Lateral Epicondylitis (Tennis Elbow) - Why There's Absolutely No Need for Surgery
POSTED ON IN Elbow BY Christopher Centeno
A research paper came across my desk in December showing just how far we've come in the last few years with platelet-rich plasma. It focused on tennis elbow and the recovery processes for 2 different surgical procedures. The fact that it read like some medieval torture tome was vindication of the fast advances being made in regenerative medicine.
What is Lateral Epicondylitis, or Tennis Elbow?
The medical term for tennis elbow is lateral epicondylitis. The problem with this term is that it suggests swelling around the epicondyle, which is the bony bump you can feel on the outside of the elbow where many forearm muscles attach at their tendons. Why is this definition an issue? Because numerous studies show that there's really very little inflammation and that the problem is caused by the tendon becoming degenerated (read: "torn up"). So a more accurate term would be epicondylopathy.
Patients have a hard time using these forearm muscles in severe cases of tennis elbow, so much so that even opening a door or shaking someone's hand can become very painful. Regrettably, modern orthopedics has been fairly agnostic as to what causes the tendon to become painful in this way. Most physicians consider the issue to be due to overuse, but we really don't see that very much outside of occupational settings where someone is performing a repetitive motion for thousands of times a day (like a factory line worker). More commonly, we see middle-aged people who have suddenly developed the issue. In our experience, almost all of them have some sort of low-level nerve issue in the neck that causes the forearm muscles to tug at their tendons where they attach to the epicondyle–regardless of whether or not they're experiencing neck pain. This sometimes means that the neck will need to be treated concurrently with the elbow.
Steroid Shots are Bad News
Lateral epicondylitis is first treated with physical therapy and if that fails, the next step is usually a steroid shot. However, recent research has shown this to be a short-term fix that makes the problem worse in the long run. More recently, platelet-rich plasma (PRP) injections have been shown to be more effective than steroids.
In fact, PRP research has shown it to be so effective for this condition that there is little question that this is the definitive treatment for most patients.
Surgery Is NOT the Answer for Tennis Elbow
The research study on orthopedic surgery mentioned above seems barbaric when compared to a precise ultrasound-guided injection of PRP. Here the authors compare tenotomy to debridement. Tenotomy is cutting the tendon or scoring it with multiple cuts while debridement is "cleaning up" the area by removing degenerated tissue. The study shows no significant differences between the 2 tennis elbow surgery groups, including no difference in recovery times–but I would argue that there is no rationale for either one of these surgeries in 99.99% of the patients. Why?
Because we've never met a tennis elbow patient who couldn't be successfully treated with PRP, and in the rare case this therapy doesn't work, we've successfully used stem cell injections instead. But PRP failures are so rare that we've only had to turn to a more powerful stem cell injection in just a handful of patients.
Lateral epicondylitis is a slam dunk indication for PRP. So much so that there is no clinical rationale for a physician to consider open surgery for tennis elbow. Why are surgeries still being prescribed when we have randomized, controlled trials showing that a much less invasive PRP shot will solve the problem? Though surgery is usually covered by insurance and PRP isn't, it's likely that this will change in the near future. Even if you have insurance, PRP is likely the more affordable out-of-pocket solution when compared to surgery. Don't put yourself at unnecessary risk by choosing to undergo an invasive surgery when research shows that a simple shot has the power to heal your tennis elbow.
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