocol for a randomised, placebo-controlled study. BMC Musculoskelet Disord. 2009;10:152. doi: 10.1186/1471-2474-10-152
3. Zhang J, Keenan C, Wang JH. The effects of dexamethasone on human patellar tendon stem cells: implications for dexamethasone treatment of tendon injury. J Orthop Res. 2013;31(1):105-10. DOI: 10.1002/jor.22193
4.Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359(9307):657-62.DOI: 10.1016/S0140-6736(02)07811-X
5. 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;9(7):RC05-7.DOI: 10.7860/JCDR/2015/14087.6213
6.Mishra AK, Skrepnik NV, Edwards SG, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463-71.DOI: 10.1177/0363546513494359