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Shoulder & Elbow

Tennis Elbow or Lateral Epicondylitis

I had this for over a year! I remember reaching for something heavy and feeling a burning sensation across the outside of my elbow. I immediately knew that I had tennis elbow…or lateral epicondylitis. I usually see those patients sometime between one month and 6 months after the onset of pain. Usually sometime after they’ve continued to “work through” the pain. And if you’ve been reading my blog, you already know that doesn’t work.

I immediately iced it and downed a couple of Aleves. I already had a wrist brace sitting around the house which I occasionally used when my carpal tunnel flared up. You probably wouldn’t have one of those, but you could go get one at your local pharmacy. Over the course of a year, I stopped using that arm for anything heavy or repetitive. I used the tennis elbow brace when active during the day. I used the wrist brace when I was going to do heavy, repetitive lifting and also at night. It gradually got better and better, but I still did a few things which continued to cause pain. I modified the way I did those things, and finally, one day, I realized that it had been a while since I noticed my tennis elbow.

The most important thing initially, is to recognize tennis elbow when you’ve got it. You don’t have to get it by playing tennis. We lug around carry-on suitcases and heavy computer bags. We shake way too many hands and play too many computer games. We lift a lot of weights. All of these things can result in lateral epicondylitis. But sometimes we just wake up with it and can’t think of a single causative factor.

And once we have it, just about anything exacerbates the pain. That’s because all of the tendons from the muscles that raise your wrist and fingers are attached to that little rounded bone on the outside of your elbow. So just raising your wrist or pointing your finger tugs on the little part of that bone. Truly resting it is almost impossible.

Now reach over to the outside of your elbow and find that little prominence there. Even if you’re not having pain there right now, I want you to remember where that little stinker is, and one day when you feel a burning pain across the outside of that bone, you’ll remember to come look up this blog and not to work through it,  thinking it will go away on its own.

Now this is the part where I need to say that if it’s your left arm and the pain is radiating all the way down the arm, seemingly coming from your chest and you’re a little short of breath at the same time, this is probably not a good time to go get a tennis elbow brace and an ice pack.

I would estimate I see at least 1-2 cases of the disease every day I’m in clinic so it definitely warrants attention. Tennis elbow was originally called washerwoman’s elbow.  That’s because in those days there weren’t that many people playing tennis, and they certainly weren’t whacking the ball with the intensity with which we now perform that task. But there were lots of women employed as cleaning ladies. There were no Swiffer sticks and Clorox wipes. You used rags, and you wrung them out in a bucket of water…over and over again.

Lateral epicondylitis is what we professionals (those having stayed in a Holiday Inn Express last night) like to call it. And we use that term because the vast majority of patients with this particular scourge haven’t even touched a tennis racquet. So, when I tell them they have tennis elbow, I get a curious look from them…the I-don’t-play-tennis look. Then I have to go through a long explanation regarding the nomenclature, and why it’s called tennis elbow, and why they have it even though they don’t play tennis. But it’s easier to call it tennis elbow than lateral epicondylitis. Less syllables.  Of course, when I tell them they have lateral epicondylitis, many times I get the oh-my-God-what-is-that-disease look. And then they tell me they just thought they had tennis elbow. You can’t win.

And even the term lateral epicondylitis doesn’t describe the disease accurately. The lateral epicondyle is that little gumball sized lump on the outside of your elbow. But the disease isn’t really inflammation of that bone. It’s a disease of the tendons which originated from that spot. So now you see what I have to deal with. But I digress.

Many of you are going to get this disease. It’s another one of those adult repetitive strain disorders. You get it after 30/40 and have the potential to get it until you’re about 65. I can’t even remember when I last saw a teenager with this. Even tennis playing teens rarely get it nowadays. And I can’t remember the last time I saw a retiree with it.

Most of us get it doing the mundane activities of daily living. That’s because the tendons which get inflamed are the tendons you use every day to do things like lift your coffee cup, wring out a washcloth, grab your tennis racquet and lift weights. And you use this muscle group over and over and over again. And one day it just says, “That’s it. I’m done. Kaput. Lay your arm down and lay it down now!” But no. You don’t lay your arm down because you wouldn’t lay your arm down unless the bone was broken in two and sticking out of the skin!

May I first suggest that you lay your arm down…for a little while anyway?

I know you’re going to try to work through the pain. Everyone does. You’ll keep lifting the weight or playing tennis or shaking hands. You’ve heard me rail against this hard-headedness in the past. It doesn’t work. Some of you only try to work through it for a week or two or three. But many of you persevere for months! And then you have this expectation that your physician should make it go away in a day or two. Maybe you see me on Wednesday and would like to be able to golf in a tournament on Saturday. Some of you saw an orthopod for this several years ago and got a shot. You got better and now you want a repeat. Or your neighbor saw someone and got cured with one shot.

Look, I’m going to try to help you out, but I can tell you that the 24-hour cure is the rare exception. It’s rare to get well and stay well after a single shot. This is another one of those conditions which much be coddled along.

You have to go back to my general principles of treating adult repetitive strain disorders. You must rest it. You must decrease the inflammation. And you must modify your activities. Somewhere in there is a brace or two, some physical therapy and maybe a shot or two. But if you learn from my personal experiences, I think you can nip these adult repetitive strain disorders in the bud…early.

You’ve got to recognize that you have a repetitive strain disorder. Be prepared if you’re over 35. All of a sudden there is a pain. In this case it’s on the outside of your elbow. Think about what you were doing today or yesterday or even a few days ago. Think of some new activity you’ve been doing. Were you travelling; lifting luggage into the overhead bin? Did you just start some new exercise program? Do you remember reaching for something and feeling a little strain over on the outside of your elbow? This could be the start of something new…and something that’s really going to mess up your game. The faster you address it, the more likely you are to get rid of it.

Years after I had recovered from tennis elbow, I got it again…for one day! I was reaching for something heavy and when I picked it up I felt the slightest little pull along the outside of my elbow. Ha! I knew immediately that I had just strained the extensor wad of muscles which attach to that lateral epicondyle. I thought, “This is how tennis elbow starts.” But then I thought… “Hey I don’t play tennis.” Not really. You didn’t fall for that one.

I went right away and strapped an ice pack to my elbow. I happen to have a wrist brace, so I put that on so I wouldn’t use my hand to lift anything for the rest of the day. I downed a couple of Aleves, and just for kicks, I took a couple more the next morning after breakfast. And I had no more pain after that. I was cautious over the next week, to avoid heavy lifting with that arm, but soon it passed into memory and I have never experienced it since.

This is how it should go for all repetitive strain disorders, but this one is a particularly buggerish one. It leaves you with this useless arm and is so frustrating to have and to take care of.

If you catch tennis elbow at an early stage (preferably day one) and you stop doing the offending activity, or at least modify it to the best of your ability, you will get better and you probably won’t have to come see the likes of me. But most of you will not do this. I’m going to go through a list of activities which commonly lead to or aggravate tennis elbow, and describe ways to modify them, so you can see what I’m talking about. Let me first say that stopping the activity cold is the best thing to do, but with tennis elbow, those activities can be the most commonly performed activities in your daily routine. They are activities you simply can’t stop doing cold turkey.

  1. So first…if you can…change hands when you take care of “your business.” I can tell you from personal experience, after breaking my right arm and being in a long arm cast for 6 weeks…that is almost an impossible task. But you can do it. That, or go install a bidet…
  2. Shaking hands can be a killer. You can try giving people what I call the “dead carp handshake.” You know what that is. It’s when you simply hand someone else your hand, like it’s a dead fish, instead of returning the firm grip. But if you give someone a firm grip and they give it back, you might just drop to your knees in pain when you have tennis elbow. Quit shaking hands. Wrap an ace bandage around your hand or put on a wrist brace, so people know you’ve got an injured wing. It’s hard to tell everyone that you can’t shake hands. Just show them the bandaged hand and make your greetings.
  3. Brief cases. The business trip can be just like playing in a weekend tennis tournament for those with tennis elbow. Three days of shaking hands and lugging a brief case around will do you in. Ditch the brief case. I often amaze myself at how little I actually need to lug around. Try to put your brief case down and leave it. Carry the brief case on one of those little rolling carts. Convert to a back pack for a few months or for good. DO NOT lift it with your fist pointed down. At least turn your palm up to grasp and lift it.
  4. Milk cartons and heavy pitchers in the refrigerator. Get smaller ones. Move them down to the lower shelf and pick them up with both hands. We should all do this any way. These big items on the top shelf of our refrigerator often contribute to tennis elbow and shoulder bursitis. Move them down…for good.
  5. Lift and carry things close to your body, palms up and using your biceps to do most of the work. If possible, stop lifting heavy things for a while. And you might as well do it now, because trust me, you will eventually have to stop. Actually, that goes for all the above. Eventually your elbow will force you to give in. The pain almost always wins.
  6. And the list goes on. If it hurts to do something…stop it or at least modify how you do it, including playing tennis! At least play a little less for a while. Forgo that 3-day tournament, where you’re playing on two teams! They can find someone else. And if they can’t, it will at least remind them of just how important you are!

At least try to make some modifications. No one ever guaranteed you’d be able to do everything at all times! Just give something up… maybe wiping yourself…just a little less??? Maybe? Please???

For the moment, let’s assume that you’ve got lateral epicondylitis and not cancer on the outside of your elbow. I’m always a little nervous about giving medical advice to people I can’t see or touch. I would hate to tell you to put a tennis elbow brace on your arm if the pain you’re experiencing is actually due to a clogged coronary artery. So, suffice it to say that if there is something growing or draining over there on your elbow, or if you experience shortness of breath at the same time you are feeling pain in your left arm…it’s probably not tennis elbow and you probably don’t need a brace! You need a doctor!

Hey! I am a doctor and I can help you with your tennis elbow! Go to the local Walgreens or sport store and buy a…tennis elbow brace! That’s easy. Put it on like they show you on the instruction sheet. I like the ones that are shaped like the one in the picture. The sleeve-like things don’t really accomplish the goal. So get one of those strap-like ones and use it as much as you can tolerate using it. It’s really hard to predict when you’re going to strain those muscles. You could go all day with no pain and then suddenly grab the doorknob which will bring you to your knees. Just wear it for a while every day. And certainly put it on when you’re going to be doing some repetitive activity you know will aggravate it. Like playing tennis. Duh. That’s why they call it a tennis elbow brace.

Get a wrist brace. That seems strange, since you’re not having pain in your wrist. But remember, the muscles which raise your wrist and fingers are attached to that little booger bone, and if you rest your wrist, you rest those muscles. If you experience pain in your elbow in the morning when you wake up, it’s because you’ve slept with your elbow bent and your wrists flexed down all night (remember the fetal position). Those muscles and tendons have been under tension all night. So if you wear the wrist brace to bed, it will eliminate that strain on the elbow! Remember how I love to multi-task. If I can get something treated while I sleep, that’s a huge bonus.

Massage your elbow. Then do it some more. Then do it with Tiger Balm or Ben-Gay or anything that gets warm. Frankly I think it’s good to massage most anything that hurts…unless it’s draining, has stitches in it or causes shortness of breath.

Try taking an over-the-counter (OTC) anti-inflammatory (NSAID) for a while. Of course, you need to follow the directions on the label and make sure there’s no reason not to take them; like a stomach ulcer, or liver, kidney or cardiac disease. And you shouldn’t take them if you’re already taking prescription anti-inflammatories like Celebrex, or Mobic or Relafen, to name a few.

If you’ve read this blog and you’re not getting well, I would first tell you to do all the above…a little longer! This condition rarely resolves quickly. We use those muscles too much! It’s just really hard to rest them. But you’ve got to try.

So when all else fails…call the doctor. I’ll tell you to do more of the above.

And I might add a prescription dosage of my favorite NSAID. We could try a short course of steroids called a Medrol Dosepak. That is pretty effective and might just knock it out if you’ve been doing everything I’ve already told you to do.

And sometimes, if you’re up for it and if I feel it will work; a cortisone injection. But let me tell you that it is rarely my first suggestion. I’m a lot more successful with an injection if it’s done as an adjunct to a complete conservative course of treatment (everything mentioned heretofore) as opposed to the first and only course of treatment.

A single cortisone injection as the first and only treatment modality is not likely to have long term benefit. But on occasion, a person is in dire straits. Either their pain is severe and disabling, or perhaps they are preparing for a major tennis tournament in a couple of days and this condition has just sprung up on them. In those rare cases, I will sometimes give a single injection of cortisone to “get them through.” It would be insensitive not to. I won’t do it over and over and over, just to allow someone to keep playing a sport which is injuring them, but I will do it occasionally. Then afterwards, we get back to those conservative principles and try to get this condition to go away.

I might prescribe a course of physical therapy. You can do stretches and strengthening exercises on your own, but the therapists have some treatment modalities which can help.

I can’t begin to count the number of patients I’ve seen with the diagnosis of tennis elbow. Hundreds? Thousands? But I can count the number of times I’ve had to do surgery for this disease on one hand. It’s a last resort. Almost ALL of you will get better with conservative treatment, especially if you start early and don’t let this frustrating condition escalate to the point of disability before trying to treat it. Just remember my mantra…do not try to work through it. That just won’t work in most cases. Deal with it early and swiftly.

 

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