“Americans love a winner. The very thought of losing is hateful”
George C. Scott as General George S. Patton in the movie “Patton”
Elbow pain is one of the most common and vexing problems I treat. There are only a few causes of elbow pain, and none of them have a simple answer. In addition elbow pain often affects relatively healthy people in their 40’s and 50’s, and they have a hard time reconciling the limits that these problems can cause on a healthy and active lifestyle.
The most common cause of elbow pain is usually called lateral epicondylitis, which is better know by it’s common name of “tennis elbow.” The pain is located on the outside of the elbow and is usually centered on a bony prominence called the lateral epicondyle. This is the bump that you feel on the outside of your elbow. This area is the attachment point of the muscles that extend of lift up your wrist, and this is the area that’s involved in tennis elbow. The underlying problem is a degeneration of a tendon attaches to the bone. The simplest way to think about this is that the tendon starts to unravel with use and activity, and your body is having a hard time healing this area on it’s own. The symptoms usually begin slowly when people notice a pulling type of discomfort on the outside of their arm with certain activities. Lifting luggage or a coffee pot are two of the most common activities that people describe to me that cause them problems. A small percentage of people, probably 5-10%, actually have pain when they play tennis. In general this starts off as an aggravation but things can spiral and get worse to the point that the pain is noticeable with almost any use of the arm. People rarely have pain at rest.
Most people try to rest their arm and perhaps take over the counter anti-inflammatory medications such as Aleve or Advil. This works a lot of the time. When the problem persists then patients will come to see me or their primary care physician for advice. The main thing I tell people is that this indeed will pass, but it may take up to a year or longer. For people engaged in active lifestyles modifying their activities for that length of time is not much of an option. In addition, the pain can get bad enough that it restricts not only leisure activities but work as well. So when it gets to this point, what can we do about it?
The first step in treatment is a good exercise program. I have a series of exercises that I provide patients. They involve stretches and some gentle strengthening exercises that try to strengthen the muscles that move your wrist. The theory is that if you can strengthen the muscles that are involved in the problem, then there will be less stress on the muscle where it originates at the elbow. I can relate to you first hand that the exercises do work since I have had problems with both tennis elbow and a similar problem called “golfer’s elbow” which occurs on the inside of the elbow. Once I took the advice I give to my patients and started the exercise program my symptoms have almost completely gone away.
Elbow braces are also a good idea for most people. These are usually called counterforce braces, and they generally are straps with a gel foam pad on them. The pad is placed over the area of tenderness on your forearm just past the elbow. The thought is that the pad absorbs the stress before it gets to the tendon and decreases pain. Again, from personal experience, I can say that these pads do a good job of decreasing pain with activity.
If these methods don’t work other options are available. Many physicians will offer a steroid shot into the damaged tendon area to try and stimulate healing. This is somewhat controversial, since some reports seem to show that the shots don’t really make too much of a difference. In my experience the shots can help when the pain is very severe, but that the long term cure rate of the problem will be the same with or without the shot. In other words, the shot can get you through a rough patch.
The last resort is surgery. Traditionally a standard open surgery which consisted of removing the damaged tendon tissue has been the mainstay of treatment, and this is still, by far, the most common surgical treatment for tennis elbow. The surgery works pretty well, and I would estimate that 85% or more of the patients who have the surgery get rid of the problem. There is usually significant down time with open tennis elbow surgery, and it probably takes 3-4 months to completely recover.
Another option is a newer procedure known as the FAST procedure, or focused aspiration of scar tissue. This was developed at the Mayo clinic using ultrasound technology developed for cataract surgery. A small probe is inserted (using anesthesia) into the area of damaged tendon using an ultrasound machine to identify the injured area. The probe then directs ultrasound directly into the tendon and can remove the damaged tissue. In general the recovery is much shorter the surgery is much less invasive than the open procedure. The technique is still new, and there aren’t a lot of reports on the effectiveness of the procedure. I have been doing the FAST procedure for several years, and my experience is that is does work very well, but that there is a lot of variability in the outcomes people experience. I will usually offer the FAST procedure for patients who want surgery with the warning that it probably doesn’t work quite as well as the open procedure.
So if you have tennis elbow, don’t get discouraged. You have a lot of company out there. Try the simple things first and this too will pass. If not, there are options available to get rid of your pain.