Two Surgeons Talk Tennis Elbow – Why Cortisone, MRIs And Surgery Are Rarely Needed

In this video, two Orthopedic Surgeons, Dr. Howard J. Luks and Dr. Jeffrey H. Berg, talk about MRIs, Cortisone Shots and surgery for Tennis Elbow. (From their video podcast series “Two Boneheads.”)

Video: Two Orthopedic Surgeons, Dr. Howard J. Luks and Dr. Jeffrey H. Berg, talk about Tennis Elbow causes, diagnosis and treatment.
Watch the video on Dr. Luk’s YouTube Channel
Or on Dr. Berg’s Channel (same video)

This is a refreshingly candid discussion in accessible terms, revealing some unexpected perspectives and even slaughtering a sacred cow or two, and I felt strongly it deserved an article!

These Doctors address the questions of:

• What is Tennis Elbow?
• Are Cortisone Shots a good idea?
• Is an MRI of the elbow needed for diagnosis?
• Is surgery needed to treat Tennis Elbow?
• And who benefits the most from Tennis Elbow surgery?

Dr. Luks opens by stating that Tennis Elbow is so common and pervasive that, according to some, pretty much everyone can expect to experience it at some point in their life.

Dr. Berg immediately whacks the biggest sacred cow: The Inflammation MTYH by dispelling the pervasive idea that this condition, often still referred to as Lateral EpicondylITIS, is primarily a form of TendonITIS, an inflammatory condition:

“there may be some inflammation present the primary problem is one of degeneration of the tendon… You get some microscopic tearing and degeneration and all that causes pain”

Two Boneheads Video Series: Tennis Elbow

Jeffrey H. Berg, MD

“…the primary problem is… degeneration”

I’ve been harping on this fact since the early 2000s when I discovered the research work of Dr. Robert Nirschl online, stretching back to the 80’s and 90s Elbow Tendinosis – Nirschl Surgical Center

Tendinosis is the proper, modern clinical term for a chronic (persistent / long term) degenerative tendon disorder.

Puddu, et al, is credited with coining the term ‘Tendinosis’ in 1976 in this paper on Tendinosis on PubMed

Orthopedic Surgeons, like Drs Luks and Berg, are intimately aware of this, They see it firsthand – But your primary care Doctor, (whom you will very likely see first) may not.

Sure, you may be thinking, but how important is this distinction really? (It’s critical.)

This distinction, between the outdated, incorrect classification of Tennis and Golfer’s Elbow as Tendonitis (inflammatory) – And the correct one; Tendinosis (degenerative – Largely NOT inflammatory)…

IS the major fork in the “treatment road” that sufferers of these tendon problems need to be aware of and choose the right direction to take.

You take one path, the “Inflammation Fighting” / “Symptom Chasing” road – (The Triple Trap of anti-inflammatories, icing and braces ) – and, together with some passive rest, you feel a little better for awhile but all too often end up much worse off several months later…

OR, you take the other path, skip all the symptom chasing, and proactively treat the underlying “issues in your tissues” by mobilizing your muscles and tendons with techniques to break the vicious cycle of stagnation and degeneration (the hallmark of Tendinosis.)

More on the Tennis Elbow Classroom treatment strategy here.

“Tendinosis is the root of most of our tendon problems… an age or activity-related degeneration of the tendon.”

“If we MRId both of our elbows 3 out of 4 MRIs would probably show signs of Tendinosis so why does one person have pain with Tendinosis and someone doesn’t?”

Howard J. Luks, MD

Dr. Berg replies that he doesn’t know. (What a refreshingly honest, humble attitude!)

Professionals of any kind at this level – but especially Doctors, it seems – Do NOT like to utter the words “I don’t know!”

Dr. Berg goes on to explain that it seems to be a middle-aged person’s issue and that most often it will resolve if given enough time. (The “Self-Limiting Condition” perspective, which can take up to 18 months, according to this resource.)

I’ve seen so many cases, however, where people have struggled with Tennis Elbow or Golfer’s Elbow for years, I tend to believe it will often only resolve on it’s own – IF the person gives up their sport, activity or passion!

Dr. Berg explains that he tries to “buy time” for his patients and put off surgery if possible. He also advocates, among other treatments, Massage Therapy (Singing my song!)

Are Cortisone Shots Helpful?

However, Dr. Berg also admits that he sometimes offers a steroid injection (Cortisone Shot) to his patients, with an acknowledgement that this is controversial.

I have to assume this demonstrates his awareness of the massive, decades-long body of medical research showing that Cortisone Shots are risky – too often leading to poorer long-term outcomes, like greater tendon degeneration and even ruptures in extreme cases.

And I appreciate his dedication to informed consent when he tells his patients:

“It’s not treating the problem. It won’t cure the problem. It won’t heal the problem! – But it can be a very good way, if used judiciously, to get rid of your pain and sometimes that buys enough time for this to heal.” – Dr. Berg

Dr. Luks chimes it that “Sometimes it makes it worse!”

And Dr. Berg replies that he hasn’t seen a lot of that but he’s right – “It’s written in the literature but a lot of things we do sometimes make things worse” and points out that everything has its risk / benefit trade offs.

Dr. Berg points out that he rarely gives more than one Cortisone Shot and admits that it can degenerate local tissues.

And even effect and damage nearby ligaments making a small problem much worse.

There are several small but very important ligaments (Ligaments help hold joints together) in the lateral (outer) elbow area, which are very close to the main tendon group involved with Tennis Elbow (the ‘Common Extensor Tendon.’)

I will also point out that these ligaments, like the ‘Lateral Collateral’ and ‘Radial Collateral’ Ligaments are often “in trouble” in people who have Tennis Elbow and need to be treated along with the muscles and tendons involved in Tennis Elbow.

And, in my experience, nearly every case that stems from tennis, golf, Pickleball and other sports (especially if it involves impact stresses) includes issues with one or more of these ligaments to some degree.

(The good news is that these ligaments are fairly easy to physically treat in my experience, though, if not significantly torn, because they’re small and easily accessible.)

Here is my strongly cautionary take on the use of steroid injections to treat tendon problems [Article, video, podcast]:

Risks of Treating Tennis and Golfer’s Elbow with Cortisone Shots

You’ll find links to several medical studies, quotes from Doctors and other references about the dangers of steroid shots there.

What’s The Root Cause?

Dr. Berg goes on to admit that they don’t really know what the issue IS with the tendon is that leads to these Tendinopathy injuries (other than the broad term ‘overuse.’)

“We don’t know what the problem is: I don’t know if they’re not strong enough – Not flexible enough – Not good enough endurance” – Dr. Berg

And, as far as I can tell, from reading the medical studies, researchers still don’t know the full causal mechanism, either.

The simple fact is that tendons (which are the rope-like connectors of muscle to bone and where the worst damage and pain is seen in Tennis and Golfer’s Elbow) are CAPABLE of healing.

Researchers can describe in minute detail everything that’s happening to the tendon on a molecular level as it’s breaking down and degenerating – but as far as I can tell, still can’t explain WHY – At least, not in any comprehensive, meaningful way that’s actionable!

There may be “overuse” but sometimes there isn’t… It occurs more often in older people but not always… It may be caused by dynamic forces in sports or tiny, repetitive tasks involved with certain types of work (computer / mouse use is a big one) playing an instrument, like guitar or piano or various “hobby” and “everyday” activities like Gardening, and dog walking.

There does seem to be growing evidence of a nutritional deficiency involving Vitamin D

The way I see it, there’s a “local” cause, driven by excessive muscle tension and adhesions in the Wrist and Finger Extensor Muscles (Flexors in the case of Golfer’s Elbow.)

And the restriction and drag from these tight, shortened muscles negatively affects the tendons, either causing or accelerating the degenerative Tendinosis damage.

As well as, a more “regional” cause, driven by Rotator Cuff weakness and other “upstream” issues that the Wrist and Finger Extensors and Flexors end up compensating for. (Significantly increasing their chronic tension.)

Both Orthopedists discuss how often it is that their patients head right back to the activity that caused the injury the second they’re feeling better and how important it is to rehabilitate properly before trying to resume ones activity.

Now, admittedly, my own clients are seldom at the severe end of the spectrum; at the point where they’re consulting with surgeons – but most of my clients do have stubborn, chronic cases and they are able to continue playing tennis, golf, Pickleball, etc. while in treatment, albeit, with a LOWER frequency and intensity!

That’s one of my guiding principles: IF you’re proactively doing the right things to encourage healing, (and are willing to slow down a bit) you can often continue with your work, sport or activity:

• Can you keep playing tennis when you have Tennis Elbow?
• Can you still work out / lift weights when you have Tennis or Golfer’s Elbow?

When Do You Need An MRI? (If Ever)

Both Doctors reveal in the video that they rarely if ever order an MRI for Tennis Elbow cases.

“I tend not to MRI these elbows because we know it’s going to show evidence of Tendinosis. We know it’s going to show some fraying… some tearing” – Dr. Luks

Dr. Berg agreed and expanded on that by stating:

“I never get an MRI if I’m pretty sure it’s Lateral Epicondylitis / Tennis Elbow. It’s really just a waste of time and money.”

“They almost always show tearing of that tendon and that gets the patient upset and nervous… These all show that. It’s just degeneration. If that tendon tore they’d actually probably feel better… When we operate that’s basically what we do!” – Dr. Berg

Now, I really appreciate the honesty of this revelation – although, at the same time, I’m confused by it. (Don’t they need confirmation that there is significant damage to the tendon before they perform surgery?)

As the surgeons explained, most middle-aged people and older will have some tendon degeneration visible on an MRI, even worse, sometimes – whether in pain or not – (It’s causing pain in some people but not others, apparently.)

At the same time, the opposite can be true: People who have  been suffering from Tennis or Golfer’s Elbow chronically for months or even over a year sometimes get MRIs only to discover that NOTHING is significantly wrong with their tendons.

Perhaps I’ll try to contact one of these Doctors and see if I can get some clarification!

In the meantime, here is (or was?) my best attempt to answer the MRI question – OR if you’ve recently had one and need a little help deciphering your Radiologist’s report:

When do you need an MRI (Tennis / Golfer’s Elbow) and what does it mean?

When Is Surgery Necessary? (Rarely)

Dr. Luks reiterates that Tennis Elbow is extremely common, age-related disorder that’s easy to self-diagnose just by the symptoms…

Explaining that if you have pain in your outer elbow when you pick an object up in a palm-down position, you pretty much have Tennis Elbow.

And he assures us that surgery is rarely called for.

“Surgery is rarely indicated but every year you manage to find a few who might benefit if the symptoms have been there more than 8-10 months and they’re just tired of it.” – Dr. Luks

(Dr Luks does seem to be a proponent of Platelet Rich Plasma therapy, according to his website, which shows promise but does still seem to be a “jury’s out on it” treatment as far as I can tell from the studies.)

Here are my articles, with videos on the question of surgery for Tennis and Golfer’s Elbow and healing tendon tears, specifically:

• When is it time to consider surgery for Tennis or Golfer’s Elbow?
• Can you heal a torn tendon without surgery? (Tennis or Golfer’s Elbow, primarily)

In conclusion, what I gather is that it’s not what the MRI objectively shows (IF one is even ordered) – For example, the presence and severity of any degeneration, calcification, tearing etc…

Rather, the driving factor in the decision about whether to have surgery, from these Drs. perspectives, is really the patients frustration with the persistence and/or severity of their symptoms.

If the patient says, “I’ve had it with this elbow pain, I’ve suffered for almost a year! I’m ready for surgery!” then they may proceed with the procedure, MRI or no MRI.

I’m simply left wondering what they do if they “get in there” without a prior “look” by MRI and they don’t find anything significantly wrong with the tendon!?

Perhaps it’s not that big of a deal since it’s such a small incision. Just suture it back up and it heals very quickly!

Learn To Treat And Heal Your Own Tennis Elbow Or Golfer’s Elbow At Home With This Video Program

You’ll get instant access to a complete VIDEO program designed by a professional therapist to help you take charge and break your vicious cycle of pain and frustration!…

I’ll be your personal tutor guiding you through step-by-step video lessons, where you’ll get the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home. (Without any special equipment.)

Tennis Elbow Home Program: Learn more about it here

Golfer’s Elbow Home Program: Learn more about it here