Tennis elbow is a painful condition affecting the outer part of the elbow joint. It is common in athletes and affects ordinary people who perform repetitive elbow activities. Generally, a tennis elbow injection of cortisone is not always the best first option. So, when should you consider an injection for tennis elbow?

Tennis elbow symptoms 

The most common symptoms of tennis elbow include:

  • aching pain on the outside of the elbow made worse by lifting or playing sport
  • pain can move to the forearm and sometimes into the hand
  • weakness in the strength of the arm and hand

Pain can occur gradually or suddenly. Moreover, intensity can range from mild to severe and debilitating.

Diagnosis of tennis elbow

A thorough medical history and examination are often needed to confirm the diagnosis and rule out other causes.

Besides asking about the pain, your doctor will also assess risk factors such as your activity or medical problems such as diabetes or rheumatoid arthritis.

Often, there will be tenderness on the outside of the elbow and pain with resisted activities such as wrist extension.

Tests for tennis elbow

Although tennis elbow is easy to diagnose, we sometimes use tests to help us make sure we get the correct diagnosis.

Ultrasound or MRI will show degenerative changes in the collagen fibres, confirming tennis elbow. Also, imaging can rule out other causes, including ligament damage, elbow joint degeneration, and a pinched nerve at the elbow – also called radial tunnel syndrome.

What is the most effective treatment for tennis elbow? 

Generally, tennis elbow will settle with an exercise program supervised by a therapist. Examples of simple treatments include exercises to strengthen the forearm and elbow and stretching the muscles and nerves in the forearm. Also, strengthening the shoulder, upper back, and lower legs is essential to correct weakness in other body parts.

A tennis elbow brace can reduce pain and improve physical therapy outcomes.

Most cases improve after 6-12 months. However, we know that a few people do not settle for exercise and need other treatments.

Does a tennis elbow injection of cortisone help?

cortisone injection elbow

Previously, cortisone injections for elbow have been given to patients with troublesome pain. However, recent studies suggest that cortisone may not be good for patients with tennis elbow. In a recent paper written by Dr. Masci, there is good evidence to suggest that cortisone injeciton for elbow is not great. While patients get short-term relief of up to 6 weeks with cortisone, they often worsen after three months. Also, we know that many people develop a re-flare after a cortisone injection. Overall, it would seem that a cortisone injection for this condition sets patients back rather than forwards.

If cortisone injeciton is not suitable for tennis elbow, what are the other options?

Fortunately, other treatments might help.

There is some evidence that shockwave can help. Shockwave produces soundwaves that cause remodeling of the tendon. Evidence is mixed regarding effectiveness in tennis elbow. Usually, 3- 5 sessions are recommended.

Glyceryl trinitrate patches for tennis elbow

Recent studies suggest that using a GTN patch can improve pain.  We place these patches on the skin directly on top of the sore tennis elbow tendon. Patches should be put on in the morning and taken off at night. Side effects include headaches and skin rash. Generally, we suggest a 2-3 months trial in connection with exercise therapy.

PRP injection for tennis elbow 

Platelet-rich plasma injections

Other injection options such as dextrose, PRP (platelet-rich plasma), or needle tenotomy may help.

In a recent study that compared injection therapy in tennis elbow, needle tenotomy was found to be the most effective in the short term.

Other studies have shown that PRP injections are better than cortisone. We obtain PRP from whole blood. The blood is spun in a centrifuge, and the plasma (containing high amounts of platelets) is separated from the red cells and injected into the degenerative tendons. A recent review comparing PRP with cortisone found PRP a better option for long-term pain relief. 

Overall, injections should be done under ultrasound guidance to improve accuracy and avoid damage to other essential structures in the elbow.

Finally, you should avoid surgery as studies suggest operations are not effective. For example, a recent study showed that surgery was no better than sham surgery in tennis elbow.

tennis elbow cortisone injection

For troublesome tennis elbow, could there be another cause? 

Possibly. Some cases of persistent tennis elbow could be caused by elbow instability. Sometimes, instability occurs after a fall that leads to a ligament rupture. This ligament rupture leads to subtle instability and persistent lateral elbow pain.

Also, Golfer’s elbow is a similar tendon injury but occurs on the inside of the elbow.

Other causes of elbow pain that can mimic tennis elbow include elbow arthritis, elbow biceps tendonitis, and radial tunnel syndrome.

Radial tunnel syndrome vs. tennis elbow: how can you tell the difference? 

Radial tunnel syndrome is the trapping of a branch at the radial nerve. This trapping can cause symptoms similar to tennis elbow.

Generally, the radial nerve moves freely through the muscles outside the elbow. However, repetitive lifting or rotation of the elbow can cause nerve trapping, leading to elbow and forearm pain.

Usually, we diagnose radial tunnel syndrome by carefully examining the elbow. However, the exact site of tenderness is different. Also, the muscles of the top part of the forearm are weaker. Finally, ultrasound can give a clue by showing thickening of the nerve suggesting a pinched nerve.

Final word from Sportdoctorlondon about tennis elbow 

Generally, we tell people with tennis elbow to be patient. Most cases will settle with simple treatments such as exercise. However, we first use shockwave or GTN patches in more complex cases, followed by injections. We suggest you avoid a cortisone injection elbow. Our preferred injection option is needle tenotomy, followed by PRP. in almost all cases. You should avoid a cortisone injection.

Other elbow and hand conditions:

Dr. Masci is a specialist sport doctor in London. 

He specialises in muscle, tendon and joint injuries.

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About Dr Masci