LifeCare Chiropractic

The Best Chiropractic Care in Mesa, Arizona

Tennis Elbow

How to Treat Tennis Elbow: Don’t Skimp on This

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Golfer’s elbow.  Tennis elbow.  Little Leaguer’s elbow.  Medial epicondylitis.  Lateral epicondylitis.  Goes by many names, but they all suck.

Regardless of what you call it, all names relate to some type of elbow pain and I see it frequently in the office.  There are a few exceptions, but most respond very well to the type of treatment approach we use.

Contrast this with typical medical treatment which consists of anti-inflammatories, exercises / physical therapy and possibly steroid injections.  I have written in a previous blog post about how ineffective steroid injections for elbow pain are in the long run that can be read by clicking here.

Overall, the mainstream approach to the treatment of elbow pain has focused on the spot of pain.  This is where we inject. Or we go completely the opposite direction and give oral anti-inflammatories that will effect the entire body, not just the problem area.  (This comment does not even begin to address the problem that the problem is not actually inflammation-driven).

Rehab approaches generally focus on curbing the inflammation (that is not even present) using ultrasound or electrical modalities, but rarely addresses the soft tissue problems really causing the condition.

This particular article addresses just how important the soft tissue (muscles, ligaments, tendons, fascia) are in lateral epicondylalgia (aka tennis elbow).  In it, researchers reviewed several available clinical studies that have demonstrated the presence of myofascial trigger points (MTrPts) in patients with elbow pain.

For anyone to even suggest that the soft tissues would NOT play a role in this type of elbow pain must not treat elbows.  The problem starts in the soft tissues surrounding the elbow long before elbow pain develops.  The pain in the elbow is just the stress point where you feel the imbalance that is present in the soft tissues.  These tissues HAVE to be addressed if you want your elbow pain to resolve.  Massage, instrument-assisted soft tissue techniques (like Graston for elbow pain), Fascial Manipulation or Active Release Technique (ART) need to be part of your treatment plan.  Any treatment from your doctor that doesn’t include these types of treatments should be avoided.

In addition to in-office treatments, there are elbow bands that can take stress off of the area that hurts (you can find high quality braces on Amazon) as well as the Tyler twist using a Therabar (again–you can buy a Therabar on Amazon).  Combining these 3 approaches should help to resolve even some of the toughest cases of elbow pain.

 

Ultrasound-Guided Needle Therapy Effective for Tennis Elbow – (12-19-02)

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Ultrasound-Guided Needle Therapy Effective for Tennis Elbow

This is an excellent article and strongly supports what I talk about in my office. For everyone out there who thinks steroid injections are a useful procedure, think again. Articles in the past have supported the concept that it is not the steroid that heals (quite the contrary–it inhibits the formation of collagen crosslinks, resulting in weaker connective tissues!), but rather the damage created by the needle that produces injury and bleeding that promotes the healing. This is right in line with many manual therapies that I use in my office–ligaments and tendons are actually injured in the therapy process, resulting in an inflammatory response that heals the lesion.

RSNA 88th Scientific Assembly: Abstract 1449. Presented Dec. 5, 2002.

A new minimally invasive treatment that combines the skills of a radiologist and a sports medicine physician effectively reduced pain and restored function in 65% of patients with a range of injuries, from tennis elbow to jumper knee, according to Levon N. Nazarian, MD, professor of radiology at Jefferson Medical College, Thomas Jefferson University, in Philadelphia, Pennsylvania.For years, sports medicine specialists have been injecting injured elbows and knees with either anesthetics or corticosteroids to treat minor tears, said Dr. Nazarian, “but we are combining ultrasound with needle therapy so that the needle is carefully guided to the point of injury.” He presented the study here at the 88th Scientific Assembly and Annual Meeting of the Radiological Society of North America.While standard “needle therapy” either draws fluid out of a joint or injects something into the injured joint, the ultrasound-guided needle therapy allows the sports medicine specialist to use the needle as a very tiny surgical instrument “to either break up scars or poke holes in an injured ligament so that bleeding occurs. The blood cells carry precursors to collagen, which eventually develops into collagen to replace the damaged tissue,” Dr. Nazarian said.All patients are initially injected with an anesthetic into the injured area. “This serves as a useful test to determine if the pathology visualized on ultrasound is the actual cause of the patient’s pain. If the pain disappears after anesthesia we know we are on the right track,” said Dr. Nazarian. But once the anesthesia is injected, the patient may be treated with just “needle surgery” or may receive corticosteroid injections or additional anesthesia. “The advantage to this procedure is that it is so minimally invasive that restoration of function is very rapid, much more so than even arthroscopic surgery,” said Dr. Nazarian. This offers a surgical option for patients who have “tears or abnormalities that are so small that they cannot be fixed by surgeons and yet they are not responding to conservative treatment of rest, ice, and support.” So far, Dr. Nazarian has accumulated more than 300 patients in his series, but he presented data on 273 patients who ranged in age from 13 to 82 years (mean age, 39.8 years). About half of the patients were men and all of the patients had failed conservative management. Patients were treated from December 1999 through January 2002 and all received ultrasound-guided needle therapy using a phased array linear transducer (7.5 MHz to 13 MHz).Two hundred forty-six patients underwent ultrasound-guided corticosteroid injection combined with needle debridement. The range of pathology treated included tendonopathy, tendon tear, muscle tear, bursitis, tenosynovitis, ligamentous injury, and plantar fasciitis. The most common anatomic areas were the common extensor tendon at the lateral elbow and the patellar tendon. The remaining 27 patients were treated with needle debridement without corticosteroid injection.The average procedure time was one hour. Patients were instructed to perform only light stretching for the first two weeks, strengthening exercises from weeks 2 to 6, and then a gradual return to higher-level activities. Symptom relieft was reported by 65% of patients within 2 to 12 weeks, while 35% were unchanged. “But these patients still had all options open to them. Since we didn’t treat with traditional surgery, no bridges were burned,” Dr. Nazarian said. Moreover, even patients who did not improve didn’t have worsening of symptoms. There were no complications from bleeding, infections, or the procedure itself.According to Michael A. Sullivan, MD, associate chairman of the department of radiology at Ochsner Clinic Foundation in New Orleans, Louisiana, using ultrasound to guide needle therapy is a major advance. “For years people have been injecting joints blindly: if it hurts here, inject here. That can be successful, but it can also cause more harm than good. This is really a logical way to improve that approach.”

 

How To Treat Tennis Elbow; Don’t Make This Mistake

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The Internet has lots of information on how to treat tennis elbow (aka lateral epicondylitis) but you need to be careful. Some treatments may leave you worse off.

As a martial artist, chiropractor and father of a young boy, elbow pain should go on the list of eventualities.  At one point when Keegan was younger and wanted to be carried seemingly all the time, I was dealing with bilateral medial AND lateral epicondylitis.  For those of you unfamiliar with the terms, the inside AND outside of BOTH elbows hurt.  A lot.

I’ve always said that the benefit of being in the martial arts for all these years is that I’ve had pretty much everything my patients come in with. And as a chiropractor specializing in treating patient’s pain, anything that I’ve had myself I find that I’m usually better at treating.  And our office is pretty darn good at treating most of what our patients come in with anyway.

With that in mind, I can tell you that treating elbow pain can be tough.  Maybe it’s because by the time patients present for treatment of his or her elbow pain it’s already been going on for WAY too long.  Maybe it’s because we are such a manually-oriented creature and the muscles, tendons, ligaments and fascia involved in elbow pain are constantly being abused.

What many patients who present with elbow pain are not aware of is that the soft tissues surrounding the elbow and associated with elbow pain are NOT elbow muscles.  Rather, they are the muscles involved in finger and wrist movements (which is why treatment of carpal tunnel HAS to involve the soft tissues around the elbow).

Further, while the condition is called an “itis,” inflammation is actually not likely to be present.  Rather, the condition is one of scar tissue.  Overuse the area and inflammation occurs initially.  Since the human body doesn’t heal at 100% some dysfunctional tissue is going to be left after that episode is done.  This is the stage where the use of NSAIDs to calm the inflammation of the initial injury is probably going to leave you with MORE scar tissue.

Scar tissue is easier to injure, so you re-injure the soft tissues of the elbow.  It heals with MORE scar tissue.  The cycle repeats over and over again.  As you can see, the scar tissue is the problem, NOT the inflammation.

This is why anti-inflammatories do almost nothing to fix the problem and why cortisone injections may only make the problem worse.

And just in case you don’t think that’s accurate, let me introduce you to this particular study.

Researchers looked at the use of physiotherapy and cortisone injections on outcomes at one year in lateral epicodylitis (aka tennis elbow–named so for the force on the outside of the elbow when the tennis ball hits the backhand swing).  Here’s what they found:

  • Patients with injections were 14% less likely to report complete recovery or “much improvement” at 1 year over placebo injection.
  • Injectors were 77% more likely to report recurrence at 1 year (Tweet this).

Given that many doctors whip out the cortisone needle before you’ve even gotten the word “elbow pain” out of your mouth, what are you supposed to do?

Here is the way we handle elbow problems in our office:

  1. The keystone of treatment is soft tissue work to the region.  This can include Graston, Active Release or Fascial Manipulation.
  2. Manipulation of the elbow and wrist to make sure the joints in this area do not break down.
  3. Eccentric strengthening exercises to rebuild strong soft tissues after we break them down with the soft tissue treatment.  Use usually recommend the use of a Therabar with some variation of an exercise called the Tyler twist.

You can watch a treatment video on YouTube here.

With this approach, the vast majority of patients will respond very well to elbow pain.  My personal opinion (which is now supported by this article, which moves it more towards “fact” and less my opinion…) is that NSAIDs and cortisone injections are very bad for elbow pain and will likely make the condition MUCH more difficult to treat in the long run.

If you have had elbow pain, what did YOU do to recover?