How Common is Tennis Elbow?
Chronic pain at the common extensor tendon of the lateral elbow is the most common form of chronic elbow pain and effects between one and three percent of the population.(1) So called “tennis elbow” is essentially an overuse injury, occurring from repetitive gripping, forced extension of the wrist, such as which occurs when striking a tennis ball with an extended elbow (backhand). However, the injury is certainly not limited to playing tennis as it occurs with many other repetitive motions like typing and hammering and tends to affect mostly middle-aged adults.
What is Tennis Elbow or Lateral Epicondylalgia?
Both microscopic and ultrasound examinations demonstrate a constellation of decreased blood flow, connective tissue degeneration, and unusual tendon stress patterns, all occurring at the origin of the extensor carpi radialis brevis (common extensor tendon). It originates from the lateral epicondyle of the elbow and inserts at the base of the third metacarpal on the back of the wrist. Its action is to extend and laterally deviate the wrist. Researchers also find calcification and scarring at the location.(2) What the condition lacks is evidence of long-term inflammation, therefore the term epicondylitis (inflammation is denoted by the suffix [itis]) has fallen out of favor. This fact should discourage the routine prescribing of non-steroidal anti-inflammatories and corticosteroids.
Its Personal Impact
Lateral epicondylalgia or epicondylosis (with the suffix [algia] and [osis] denoting pain and deterioration respectively) often produces a significant social and economic impact on individuals. An individual can lose several days and even weeks of work leading to temporary disability. Equally distressing is the fact that the condition interferes with activities that individuals find meaning and enjoyment in such as playing tennis, weightlifting, or other hobbies. Although the condition is self-limited in most, resolution typically takes long, sometimes up to a year and a half. For much of this time individuals are forced to make life altering accommodations that can impact financial earnings and enjoyment.
Conventional Treatment No Better than Placebo
There is no specifically agreed upon conventional therapy found to be more effective than any other. Halting the insinuating activity, splinting, non-steroidal anti-inflammatory medications, and waiting is perhaps the most common recommendation. However, corticosteroid injections, occupational or physical therapy, laser therapy, iontophoresis or phonophoresis are also prescribed.(3) Corticosteroids are effective for short term pain relief and are the most common type of injection for lateral epicondylalgia. However, long term outcomes show they are no more effective than placebo.(4,5) Unfortunately, it is well established that corticosteroids ultimately contribute to further connective tissue degeneration. According to conventional notion, nothing seems to outperform just waiting. Despite a poorly designed study of autologous blood and platelet-rich plasma injections, the lack of effective conventional modalities for lateral epicondylalgia begs for turning to a regenerative paradigm.
Faulty Studies, Erroneous Conclusions
A group of researchers randomized 119 participants to receive a single injection of either their own blood, platelet-rich plasma (PRP), or saline.(6) The participants were reevaluated for improvements in pain and grip strength at a duration of one year.(6) The authors site that no one injection outperformed another and conclude that neither PRP nor autologous blood reduce pain or improve function in lateral epicondylalgia.(6) Ignoring several oversights of the study, other authors cite this same study to dissuade the use of these regenerative therapies for lateral epicondylalgia.
The oversights include that the study did not contain a true control group since even injecting saline into connective tissue, and for that matter even dry needling is therapeutic and regenerative. A proper control would include a group that received no injections, although the study would no longer be blinded. Additionally, each participant received only one treatment. It is well established that successful regenerative treatment requires roughly three to five treatments. Finally, during the treatment phase of this study, the participants received only one single injection. During Prolotherapy of the lateral elbow, as with any other region of the body, injections are scattered throughout the damaged area as opposed to one single injection. Drawing the conclusion that these regenerative injections do not work is simply the result of a poorly designed trial. However, properly designed studies shed light on the true benefits of Prolotherapy for lateral epicondylalgia.
Proven Benefits of Prolotherapy for Lateral Epicondylalgia
A group of researchers reviewed eight randomly controlled trials which evaluated the response to Prolotherapy for lateral epicondylosis on pain and functioning and compared the outcome to other active treatments.(7) The studies had 354 participants. The researchers conclude that dextrose prolotherapy was superior to other treatments for decreasing pain and improving functioning.(7) In another study, Scapone and company set out to determine if Prolotherapy injections improve pain, grip strength, and extension strength in lateral epichondylosis. (8) Twenty-four adults were treated in this double blind, randomized trial. The participants each received three treatments which consisted of three injections at three different anatomic locations of the lateral elbow. The three treatments were administered four weeks apart. The researchers found that the individuals who received Prolotherapy reported significantly improved pain scores compared to controls by week sixteen.(8) The Prolotherapy subjects reported improved grip and extension strength as well. These benefits were impressively maintained at one year.
Summary
Tennis elbow or chronic pain at the lateral elbow from overuse is the most common cause of chronic elbow pain. The term lateral epicondylitis has fallen out of favor since the condition is not characterized by inflammation. Epicondylalgia or epicondylosis are more accurate terms. There is no effective and agreed upon conventional therapy that significantly improves the outcome of epicondylalgia and although it is often self-limited, it can take one and a half years to resolve. Lateral epicondylalgia can therefore profoundly impact an individual, resulting in lost workdays, disability, and the inability to participate in hobbies and other meaningful activities. Because Prolotherapy promotes the regeneration of connective tissue, it may be the most sensible therapy for lateral epicondylalgia. Studies show that Prolotherapy compared to other active therapies significantly improves grip strength, extension strength, and function in those with the condition.
Dr. Ayo Bankole received advanced training in Prolotherapy and is a member of the American Osteopathic Association of Prolotherapy Regenerative Medicine, the California Association of Naturopathic Doctors www.calnd.org, and the American College for the Advancement of Medicine www.acam.org. He uses Prolotherapy to treat painful conditions of the back, hips, knees, feet, shoulders, elbows, and hands.
To learn if Prolotherapy is right for you call 909-981-9200 for a free DISCOVERY CALL.
References
- Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. J Hand Surg Am . 2007;32:1271-1279.
- Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309:461-469.
- Sims SE, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (N Y). 2014;9:419-446.
- Edwards SG, Calandurccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg Am. 2003;28:272-278.
- Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid and saline injection in the treatment of lateral epicondylitis; a prospective, randomized, controlled multicenter study. J Hand Surg Am. 2011;36:1269-1272.
- Linnanmäki L, Kanto K, Karjalainen T, Leppänen OV, Lehtinen J. Platelet-rich plasma or autologous blood do not reduce Pain or improve function in patients with lateral epicondylitis: a randomized controlled trial
- Zhu M, Rabago D, Chi-Ho Chung V, Reeves KD, Yeung-Shan Wong S, Wing-Shan Sit R. Effects of hypertonic dextrose injection (prolotherapy) in lateral elbow tendinosis: a systematic review and meta-analysis. Arch Phys Med Rehabil.2022 Nov;103(11):2209-2218.
- Scarpone M, Rabago D, Zgierska A, Arbogest J, Snell E. The efficacy of prolotherapy for lateral epicondylosis: A pilot study. Clin J Sport Med. 2008 May; 18(3): 248–254.