Friday, June 2, 2023

Cortisone Injection For Tennis Elbow

The Challenges Of Treatment For The Non Responsive Tennis Elbow

Tennis Elbow Cortisone Injection | Auburn Medical Group

An August 2021 paper 00293-9/fulltext” rel=”nofollow”> 1) outlines the difficulties in treating the difficult to treat tennis and golfers 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 612 months of treatment. Most 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.

More Caring Medical Research

In the October 2009 issue of Practical Pain Management we presented a study on 36 patients with unresolved elbow pain who were treated with dextrose Prolotherapy at a quarterly clinic, which included a sub-group of 15 patients who were told by another practitioner that there was no other option for their pain. The patients average age was 53 years old. They reported an average of four years and one month of pain and saw 2.4 MDs before receiving Prolotherapy.

  • Patients received an average of 4.3 Prolotherapy treatments per elbow.
  • The average time of follow-up after their last Prolotherapy session was 31 months.
  • Patients were asked to rate their pain and stiffness levels on a scale of 1 to 10, with 1 being no pain/stiffness and 10 being severe crippling pain/stiffness.
  • The 36 patients had an average starting pain level of 5.1 and stiffness of 3.9.
  • Their ending pain and stiffness levels were 1.6 and 1.4 respectively.
  • Sixty-one percent had a starting pain level of 6 or greater, while only 11% had a starting pain level of three or less whereas, after Prolotherapy, only 5% had a pain level of 6 or greater and 94% had a pain level of three or less.
  • One hundred percent of patients stated that the pain and stiffness in their elbows were better after Prolotherapy. Over 78% said the improvements in their pain and stiffness since their last Prolotherapy session have continued 100%.

Prp Treatment For Tennis Elbow

A tremendous effort has been underway to define whether or not PRP or Platelet Rich Plasma has a role in the treatment of tennis elbow. PRP therapy involves an injection of a portion of your own blood back into the painful tissues. The thought is that the regenerative chemicals and cells in the blood will enable the tendons of the elbow to heal themselves. The scientific literature is mixed, but many agree that PRP is a reasonable option in patients who have failed to improve with rest, ice, moist heat, therapy, Flexbar and even acupuncture. The recovery from a PRP injection is generally brief, and it is viewed as a worthy treatment to attempt when all else fails and you are told that surgery is your only other option.

With the success we have seen with both the flexbar and PRP we have found that very very few patients ever go on to require surgery to treat their tennis elbow.

Bottom Line

You should likely avoid a cortisone injection for tennis elbow unless you clearly understand the risks, and are truly miserable because of the pain. Talk to your doctor about a compression sleeve, or flexbar, try to lift with your palm facing up and try to avoid offending activities as best you can.

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Surgeons Question The Validity Of Tennis Elbow Surgery Recommendations

A December 2021 study by Clinical Orthopaedics and Related Research questioned the validity of tennis elbow surgery recommendations, suggesting a degree of overzealousness. Here are the study learning points:

  • Surgeons often recommend surgery if symptoms persist despite nonsurgical management, but operations for tennis elbow are inconsistent in their effectiveness, 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 analyzing results from the control arms of tennis elbow studies can help us to evaluate this premise, but to our knowledge, this has not been done.

The results

Benefits And Risks Of Prp Treatment For Tennis Elbow

Tennis Elbow Classroom: Cortisone Shots For Tennis Elbow: Think Twice!

Unlike cortisone treatments to provide pain relief, platelet rich plasma treatments are used to try to heal the injured tendons. Theres a clear benefit dichotomy between trying to heal a tendon with PRP versus making it feel better for a while with cortisone, notes Dr. Scofield. However, because PRP is an emerging treatment that has yet to be FDA-approved, it is not covered by insurance. In addition, because PRP uses your own platelets to repair injury, treatment results are going to vary from patient to patient.

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Does Resting Your Arm Help

In the first few days or weeks after the symptoms appear, it makes sense to put as little strain as possible on the arm, and especially to avoid any activities that trigger the pain. If the pain arises when you do specific exercises, for example, then you should stop doing them for a few weeks. If some activities are impossible to avoid completely like working on the computer, lifting or writing the strain should at least be reduced enough so that the pain improves.

Some people wear a brace or a bandage to reduce the strain put on the muscles, but it isnt clear whether this helps.

You can only start to gradually put more strain on the arm and do daily strengthening exercises once the pain has improved a lot.

Research: Prolotherapy Superior To Cortisone Injections

A November 2019 study in the journal Orthopedic Research and Reviews compared the effectiveness of Prolotherapy to corticosteroid injections. This is what the researchers wrote:

This investigation showed that both corticosteroid injection and dextrose prolotherapy efficiently improved pain and function in patients with chronic lateral epicondylitis. In the Prolotherapy group, this improvement persisted even after a 1-month follow-up and the results after one injection were still improvable, whereas, in the parallel group, steroids only provided a short-term improvement. This finding proved that dextrose prolotherapy had better and longer effects in treating chronic tennis elbow.

Prolotherapy works on a simple concept: reignite the immune system to heal by causing targeted inflammation at the spot of the injury. This is achieved by, in most cases, injecting a simple sugar 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.

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Tennis Elbow Cortisone Injection

Lateral epicondylitis is a common painful and functionally limiting presenting injury here at KUER Clinic. It is a common condition that causes pain around the site of the elbow resulting usually from overuse of the wrist extensor complex, however it is also common for this to be because of altered postural control.

In spite of the name this is commonly a condition seen as a result of every day activities. Tennis elbow is a condition which affects 3 people in every 100. Depending on severity of the tendinopathy a cortisone injection is recommended with a successful rate in reducing the inflammation causing the pain thus enabling a client to participate in an exercise programme to return quickly to full recovery.

The injection itself is a straight forward procedure whereby inserting lidocaine a local anaesthetic to reduce pain within the area and then a corticosteroid aiming to flush the area reducing inflammation at the site of the tendon. It is important after the appointment to rest the area for 48 hours refraining from too much activity. After this time we recommend a gentle return to full activity with guidance from the consultant regarding management from there.

A course of physiotherapy is recommended after the injection to focus on mobilisation and full return of strength to focus on returning to normal or sporting activity.

Comparing Extracorporeal Shock Wave Therapy And Prolotherapy For Tennis Elbow

Injections for tennis elbow

A June 2022 paper in the publication: Arthroscopy: The Journal of Arthroscopic & Related Surgery examined the effectiveness of extracorporeal shock wave therapy and injection therapies by synthesizing direct and indirect evidence for all pairs of competing therapies for lateral epicondylitis. To do this the researchers collected previously published studies assessing the effect of ESWT or injection therapies. The primary outcome was short-term and medium-term pain, while the secondary outcomes were grip strength and patient-reported outcome measures.

Extracorporeal shock wave therapy was then compared to five different injection therapies, including corticosteroids, autologous whole blood, platelet-rich plasma , botulinum toxin A, and dextrose prolotherapy.

  • Dextrose prolotherapy, ESWT, PRP, and botulinum toxin A outperformed placebo for short-term pain relief
  • Dextrose prolotherapy was ranked as the most optimal short-term and medium-term pain reliever
  • ESWT was ranked as the most optimal short-term and medium-term grip strength recovery.
  • Corticosteroids were not recommended.

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Why Has Nothing Helped Have You Had The Right Problem Treated With An Appropriate Treatment If You Have Chronic Pain Probably Not

Lets 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?

No therapeutic option seems clearly superior to the other.

Here are the findings published in an August 2020 study where the researchers had to conclude that: No Therapeutic Option Seems Clearly Superior to the Other.

Here are the learning points:

  • Fifty patients were enrolled in the study.
  • The average age of patients was about 45 years old.
  • Almost 3 out of 4 patients were female.
  • Half of the patients were active and the majority of them worked in a traditional office environment.
  • The right elbow was most affected .
  • The average duration of symptoms was just about 15 months.
  • Clinical examination showed tendon damage in the lateral epicondyle in 96% of cases.
  • All patients received painkillers
  • 84% of patients received non-steroidal anti-inflammatory drugs,
  • only 8 patients received corticosteroid injections.
  • One patient underwent surgery after therapeutic failure.
  • Ninety-two percent of patients were scheduled for physical therapy.
  • How successful were the non-steroidal anti-inflammatory drugs? The cortisone injections? Physical therapy?

    Short Term Gain Vs Long Term Harm

    The research shows that steroid injections better pain relief for the first 6 weeks compared to other treatments.

    The problem is that when you look at the same patients 3, 6 and 12 months later, the ones whove had steroid injections are actually worse off than the ones whove not had steroid injections.

    So steroid injections decrease your initial pain from your tennis elbow more quickly, but after 6 weeks it then seems to slow your recovery down. Other treatments like physiotherapy exercises, shockwave or injections like PRP may not reduce your pain as quickly, but they seem to allow your injury to heal better in the long run.

    There is also evidence that suggests that people who have more than one corticosteroid injection for their tennis elbow are more likely to progress to having surgery.

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    Cortisone Shots: Bottom Line

    As welcome as the injections are, Vicenzino says skipping the injections appear to be a reasonable option when you consider recovery rates and the chance of recurrence.

    “If we look at delaying recovery and recurrence rates, then there is solid evidence, especially for the tennis elbow steroid injections, that they will delay recovery and there will be a high probability of recurrences beyond that if the patient had just adopted a wait-and-see policy .”

    While the new non-steroid injections are becoming more popular, Vicenzino says many questions remain about them.

    One of them, sodium hyaluronate, ”demonstrated vastly superior results across all time points,” he says, and he believes that one should be further studied.

    Whatever the injection that may be used, he says, it’s not enough. The tendon needs to be ”mechanically stimulated” through exercise or physical therapy, he says, to address the disruption in collagen and at a cellular level that occurs with the tendon injury.

    Researchers Say A Lifetime Of Braces Sleeves Tapes And Elbow Bands May Be A Waste Of Money And Prevent You From Getting Treatments That May Help

    Tennis Elbow and (avoiding) Cortisone Injections

    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, 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,

    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

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    Learn To Treat And Heal Your Own Tennis Elbow Or Golfer’s Elbow At Home With This Video Program

    You’ll get instant access to a complete VIDEO program designed by a professional therapist to help you take charge and break your vicious cycle of pain and frustration!…

    I’ll be your personal tutor guiding you through step-by-step video lessons, where you’ll get the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home.

    How Prp Injections Work

    We draw patient blood and extract platelets from that blood for the PRP injection, says Dr. Scofield. Everyones body is different, so each patient is going to have a slightly different PRP. For example, some people have over 300,000 platelets per microliter. Others have 120,000 platelets per microliter. That variation is normal, and has an impact on the effectiveness of the treatment. Age is another factor. If youre young, you probably have more robust platelets than older patients. Because there are so many factors at play, I encourage patients to discuss all of their treatment options with a regenerative medicine specialist.

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    Steroid Injection For Tennis Elbow

    If pain persists and no other treatments are effective, steroid injections for tennis elbow may be required. Under the direction of a real-time ultrasound scan of tennis elbow, a mixture of local anaesthesia and corticosteroid is given. This ensures that the damaged area is precisely targeted. Ultrasound guided injections for tennis elbow are more accurate and effective at reducing pain than non-guided injections, according to research.

    Shockwave Therapy For Tennis Elbow

    Tennis Elbow Cortisone Shot

    Shockwave therapy is a non-invasive treatment, where high-energy shockwaves are passed through the skin to help relieve pain and promote movement in the affected area.

    The number of sessions you will need depends on the severity of your pain. You may have a local anaesthetic to reduce any pain or discomfort during the procedure.

    Shockwave therapy, while safe, can cause minor side effects including bruising and reddening of the skin in the area being treated.

    Research shows that shockwave therapy can help improve the pain of tennis elbow in some cases. However, it may not work in all cases, and further research is needed.

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    Some Background On Tennis Elbow

    Tennis elbow can be quite debilitating, whether you are actually a tennis player or you developed it otherwise. In fact, the vast majority of those with “tennis elbow” did not get it from playing tennis. But for those that are tennis players, somewhere around50% will develop Tennis Elbowin their life.

    If you would like to learn more about what Tennis Elbow is, readthis blog article.

    The aim here is to help guide those that are getting fed up with the recovery process and want aquick fix. You should know what you’re asking for.

    What Is Tennis Elbow

    Tennis elbow is a painful condition caused by overuse of the extensor muscles in your arm and forearm, particularly where the tendons attach to rounded projections of bone on the outside or lateral aspect of the elbow. The muscles you use to grip, twist, and carry objects with your hand all attach to the lateral epicondyle at the elbow. Thats why a movement of the wrist or hand can actually cause pain in the elbow.

    Prolonged use of the wrist and hand, such as when using a computer or operating machinery and, of course, playing tennis with an improper grip or technique can lead to tennis elbow. It can happen to athletes, non-athletes, children, and adults. It occurs more often in men than women, and most commonly affects people between the ages of 30 and 50.

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    Does Cortisone Shot For Tennis Elbow Actually Work

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    Which Is Better A Counterforce Brace Or Physical Therapy


    A July 2020 study in the journal Prosthetics and Orthotics International examined the popular counterforce brace in people with problems of lateral elbow tendinopathy. In this study, the researchers explored the outcomes of seventeen studies with a total of 1145 participants.


    • A small improvement in pain over the short term and a moderate-to-large improvement in pain in subjects 45 years or younger in favor of the brace versus physiotherapy interventions were found.
    • In contrast, long-term physiotherapy interventions, wrist splints, and laser therapy had better effects on pain improvement versus the brace.

    For some people, these treatments may be very effective. We usually do not see the people for whom these treatments worked. We see the people for whom these treatments did not provide long-term pain reduction and improved functionality and for whom surgery is now being recommended.

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