Tennis Elbow Injections & Surgery – Do they Work?

When people who have a bad tennis elbow, something as simple as trying even grip a cup can cause a lot of pain. While many people advocate tennis elbow injections or surgery, there are other options.

Tennis player

In this article, we’ll look at:

What Causes Tennis Elbow?

The tendon that becomes damaged in tennis elbow is the tendon that joins extensor carpi radialis muscle to the humerus. This tendon joins into the the side of the elbow (lateral epicondyle,) and that’s where the tendon becomes damaged.

So whenever you use this muscle to grip and lift, this stresses the tendon and causes pain.

Extensor carpi radialis
Extensor Carpi Radialis Muscle & Tendon

The majority of people who have tennis elbow don’t play tennis, they’re doing some other task which requires them to lift and rotate their wrist.

Tendonitis vs Tendinosus

The thing about treating tendons is that it’s difficult. When you look at them in anatomy studies, tendons are shiny white because they don’t have a good blood supply. (Unlike muscles, which are red and have a great blood supply.)

They do a lot of work, acting as restraining ropes for your joints and muscles. They have to stretch and load up again and again, with very little blood supply.

When they do become damaged, this is a real difficulty. This is especially true when you look at that process of moving from -itis, which is inflammation, into healing.

If you have a tear in your muscle, which has a great blood supply, you have a lot of inflammation and then the muscle heals. It heals beautifully and there’s no degeneration.

But tendons typically move from a tendinitis to a tendonosis (or degeneration.) This means that it hasn’t healed completely.

If you want to give your tendon the best chance of healing, you need to give it a large stretch of time when it’s no longer being stressed.

Relative Rest vs Absolute Rest

The best way to rest a tendon is first with absolute rest, then with relative rest. Every time the tendon is overstressed, it will form new little tears. If you don’t move the tendon at all in the beginning you have absolute rest. The tendon is then able to turn on its healing and all the little areas that have been torn will start laying new collagen fibres in those areas.

As time goes on, (and this is usually after a few weeks,) you then can start to stress the tendon but you need stay underneath the level of tension that would cause micro-tears. Over six to eight to 12 weeks of rest the tendon will improve dramatically.

Tennis Elbow Surgery

Surgery for tennis elbow is a controversial topic. The cynic in me says that the main reason tennis elbow surgery works is that it forces you to stop using the tendon and gives it time to heal.

There are many different types of surgery for tennis elbow, golfer’s elbow and tendinitis conditions.

For most of them, what the surgeon is essentially doing is stimulating healing in your tendon. The usual way to do this is by either scraping or roughing up the tendon to increase blood flow into the area.

Tendonitis Elbow Surgery: Recovery Time

Then, for weeks after this surgery, you rest. You have your arm in a sling, and you do not move your arm. After a few weeks, you slowly start to increase the movement and stress on the tendon.

This rest is a huge aid to your tendon healing. The evidence is still out as to whether the rest is the most important part.

It does mean people with surgery give their tendons the proper amount of rest. Also, the surgery is slightly destructive, and will make your arm more painful to move for quite some time, further promoting rest.

Rehab Exercises: Concentric and Eccentric Loading of Tendons

You can load a tendon in two ways. There is concentric loading. And example of this is doing a bicep curl – lifting the weight up towards your shoulder. The tendon is being loaded up while the muscle shortens. Concentric loading tends to be bad for tendons.

The other kind of loading is eccentric. This is what happens when the tendon is being loaded and the muscle is being lengthened. For example, letting a weight back down – your arm is straightening while you’re carrying a weight. It turns out that eccentric loading is helpful for tendons.

The Alfredson exercises are eccentric loading of the tendon. Alfredson exercises for this tendon are that you support your arm on the edge of a desk. This isolates the wrist. You put your hand around a small weight, just 500 grams. You lift your arm and the weight up with your other hand, to avoid doing any concentric contraction and causing pain and damage to your tendon.

Then you take your hand away and slowly drop your wrist down. When you do this, you’re stressing the tendon, but lengthening the muscle. You’re doing an eccentric contraction, which is known to help strengthen tendons.

You do a set of 10, then rest, then do another set of ten. Do 2-3 sets of ten twice a day, morning and night.

How to Continue to Play Tennis with a Tennis Elbow

Let’s look at tennis player with pain in their elbow, and see why tendonitis happens. Every time a player grips their racket and applies force, the tendon that causes tennis elbow is being stressed.

Tennis shot

As you serve, and play backhand particularly, you’re gripping the tennis racket and rotating and lifting your wrist. These are all the movements that set off the pain of an overworked tendon.

There are several other workarounds that can help you continue to play tennis. They all involve changing the forces that act on your extensor carpi radialis tendon.

Here are some workarounds, and you can use some, or all of them:

  1. Get a bigger grip on your racket. The larger the area to grip, the less this tendon gets stressed.
  2. Change your tennis style so that you don’t have as much pulling up (extension) and rotation when you play your backhand. (Work with a coach on this one if possible.)
  3. Move from a single to a double handed backhand, which will take a lot of the stress off the tendon
  4. Use a tennis elbow splint (see below)

Elbow Strap for Tennis Elbow

An elbow strap or splint for tennis elbow is a fascinating and very clever thing. It acts as a counter-force brace.

Here’s how it works. As you squeeze, lift your arm and rotate very slightly, you create a very precise pattern of stress in the tendon, causing pain. The counter-force brace is a thick band which you tighten and wrap around your forearm, below the tendon.

You tighten it just enough to not cut off circulation. It should be tight enough so that when you do the movement causing pain, the force going through the strap changes the angle of the stress in your tendon.

It reduces the amount of stress on the tendon by spreading and transferring it into your forearm. This is a surprisingly effective way to reduce stress on the tendon with concentric contraction. This can also aid healing.

Tennis Elbow Injections: Platelet Rich Plasma

How else can you improve the ability of the tendon to heal?

When the surgeon does surgery and roughens up the tendon, essentially what’s happening is increased blood flow into the area.

When I was doing general practice, I would do something called an autologous blood injection. I would take blood out of somebody’s forearm, let it start to clot, then re-injected around the tendon.

This works because the main part of the healing came from the platelets in your blood. The platelets, as they start to activate, send a chemotactic message out.

This message says: “We’ve got major problems, send in the troops into heal this area.” This is what happens after you injure yourself.

If you cut yourself, you start bleeding, but quite quickly the blood forms a clot. Very soon after that, the whole area becomes red and swollen. This is because the platelets’ chemotactic message has turned on inflammation.

Because there’s a not much blood supply to tendons, you get a limited healing response. Therefore, if you take partially clotted blood and inject it around the tendon, this fills the little spaces where they are tendon tears. The partially clotted blood then speeds up healing.

This practice has now been refined. Doctors spin down the blood in a centrifuge. They inject just the platelets and the plasma and in and around the tendon. This centrifuged blood has a higher concentration of platelets.

This type of injection is called PRP – Platelet Rich Plasma. The reason this practice is so safe is that you’re using the person’s own blood, not a foreign substance.

The other reason why it’s often effective is that you’re increasing your body’s natural healing ability, so you get healing with very little risk of side effects.

Tennis Elbow Injection #2: Cortisone

Cortisone injections are now done more than autologous blood and platelet rich plasma. The reason to use cortisone is that it’s fast.

You can have somebody come in with an incredibly painful tendon, you do a cortisone injection around the tendon and a week later that person is your best friend. The cortisone has damped down the inflammation in the area very quickly.

However, cortisone injections are a symptomatic treatment. They’re a treatment that makes the elbow feel much better.

That’s the good news.

Pros and Cons of Cortisone Injections

The bad news is cortisone injections don’t do much for the underlying cause of pain. It’s important to understand that the way you heal is with inflammation. If you do an injection that’s going to damp down inflammation, you’re going to have less pain, but you’re also going to have less healing.

In the long run, if you use cortisone, this can help with extremely sore tendons. (And tendons can get really sore.) A little bit of cortisone in the beginning to quieten things down can be really helpful.

But the traditional use of a big doses of cortisone around inflamed tendons has issues. At the end of six weeks the cortisone effect is reducing. By eight weeks, the pain is back. And by 12 weeks you’re back to square one.

Except you’re worse. You’re back to minus square one because the tendon hasn’t healed, and there’s often more degeneration, because you’ve been using a tendon that really needed to rest.

Other Dangers of Cortisone Injections

The other concern is when you put a fine needle into the area around the tendon, you can easily penetrate the tendon itself. If you inject cortisone into a tendon, you weaken the tendon significantly.

There’ve been many, many stories about people who’ve had large amounts of cortisone injected around the Achilles tendon. Later on the Achilles tendon has ruptured, because too much cortisone reduces the structural integrity of the tendon itself.

Also, if the tendon is no longer hurting (but not healed) people will overuse the tendon. This further slows down healing and causes micro-tears in the tendon, and the degeneration will be more significant.

So, while small doses of cortisone can be useful for short term pain relief, they’re not your best option for long term healing.

Trigger Points and Tennis Elbow

When a tendon is damaged, it’s a long, slow process to heal. Because it’s painful for a long time, the nerves to that area often become sensitized.

This will then send a message to the muscles to protect the area. When you have a damaged tendon, the muscle that supplies that tendon will often go into a protective spasm. It will get very active and tender trigger points.

Trigger points are a neuromuscular response as part of sensitization. They’re small micro-spasms in the muscle which cause pain and stiffness.

It’s very, very common for trigger points to be turned on in muscles where there is a tendonitis. It’s your brain’s way of saying “use this less.”

The other factor is that when a tendon is damaged, you start to use the muscle in a an abnormal way to avoid pain. This changes mechanics of use and can also turn on trigger points. This means you have not only pain from the tendon, but you also have pain from the trigger points.

biceps trigger points
Biceps Trigger Points

The pain zone arising from particular trigger points can extend other the tendon that is inflamed or damaged. Part of the pain that you get when you do specific movement (like gripping and twisting) is from the tendon.

But part of it is often from trigger points in the forearm and upper arm muscles.

Healing will occur with giving the tendon a chance to have a rest. Sometimes though, everything can heal, but the trigger points remain. So for full treatment, you need to to look for trigger points in the muscles and treat them as well.

Extensor Carpi Radialis Trigger Points
Extensor Carpi Radialis Trigger Points

If you have tennis elbow, there will be exquisite tenderness just where the elbow tendon comes in. But if you follow the muscle down, you’ll find trigger points in the muscles of the forearm. When you press on them, the pain goes up into the elbow.

Treating these trigger points will improve some of your pain, and the function of the muscle will improve. Finally, active trigger points cause tightness in the muscle. If the muscles are very tight this increases tension in the tendon, and causes more stress and pain. This is a another way treating triggers gives good pain relief when you have tennis elbow.

If you want to find out more on treating triggers, here’s where to get with a free trigger point manual >>>