Were You Told the Next Step Is Another Cortisone Shot? There Is a Better Option.
Tennis elbow is one of the most common problems in orthopedics, and one of the most poorly treated. Patients are often cycled through repeated cortisone injections for months or years, told the pain is inflammation, and then told that surgery is the only remaining option.
The problem with that sequence is that it is built on a misunderstanding of the disease. Tennis elbow is not an inflammatory condition. Once you understand that, the entire treatment approach changes — and so do the results.
Dr. Raffy Mirzayan is a double board-certified orthopedic sports medicine surgeon and elbow specialist in Los Angeles who has performed hundreds of tennis elbow procedures and has lectured nationally on elbow tendinopathy and orthobiologics. His approach starts with what actually helps the tendon heal, and reserves surgery for the patients who genuinely need it.
Why Cortisone Doesn't Make Sense for Tennis Elbow
This is the single most important thing to understand about your diagnosis.
The name "lateral epicondylitis" ends in -itis, which means inflammation. That name is wrong, and it has misled the treatment of this condition for decades.
When surgeons remove the diseased tissue from the lateral epicondyle and send it to pathology, the tissue does not contain inflammatory cells. In the landmark study on this, Kraushaar and Nirschl examined surgical specimens using histology, immunohistochemistry, and electron microscopy, and found a general absence of the inflammatory cells you would expect in an inflammatory condition — no meaningful population of neutrophils, lymphocytes, or macrophages (Kraushaar & Nirschl, Journal of Bone and Joint Surgery, 1999). What they found instead was disorganized collagen, abnormal fibroblasts, and immature blood vessels — a failed healing response. Nirschl named it angiofibroblastic tendinosis, and the correct term for your condition is tendinosis, not tendinitis.
So the question is simple: if there are no inflammatory cells in the tissue, what is a powerful anti-inflammatory steroid supposed to do?
The clinical evidence has answered that question, and the answer is uncomfortable. In a randomized controlled trial published in JAMA, patients who received a corticosteroid injection for tennis elbow did better in the first few weeks — and then did substantially worse at one year than patients who received a saline placebo injection. Recurrence was dramatically higher in the corticosteroid group (Coombes et al., JAMA, 2013). A systematic review in The Lancet covering corticosteroid injections across tendinopathies reached the same conclusion: helpful in the short term, harmful in the longer term (Coombes et al., The Lancet, 2010).
Cortisone is very good at what it does. It relieves pain quickly and convincingly. But it relieves pain in a tendon that is degenerating, and it does nothing to reverse the degeneration — and repeated doses appear to make the underlying tissue worse.
What repeated cortisone can do to the tissue
As an elbow specialist, Dr. Mirzayan sees the end stage of this pattern regularly: patients referred to him after so many cortisone injections that the tendon, the lateral ligament complex, and the joint capsule have thinned or disappeared altogether. This is a recognized phenomenon in the literature — repeated corticosteroid injection is a documented cause of soft-tissue atrophy at the lateral epicondyle (Arthroscopy, Sports Medicine, and Rehabilitation, 2026) and of posterolateral rotatory instability of the elbow, in which the ligament that stabilizes the joint becomes incompetent.
These are among the most difficult elbow problems to fix, and they are reconstructive operations rather than simple ones. Dr. Mirzayan performs these reconstructions. He would much rather you never need one.
If you have already had one or two cortisone injections, this is not cause for alarm — but it is a good reason to stop and reconsider the plan before having another.
What Actually Works: Non-Operative Treatment
The great majority of tennis elbow patients never need surgery. The goal of non-operative treatment is to stimulate the tendon to finish a healing process it started and failed to complete.
Activity modification and load management. Not rest — tendons do not heal with rest alone. The aim is to reduce the specific loads that provoke symptoms while keeping the tendon working.
Eccentric and progressive loading therapy. Structured, progressive strengthening of the wrist extensors is the foundation of treatment for tendinosis and has the best long-term track record of any non-operative intervention. This takes months, not weeks, and patients who abandon it early are the ones who end up in an operating room.
Counterforce bracing. A properly positioned strap reduces load at the tendon origin and can meaningfully reduce pain during activity.
Time and realistic expectations. Tennis elbow is a resilient condition. Most cases resolve, but the natural history is measured in many months.
PRP for Tennis Elbow
Platelet-rich plasma is the intervention that addresses the actual pathology. Rather than suppressing an inflammation that is not there, PRP delivers a concentrated dose of your own platelets and their growth factors into the degenerated tendon, stimulating the healing response that failed.
Tennis elbow is one of the best-supported indications for PRP anywhere in orthopedics. In a multicenter randomized controlled trial of 230 patients with chronic tennis elbow, leukocyte-rich PRP produced significantly greater improvement in pain and tenderness than an active control at 24 weeks (Mishra et al., American Journal of Sports Medicine, 2014).
Two details from that trial matter for your expectations:
It takes time. The difference between PRP and the control group was not statistically significant at 12 weeks. It was significant at 24 weeks. PRP stimulates biology; biology is slow. Patients who judge the result at six weeks conclude it failed.
Formulation matters. That trial used leukocyte-rich PRP. For tendon conditions, the white blood cells appear to be part of what drives the healing response — which is the opposite of what you want inside an arthritic joint. Many PRP systems cannot produce both formulations, which means many patients are receiving the wrong product for their condition.
It is also worth being straight with you about the evidence: a Cochrane review of autologous blood and PRP for lateral elbow pain concluded that the certainty of evidence remains low and that benefit over placebo is not firmly established (Karjalainen et al., Cochrane Database of Systematic Reviews, 2021). Dr. Mirzayan's view is that much of the inconsistency across PRP studies comes from enormous variation in how PRP is prepared — platelet dose, leukocyte content, and volume differ wildly between systems, so trials are often not studying the same product at all. He will tell you this directly rather than promise you a result the literature does not support.
Dr. Mirzayan uses the Arthrex Angel system, which allows him to control both the platelet dose and whether the final product is leukocyte-rich or leukocyte-poor.
Learn more about PRP, the Angel system, and how to prepare for your injection →
When Surgery Is the Right Answer — And Why the Technique Matters
If you have done genuine non-operative treatment for six to twelve months, including a properly performed PRP injection, and you still cannot grip a coffee cup without pain, surgery is reasonable.
There are many surgical techniques for tennis elbow, and they are not equivalent.
The simplest option is a release. The diseased tendon origin is cut free from the bone and left to scar down on its own. It is quick, technically straightforward, and it does relieve pain in many patients. Its limitations are that nothing is repaired, the extensor origin is left detached, and grip strength does not always return fully.
Dr. Mirzayan's approach takes longer and does more. He elevates the diseased tendon off the bone, carefully debrides the degenerated angiofibroblastic tissue back to healthy tendon and clean bone — the pathologic tissue identified in the Nirschl studies — and then repairs the healthy remaining tendon back to the bone with anchors. The goal is not simply to relieve pain by detaching the tendon, but to restore a healthy tendon-to-bone attachment.
Protecting the lateral collateral ligament
This is where being an elbow specialist matters most.
The most consequential complication of tennis elbow surgery is inadvertent injury to the lateral collateral ligament complex, which sits immediately deep and posterior to the tendon origin. Release or debridement that extends too far posteriorly can detach or compromise this ligament, producing posterolateral rotatory instability — an unstable elbow that clicks, gives way, and eventually develops arthritis if untreated.
This is not a rare, theoretical concern. One institution reported 103 patients who required lateral ulnar collateral ligament reconstruction after failed open release of the common extensor origin (Schneider et al., Orthopaedic Journal of Sports Medicine, 2022), and iatrogenic injury during lateral elbow surgery is a recognized cause of instability in the published literature (systematic review, Orthopaedic Journal of Sports Medicine, 2020).
Dr. Mirzayan's surgical technique is specifically designed to identify and protect this ligament. If the ligament is already compromised — whether from the disease itself, from prior cortisone injections, or encountered during the procedure — he repairs or reconstructs it in the same operation. That capability is not universal, and it is a direct consequence of subspecialty elbow training.
Biologic augmentation at the time of surgery
Dr. Mirzayan frequently adds PRP or bone marrow aspirate concentrate (BMAC) at the time of repair, delivered directly into the tendon, tendon-to-bone interface, and bone to support healing where the tendon is being reattached.
To be clear about what this is and is not: there is no randomized trial proving that biologic augmentation improves the outcome of tennis elbow surgery. What Dr. Mirzayan can tell you is that across hundreds of these procedures, his own patients who received biologic augmentation at the time of repair have in his observation done better than those who did not. That is clinical experience, not published evidence, and he will present it to you as exactly that.
Tennis Elbow Is a Resilient Condition — Here Is the Honest Version
Most surgeons will tell you tennis elbow surgery has a high success rate. That is broadly true. But Dr. Mirzayan will also tell you something most patients are not told up front: some patients continue to have pain even after a well-performed operation.
This is a stubborn disease. The tendon has often been degenerating for years before anyone operates, and a subset of patients retain some discomfort regardless of technique. Knowing this before surgery is far better than discovering it afterward.
It is also why Dr. Mirzayan spends most of his effort trying to resolve tennis elbow without an operation, and why he will tell you plainly if he does not think surgery is likely to give you what you want.
Out-of-Network and Out-of-State Patients
Dr. Mirzayan's practice is out-of-network with major commercial insurance carriers. This allows him to spend the time each patient's problem actually requires, rather than the time an insurance contract allows. Our team will review your benefits with you before your visit and explain your expected costs clearly.
He regularly treats patients traveling from Las Vegas, Henderson, Phoenix, and Scottsdale, as well as from across the country, and also sees patients at his offices in Las Vegas, Nevada, and Long Beach, California. For out-of-state patients, imaging can be reviewed remotely before you travel, and surgery and the initial post-operative visit can frequently be coordinated into a single trip. Call (310) 746-5918 to discuss how to arrange this.
Frequently Asked Questions
Why does my doctor keep offering cortisone if it doesn't work?
Cortisone works well in the short term, which makes it satisfying for both patient and physician at the four-week mark. The problem only becomes visible at six months and a year, when recurrence rates are higher than with placebo. It is also fast, inexpensive, and covered by insurance. None of that makes it the right treatment for a degenerative, non-inflammatory tendon.
I already had several cortisone shots. Did I ruin my elbow?
Almost certainly not. One or two injections are unlikely to cause lasting structural damage. The patients who develop tendon and ligament loss have typically had many injections over an extended period. If you are concerned, an examination and MRI can assess the integrity of your tendon and lateral ligament directly.
How long should I try non-operative treatment before considering surgery?
Generally six months of genuine, structured treatment — meaning consistent progressive loading therapy, activity modification, and in most cases a properly performed PRP injection. "Genuine" is the operative word; many patients who believe they have failed conservative treatment have never actually completed a loading program.
Will PRP work for my tennis elbow?
It is one of the better-studied uses of PRP, with randomized trial support at 24 weeks. It is not guaranteed, results take months to appear, and the quality of the PRP you receive matters a great deal. Dr. Mirzayan will tell you if he thinks you are a poor candidate.
Does insurance cover PRP for tennis elbow?
No. PRP is not covered by any insurance plan, including Medicare. It is a self-pay procedure. Call (310) 746-5918 for pricing.
What is the recovery after tennis elbow surgery?
PRP injection for tennis elbow is quite painful. It is important to take Tylenol 1 hour prior to the injection. After a brief period of immobilization, followed by progressive range of motion and then strengthening. Most patients return to desk work within one to two weeks. Full strength and return to sport or heavy manual work typically takes three to six months.
I had tennis elbow surgery elsewhere and my elbow feels unstable. Can that be fixed?
Yes. Instability following extensor origin surgery is a recognized problem, and it is reconstructible. Dr. Mirzayan performs lateral ulnar collateral ligament reconstruction for exactly this situation. Bring your operative report and any imaging to your consultation.
You May Also Be Interested In
Elbow Arthroscopy and Tight Elbow Release
Chronic (Old) Distal Biceps Reconstruction
Tommy John Surgey (UCL Reconstruction) with Internal Brace
Medial Epicondylitis (Golfer's Elbow)
Cubital Tunnel Syndrome (Ulnar Nerve Compression)
Elbow Fracture Radial Head Replacement
Osteochondritis Dissecans (OCD) Capitellum of the Elbow
About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan is a double board-certified orthopedic sports medicine surgeon and Clinical Professor at the Keck School of Medicine of USC, practicing at DOCS Health in Los Angeles. He completed his fellowship at the Kerlan-Jobe Orthopaedic Clinic and has a subspecialty focus on the elbow, with a personal series of more than 1,000 elbow arthroscopies. He has authored more than 88 peer-reviewed publications and over 150 total works including book chapters and abstracts, has edited three orthopedic textbooks, and has lectured nationally on orthobiologics and elbow disorders, including at the American Academy of Orthopaedic Surgeons Annual Meeting, the American Orthopaedic Society for Sports Medicine, and the San Diego Shoulder Institute course. He is the inventor of Biologic Tuberoplasty™ and the Double Button Tommy John technique, an Arthrex consultant and educator, and co-founder and director of Shoulder360™.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 Additional offices in Las Vegas, NV and Long Beach, CA (310) 746-5918 | raffymirzayan.com
Dr. Mirzayan is a paid consultant and educator for Arthrex, the manufacturer of the Angel PRP system. He selected this system for his practice on clinical grounds, and discloses this relationship so patients can weigh it for themselves.
This page is for educational purposes and does not constitute medical advice or establish a physician-patient relationship. PRP and BMAC are not FDA-approved for orthopedic indications and are not covered by insurance.
