There is some new and exciting research to share in the non-surgical treatment of elbow pain and instability.
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 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.
What is Tennis Elbow? It is elbow pain?
There is a great likelihood that 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.
- It’s usually caused by a partial tear in the tendon fibers, which connect muscle to the bone.
- 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.
Can tape and sleeves really help your elbow?
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.
A new study from January 2019 (1) had three groups of people (10 in each group) with a new onset of their elbow pain go to physical therapy.
- Ten patients received kinesiotaping plus exercises
- Ten patients received sham taping (Tape that would not help) plus exercises
- Ten patients received exercises only.
Findings: “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.
When conservative treatments do no 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 comparing tennis elbow surgery to placebo surgery.
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
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.”(2) So the surgical removal of damaged tissue did not help the patient anymore than the conservative treatments. How about regenerative treatments?
PRP and Stem Cells for Tennis Elbow – Realistic treatment options
Platelet Rich Plasma therapy extracts the healing platelets from your blood and then re-injects the Platelet-Rich Plasma into the injured elbow. While our own clinical observation attests to the high success rate PRP and stem cells can have for patients with tennis elbow, the research below from leading medical universities and research centers from around the world helps confirm our observations with scientific rationale.
PRP injections vs. Cortisone
In December 2018 a multi-national team of doctors wrote in the journal Current reviews in musculoskeletal medicine 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.”(3)
- 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. (4)
- 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. (5)
- In the journal The Physician and sportsmedicine, 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.(6)
- 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.(7)
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.”(8)
- 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.(9)
Long term-benefit of PRP vs Physical Therapy
- In some of the more research reported in the surgical journal – Journal of Hand and Microsurgery 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.(10)
PRP can eliminate the need for elbow surgery
A team of researchers in the United Kingdom wrote in the Journal of orthopaedics (11)
- “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.”
Bone Marrow derived stem cells, containing PRP for the treatment of tennis elbow
A study in the Journal of natural science, biology, and medicine found that a bone marrow aspirate (containing plasma rich in growth factors and mesenchymal stem cells) injection was an effective treatment for tennis elbow. In this study, treatment of tennis elbow patients with single injection of bone marrow derived stem cells 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.
The research team suggested that as recent studies (like those pointed out above) show a beneficial role of locally delivered biological growth factors in form of platelet rich plasma (PRP) and autologous blood in healing of various tendinopathies and, that since bone marrow stem cell treatments derived from the iliac crest contains PRP, stem cell 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 recommended. (12)
An update on Umbilical Cord Stem Cells
Throughout this website you read about our clinical observations surrounding the use of bone marrow derived stem cells in the treatment of degenerative joint, tendon, ligament, and spine disease. In late 2018, after much research, I decided to add new products to our treatment line. Part of my decision was based on research like this, published in October 2018 in the journal Regenerative Medicine. (12)
“Stem cell-based therapy for the treatment of orthopedic diseases is arguably one of the most remarkable developments in the field of regenerative medicine. A better understanding of Mesenchymal stem cell biology and identification of Mesenchymal stem cells in (umbilical) cord blood have added umbilical cord blood to the sources of stem cells used for treatment of nonhematopoietic diseases.”
In the initial results we are seeing in patients, we are seeing that when umbilical cord stem cells are mixed with PRP, we get very similar results to that of bone marrow stem cell injections.
To learn more about this choice go to our article Umbilical Cord Blood Stem Cell Therapy
Is this treatment right for you?
So now that we have presented the research, let’s talk about typical patients. Obviously not everyone with tennis elbow plays tennis as we discussed above. We see people who are office workers, clerical workers, people who do minor and heavy lifting, or spend a lot of time in front of a computer. Many of the people we see may have had tennis elbow for many years and they have it in both arms. In our more than 20 years of practice we have seen many patients with chronic elbow problems, we have found Platelet Rich Plasma therapy and stem cells to be effective and reliable in helping to heal tennis elbow.
When do we decide between stem cells and PRP?
Sometimes will do offer a patient stem cell therapy if they have an advanced elbow tendinopathy or a tear in the tendon. What we do in the treatment is to use ultrasound to look in that elbow and look at where the inside or outside extensor or flexor tendons of the elbow inserts. This will help us give the patients a realistic expectation of how long the healing recovery period will be. Will PRP and stem cells work for your tennis elbow? You need to start with a conversation
Ask Dr. Darrow about tennis elbow
A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
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1 Giray E, Bingul DK, Akyuz G. The effectiveness of kinesiotaping, sham taping or exercises only in treatment of lateral epicondylitis: A randomized controlled study. PM&R. 2019 Jan 4.
2 Kroslak M, Murrell GAC. Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial. Am J Sports Med. 2018 Mar 1:363546517753385. doi: 10.1177/0363546517753385.
3 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.
4 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.
5 Seetharamaiah VB, Gantaguru A, Basavarajanna S. A comparative study to evaluate the efficacy of platelet-rich plasma and triamcinolone to treat tennis elbow. Indian journal of orthopaedics. 2017 May;51(3):304.
6 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.
7 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.
8 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.
9 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.
10 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.
11 Hastie G, Soufi M, Wilson J, Roy B. Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention. Journal of orthopaedics. 2018 Mar 1;15(1):239-41.
12 Singh, A., Gangwar, D. S., & Singh, S. (2014). Bone marrow injection: A novel treatment for tennis elbow. Journal of Natural Science, Biology, and Medicine, 5(2), 389–391. http://doi.org/10.4103/0976-9668.136198
13 Sane MS, Misra N, Mousa OM, et al. Cytokines in umbilical cord blood-derived cellular product: a mechanistic insight into bone repair | Regenerative Medicine 22 Oct 2018https://doi.org/10.2217/rme-2018-0102.
There is controversy in the medical community about umbilical cord blood stem cells. Some insist that the injectable solution contains abundant live umbilical cord blood stem cells. Some suggest that the stem cells are not alive. I have seen the flow cytometry showing live stem cells. The research shows that these stem cells release cytokines and growth factors that awaken native stem cells. I have tried this treatment on myself for both shoulders and knees. After great success, I started using this treatment on patients. I still use PRP and bone marrow depending on the patient’s pathology and requirements. To date the results are excellent for all of these treatments. We are in the process of doing a study on cord blood stem cells (we have done others on bone marrow and PRP) to see which treatments are the most successful. We are awaiting more long term results.