Tennis Elbow Lateral Epicondylitis Therapy

Tennis Elbow Injection

Tennis Elbow Lateral Epicondylosis is not an inflammatory condition but is now considered to be microscopic tearing with formation of scar tissue in the attachment of the extensor carpi radialis brevis (ECRB) muscle at the outside of the elbow. (See Tennis Elbow Injury – What is Tennis Elbow? for more details)
This microtearing and repair response can lead to full-blown tearing and structural failure of the origin of the ECRB muscle. The picture opposite is taken from an arthroscopic surgery to the elbow showing the radio-humeral joint and the damaged ECRB tendon. (www.elbowclub.com)

Tennis Elbow Lateral Epicondylitis Therapy – Should I have an elbow injection?

If recommended by your specialist YES -
BUT in my opinion only after

1. you can fully straighten your elbow – see Elbow Injuries -Can You Straighten Your Elbow
2. you have a good stretch in your extensor muscles – see Tennis Elbow Lateral Epicondylitis Exercises – How to Stretch
3. you have tried a few weeks of a structured rehab program – at least these

AND you still have pain!

Injections for Tennis Elbow

• Local Anaesthetic
• Corticosteroid
• Autologous Blood
• Botulinum Toxin

1. Local Anaesthetic Injection

Your Doctor or specialist may inject local anaesthetic into your elbow. This is purely diagnostic and is used to decide if the common extensor origin (where the tendons attach to the humerus) is the sole cause of your pain or whether there are other factors involved.

2. Corticosteroid Injection

These drugs include Triamcinalone (intermediate acting), Dexamethasone and Methylprednisalone (long acting). Their mode of action includes a reduction of the inflammatory reaction of the small blood vessels and restricts the accumulation of white blood cells and the release other inflammatory triggers.

However, as I said in the opening paragraph, Tennis Elbow is not considered to be an inflammatory process!!

BUT these injections are clinically proven to be effective!!

There are either other chemical effects taking place with the drug or the reason is physical.
The physical factors can be quite significant. Good injection technique involves placing multiple droplets around the tendon – I was taught to think of injecting droplets around a sugar cube and trying to get the corticosteroid on as many surfaces as I could.
This obviously has a mechanical affect on the scar tissue and the surrounding tissues with multiple to-ing and fro-ing of the cutting edge of the needle in these tissues.
If you are considering an injection as a patient – let me reassure you (before you panic) that this is all done through one or perhaps two holes in the skin – it is all the same injection not many!!

The corticosteroid generally will not be injected into the body of the tendon itself as this is thought to contribute to possible rupture of the tendon.

If you are a Doctor or Pharmacologist and can help explain why anti-inflammatory injections work with a non-inflammatory condition then please leave a comment below or please E-Mail me at

and I will include your explanation here.

3. Autologous Blood Injection

Blood is a rich source of growth factors that can stimulate an influx of cells that repair damaged tendon (fibrocytes) and help growth of new blood vessels. These properties are able to stimulate a healing response in chronic degeneration of a tendon (tendonosis).
The little blood is taken from one of your veins just like a routine blood test and this is then injected directly into the tendon at the elbow. The results of the studies I have seen are impressive – the patients in the studies had problems for a long time and had tried physical therapy, bracing and corticosteroid injections with no success.
Picture from orthosupersite.com
A study in rabbits showed that injecting the blood directly into the tendon had no damaging effect on the structure of the tendon unlike corticosteroids so it is a safe procedure.

4. Botulinum Toxin Injection

Injection of Botox into the muscles has been the subject of a few tests recently. One study in China showed success while others in the UK have not. The Botulinum toxin paralyses the muscle for a period of a few months which produces some weakness which may be an issue.
“One possible explanation is that the paralytic effect of botulinum toxin forces the extensor group of muscles to rest for a period of two to four months, thereby allowing the tendon fibers close to the lateral epicondyle time to repair,” reports the Chinese study.

Conclusion

Both corticosteroid and autologous blood injections have been shown to be effective. Corticosteroid injections at the lateral epicondyle have been shown to significantly decrease pain scores in the early post-injection period. Autologous blood injections for lateral epicondylitis were described in 2003 and showed encouraging pain relief in two thirds of patients treated.

My advice is

YES – BUT only after

1. you can fully straighten your elbow – see Elbow Injuries – Can You Straighten Your Elbow
2. you have a good stretch in your extensor muscles – see Tennis Elbow Lateral Epicondylitis Exercises – How to Stretch
3. you have tried a few weeks of a structured rehab program – Tennis Elbow Exercises

Try the conservative management of your problem first.

Please leave a comment below

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Tennis Elbow Injury

It is thought that an Acute Tennis Elbow injury consists of microscopic tears in the attachment of the Extensor Carpi Radialis Brevis muscle to the bone.
This tearing results in the stimulation of the repair process which increases collagen production and new blood vessel growth.
This increase in blood vessels may explain the Tennis Elbow symptoms as well as a local increase in temperature.

Tennis Elbow Symptoms

In the past it was thought that Tennis Elbow Symptoms were a result of a local inflammatory reaction. However it is now more commonly thought that even acute tendinitis is due to a sudden increase in stress which causes further aggravation of an already degenerated area of tendon.
The thinking is that the elbow symptoms are produced by the new blood vessels and their nerves at the repair site rather than from a local inflammatory response.
That is why it is considered more correct to name Tennis Elbow Injury as Lateral Epicondylosis

Lateral Epicondylitis / Lateral Epicondylosis

These are the medical names that you may see for Tennis Elbow.
Epicondylitis – the “itis” indicates that there is acute inflammation taking place (think of Appendicitis).
Epicondylosis – the “osis” refers to a more chronic and degenerative condition.

Both these terms refer to the Lateral Epicondyle which is a raised area of bone on the upper arm bone or Humerus. If you look at the diagram of the back of the right arm opposite you can see that the lower end of the Humerus widens out to form the upper portion of the Elbow joint.
There are two epicondyles one on the inside (medial – labelled A) and one on the outside (lateral – B).

The lateral epicondyle is where the Tennis Elbow muscles (Extensor Carpi Radialis Brevis, Extensor Digitorum and possibly Supinator) attach.
The Extensor Carpi Radialis Brevis muscle is the main culprit in Tennis Elbow.
It is degeneration of the tendon attachment to the Lateral Epicondyle that causes the pain and disability.

Extensor Carpi Radialis Brevis

This muscle has its upper attachment to the Lateral Epicondyle, (B in the diagram), the Radial Ligament and surrounding tissues.

It passes down the forearm deep to the Extensor Carpi Radialis Longus and Extensor Digitorum muscles and lies under the skin in the lower half of the forearm (M in the diagram opposite).

The muscle becomes tendon in the lower forearm and the tendon crosses the wrist and attaches to the base of the 2nd and 3rd Metacarpal bones in the hand (I in the diagram).

The action of the muscle is to help to extend the wrist and deviate it towards the thumb side. (Extension and Radial Deviation)

Summary

You now understand:-

• that Tennis Elbow is micro-tears in Extensor Carpi Radialis Brevis tendon
• that Lateral Epicondylitis and Epicondylosis are the same as Tennis Elbow
• where the Lateral Epicondyle is on the Humerus
• where Extensor Carpi Radialis Brevis attaches and its actions

For more information see Tennis Elbow – Get to Grips

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IS YOUR TENNIS ELBOW NEW?

The attachment of the Extensor Carpi Radialis Brevis muscle to the lateral epicondyle may be inflamed although there is some debate about that. (See What is Tennis Elbow)
In this instance rest can help to stop aggravating the problem and the inflammation will settle down.
In fact rest is an essential element in settling acute tendonitis.

IS YOUR TENNIS ELBOW MORE THAN A FEW WEEKS OLD?
(Or have you had repeated bouts of Tennis Elbow?)

If this is the case then there are degenerative changes in your tendon attaching to the Lateral Epicondyle.
Resting your arm will settle the pain in your elbow.
HOWEVER – if you do anything that uses your arm strongly then the problem will return and you won’t cure tennis elbow!

This is because rest allows the pain to settle but the repair that takes place is not structurally as good as it could be and it easily breaks down again.

You need to stimulate repair of the degenerated tendon by doing specific exercises in a controlled fashion over the course of several weeks.

This produces an effective repair of the damaged tendon and means that you are much less likely to suffer a recurrence of the problem. See “How do I stop Tennis Elbow coming back?”

You also need to make sure that the muscles in your forearm do not shorten – see Best Stretch for Tennis Elbow

My Advice

For a Tennis Elbow cure – If your problem is new then rest, ice and gently stretch.
If not new then stretch, exercise and relative rest (don’t do things that make it worse).

Have you taken my Extensive Professional Tennis Elbow Self-Assessment Tool?
Find out

• what type of Tennis Elbow Lateral Epicondylitis do you have
• if you are doing the correct exercises
• what underlying problems are stopping your elbow from getting better
• if your neck is causing the problem
• and many more things…..

Take the FULL ASSESSMENT at Tennis Elbow Assessment

Back to Tennis Elbow Top 10 Questions