Tennis Elbow: What to Know About Regenerative Treatments

Tennis elbow may sound like a simple overuse injury, but as Dr. Kevin O’Donnell explains, it is often more nuanced than people realize. At Revitalize Regenerative Orthopedics, the goal is not to just temporarily calm symptoms, but to understand what is actually causing the pain and use regenerative treatments such as PRP therapy to help the tendon heal. Whether someone developed tennis elbow from pickleball, tennis, weightlifting, repetitive work, or just the wear and tear of daily life, the right diagnosis matters.

When you evaluate a patient with tennis elbow, how do you differentiate between true tennis elbow and other causes of elbow pain that may mimic it?

First, I usually do not call it lateral epicondylitis because it is really not an inflammatory condition. That matters, because if something is inflammatory, you treat it one way. But most people who come in with tennis elbow have a chronic degenerative tendon issue, not an inflammatory one.

If we took a piece of that tendon, put it under a microscope, and looked at it, we would see disorganized collagen fibers and very few, if any, inflammatory cells. That is why the old idea of treating tennis elbow with anti-inflammatories or steroid injections does not really make sense biologically. Yes, steroids may help it feel better for a while, but you are doing yourself a disservice if you keep using them, because the tendon itself is sick. If you put something toxic into a tendon, you can make it worse.

When I see someone with a really bad tennis elbow, I always ask about prior treatment. You can often tell the patients who have had one or multiple steroid injections because the tissue is just beat up.

There are also a lot of things that can mimic tennis elbow. There are nerve issues, joint issues, and ligament problems that get lumped into that diagnosis all the time. I see patients who have been told they have tennis elbow, they have done physical therapy, had a couple cortisone injections, and they are not getting better. Then it turns out to be something completely different. There is also a fairly high percentage of people who have more than one issue going on. Yes, they may have tennis elbow, but they may also have a ligament strain deeper than the tendon or nerve irritation along with it.

I would say probably about 75% of the time, it really is just tennis elbow. But there is probably a good quarter of patients who have one or more additional issues. That is why we differentiate it through history, physical exam, ultrasound, and just having the experience and knowledge to recognize that other structures can be involved. It is a little more nuanced than just, “You hurt here, so it must be tennis elbow.”

Where do regenerative treatments like PRP fit into the treatment spectrum for tennis elbow?

For probably 95% of patients who have had tennis elbow for more than three months and have already tried other things like bracing, cortisone, or physical therapy, I am going to jump to PRP therapy. PRP has the most Level 1 evidence for efficacy of anything you can do for tennis elbow. That includes rest, physical therapy, surgery, and cortisone injections.

It is my go-to treatment unless the patient has a larger or more complex tear that changes the picture. I am not usually using stem cells for standard tennis elbow. Most of the time it is one or two PRP treatments, and sometimes I will combine that with shockwave. But tennis elbow is one of the easier things for me to get better. Ninety-nine percent of people I am able to help.

There is a real need out there for this because a lot of people still do not know what regenerative medicine can do for tennis elbow. If they understood the biology and the outcomes, I think a lot more people would choose it.

Are people with tennis elbow usually trying to avoid surgery? Is tennis elbow surgery ever necessary?

There are surgeries for tennis elbow, but the problem is that surgery does not necessarily address the underlying pathology.

Most people with tennis elbow have a degenerative tendon. It is not usually one acute injury where they tore the tendon in a clean, simple way. Most of them have microtears in tissue that is already unhealthy. So if you go in surgically, scrape out the bad tissue, and sew up the tears, you may feel good because the tear was repaired, but you have not really changed the biology of the tendon.

That is why some people do well after surgery, but a lot of people also have it come back or retear. The tear was not really the main issue. The bad tendon created the tear. What we are trying to do with regenerative treatment is improve the overall health of the tendon, stabilize it, and strengthen it so it does not keep failing.

So yes, a lot of people are trying to avoid surgery, and in many cases they should, especially when we have options that address the tendon in a more meaningful way.

Would a 45-year-old recreational athlete and a 65-year-old patient trying to get back to daily activity need different tennis elbow treatment plans?

For tennis elbow specifically, I am going to treat those two patients pretty similarly.

In other areas, like arthritis, your goals matter a lot. If someone wants to be able to pick up a grandchild, go up the stairs, or move around the kitchen with less pain, that is one treatment conversation. If someone with arthritis wants to run marathons, I am going to be more aggressive because the ceiling is higher.

But when it comes to tennis elbow, this should be eminently curable. That is a big difference. It is not usually a situation where I am trying to get someone halfway better. We should be going for a cure when it comes to tendon issues.

Now, it still depends on the pathology. Occasionally I will do two PRP treatments. But if I am doing more than two PRPs for tennis elbow, then either I am missing something or the pathology is worse than I initially thought. Typically, it is a one-and-done situation, or close to it.

With the rise of pickleball, are you seeing more tennis elbow patients who want to get back to their sport?

Absolutely. All the time.

I have a whole group of women I have treated from tennis and pickleball, and I would say it is probably about half and half in terms of which sport they are coming from. There are definitely active patients who develop this from racquet sports or other repetitive athletic use.

But I would also say that probably 50% of the people who end up with this condition are not athletes or do not play tennis at all. It is called tennis elbow, but it can come from just living your life. Gripping things, opening things, lifting things, dragging luggage through an airport, doing repetitive work around the house—those are all common ways people end up with it.

So I do not love the term tennis elbow, even though that is what people recognize. Really, it is a tendon issue on the outside of the elbow, and it can come from aging, hormones, repetitive motion, or injury. There are a lot of different causes.

What role do load management and biomechanics play in recovery and preventing recurrence of tennis elbow?

They matter, but tennis elbow is tricky because it hurts with a lot of normal daily activities. In general, my advice is simple: if it hurts, do not do it. Or at least do less of it.

The problem is that even everyday activities can flare it up. Grabbing a milk carton, opening a door, lifting a bag, or using your hand in a repetitive way can all aggravate the tendon. So yes, load management is important, but it is not always easy because the elbow gets irritated by basic life.

After PRP, I usually put patients in a wrist brace for about a week. Even though the pain is felt at the elbow, the tendon involved is actually a wrist extensor tendon. So the brace helps stop the motion that keeps irritating it. We use relative rest at first, and then after about a week we start loading the tendon again with physical therapy exercises. That controlled loading helps stimulate the healing response we are trying to create with PRP.

So the progression is not completely shut down forever. It is to protect it, calm it down, then gradually load it the right way so the tendon can actually remodel and recover.

What is the big takeaway for people dealing with tennis elbow that just will not go away?

The biggest thing is that chronic tennis elbow is usually not an inflammatory problem, and if you keep treating it like one, you may just keep spinning your wheels.

If you have had pain for months, tried braces, therapy, anti-inflammatories, or cortisone injections, and it still is not getting better, there is a good chance the tendon itself needs help healing. It may also mean there is more going on than just standard tennis elbow. That is why getting the diagnosis right is so important.

The good news is that tennis elbow is one of the more straightforward tendon problems we treat with regenerative medicine. In the right patient, with the right diagnosis, it is something we can often improve dramatically and in many cases essentially resolve.

If elbow pain is keeping you from pickleball, tennis, the gym, work, travel, or just normal day-to-day life, the team at Revitalize Regenerative Orthopedics can help identify what is really going on and whether PRP therapy or another regenerative treatment may be the right fit. To take the next step, book a 90-minute assessment and get a deeper, more personalized look at your pain, your tendon health, and your treatment options.