Tennis Elbow: The Most Misnamed Orthopedic Condition

Fewer than 10% of patients that have tennis elbow actually play tennis. In addition, the medical term for this condition is "lateral epicondylitis." This also is misnamed. Why? The lateral epicondyle is the bony prominence on the outside of the elbow. This sometimes stubborn condition is not a bone problem, but a tendon problem, actually involving what we call the common extensor tendon. This also can be a very humbling condition. It can cause significant pain with some simple, everyday activities- lifting a coffee cup, shaking hands, pulling your bedsheets, just to name a few. Why you ask? Stress to this tendon is not only related to the weight of a lifted object, but also the arm and wrist position. Certain positions cause overloading of the damaged and/or inflamed tendon. Turning our attention to treatment options, there are traditional and innovative options. At Impact Sports Medicine, we actually specialize in both types:

Traditional:

1) REST and changing the biomechanics- how and how much you lift, grip and grab

2) A wrist splint- yes, immobilizing the wrist and forearm unload the tendon far more than immobilizing the elbow

3) A cortisone injection- in our hands, 90% of patients experience relief with an ultrasound-guided injection. However, since tendon damage is often the cause of the stubborn pain, cortisone, at times, may only provide temporary benefit.

4) Physical Therapy- helpful in changing the biomechanical problems that led to the tendon damage. However, the benefit can be limited if tendon is partially torn.

Innovative:

1) The Tenex procedure- a true game-changing minimally-invasive procedure. This is our favorite option for those patients that have not improved with the traditional treatments. Local anesthesia only, a tiny incision, 2 minutes of tendon treatment with a small probe, no stitches, covered by insurance and a 90% success rate. How does that sound? We've loved this procedure for 6+ years.

2) Regenerative injections- platelet-rich plasma (PRP) and amniotic membrane are very solid choices, utilizing solutions rich in human growth factors to stimulate healing of the tendon.

3) Nitroglycerin patches- placed on the skin over the tendon, these are good choices for those patients needing something extra, but prefer a treatment that is non-invasive. These work by producing nitric oxide in the tissues, which then can be responsible for tendon healing.

In summary, we hate that you have "tennis elbow," but love the opportunity to treat you. It's our mission to make this common cause of elbow pain leave your life and never return! Let us know if we can help.

Regenerative Injections- Let's Be Honest Here

Concerned. Disappointed. Those are the first words that come to mind when I read or hear about another non-physician advertising regenerative injections, such as stem cell or platelet-rich plasma. I’ll be honest here…the greatest number of advertisements come from the practices of chiropractors. Here’s the irony: chiropractors cannot legally give orthopedic-based injections. So, what’s the catch? Most hire mid-level providers, physician assistants (PAs) or nurse practitioners (NPs), to give these injections. Mid-levels serve very valuable roles in our healthcare system. Some are skilled enough to provide injections in a very competent fashion. However, our medical system has been designed such that mid-levels are mentored and directly supervised by medical doctors who have expertise in providing procedures such as injections. In the case of a chiropractor’s office, how can the supervising chiropractor mentor or teach the mid-level to do an injection when he or she has never given a joint, tendon or other similar injection in his or her entire career? It just doesn’t make sense, plain and simple. Then, you are talking about very advanced injections, most of which are not covered by insurance and cost the patient hundreds to thousands of dollars. Finally, many of these injections done by mid-levels are not guided in any fashion, meaning neither ultrasound nor fluoroscopy (live x-ray) is used. Thus, the accuracy of the injection is likely less than optimal.

Here’s the bottom line: even with all the radio, magazine, TV and social media advertising done by some practices claiming to be experts in “regenerative injections,” you need to carefully choose who you want to provide these advanced office procedures. I have a very healthy respect for several of my colleagues who are chiropractors. I freely refer to them. They do an excellent job with care of the spine and rehabilitation of some extremity issues as well. However, orthopedic injections are just not in their wheelhouse.

At Impact Sports Medicine and Orthopedics, we have used ultrasound guidance for 10 years and only after taking a minimum of 6 courses on the subject. We are carefully studying the science and trends pertaining to regenerative injections and have provided these to our patients over the past 8 years. We are not the only ones in the Nashville area doing these advanced injections, but you will be hard-pressed to find any practice more experienced or dedicated to the honesty and integrity of the process.

-F. Clarke Holmes, M.D.

The Top 3 Activities that Lead to Summer Injuries in Adults

What are the top 3 activities that lead to summer injuries for adults?

1) Yard work- often a situation of doing too much at one time. Repetitive bending, lifting, pushing and trimming frequently lead to low back, neck, shoulder and elbow issues. Our advice- spread the work load among several family members and among several days. Instead of 4 hours of work on one day, divide the work load into 2-3 days. Get as close as you can to something you are lifting or trimming. Doing these with your arms further away from your body can overload the spine, joints and tendons. 

2) Tennis and golf- these are great warm-weather sports, but lead to a elbow tendon and low back problems quite frequently. The same concept discussed above applies: avoid overuse situations. Play 9 holes instead of 18 on some days. If you are a middle-ager, don't expect to play 72 holes on a weekend and not feel some aches and pain. With tennis, consider playing with a 2-handed backhand. Play some doubles, not just singles, as this can decrease your reps, but lead to similar enjoyment of the game. 

3) Running and power walking- many love just being outdoors for these fitness activities, while others are starting to train for 1/2 and full marathons in the fall. A couple of pieces of advice: if training for a race, follow a program/regimen. 12 weeks to train for a 1/2 marathon, 18 weeks for a full. To all: update your athletic shoes every 9-12 months or if any wear is present on the tread. Also, make sure your other shoes are supportive. Flimsy sandals and flip-flops lead to foot, ankle and knee problems, especially if these areas are already being stressed by other fitness activities. When it comes to summer shoes, to some degree, you get what you pay for. A quality pair of sandals or flip-flops will run you $50-$100. 

Enjoy the summer!

The Guide to Regenerative Injections

Dr. Holmes’ Guide to Regenerative Injections

Regenerative injections are those specifically utilized to promote healing of damaged tissue, reduce or eliminate unhealthy inflammation and slow or halt the progression of soft tissue and joint deterioration. We now use them regularly for tendon problems including tennis elbow, golfer's elbow, the rotator cuff, the high hamstring, patellar and Achilles tendons. We also have seen great success in treating osteoarthritis of the knees, shoulders, hips, thumb and great toe joints. Plantar fasciitis, ligament and muscle tears are great candidates for regenerative injections as well. 

·      Platelet-Rich Plasma Injections

o   Blood obtained from an arm vein is centrifuged for 15-20 minutes, isolating the platelet-rich plasma

o   Platelets are very rich in our natural growth factors (healing agents), and are concentrated 6-10 times their natural concentration

o   Under ultrasound-guidance, the PRP is injected into the damaged tendon, ligament, fascia, joint or muscle

o   Great option for tennis elbow, golfer’s elbow, small rotator cuff tears, small patellar tendon tears, high hamstring tendon tears, Achilles tendon tears, plantar fasciitis, etc.

o   Widely-used also for osteoarthritis of numerous joints

o   PROS: very natural and safe (your blood); used in orthopedics for ~10 years, Dr. Holmes has used for 7 years; numerous medical studies confirm significant benefit; 2-3 areas can be injected at one time; long-term benefit for most patients

o   CONS: these work gradually, over weeks to months; increased pain after the procedure for 2 days to 2 weeks; immobilization required with a splint or boot for some injections

o   UNKNOWNS: length of benefit (can be months to years); number and frequency of required injections. 1-2 injections initially for most soft tissue problems; 2-3 initially for arthritis/joint problems

·      Amniotic Membrane Allograft Injections (brand- AmnioFix)

o   Utilize one of the placental membranes (these cover the fetus during pregnancy) to form a product containing numerous types of growth factors

o   Intended to reduce inflammation, reduce scar tissue formation and enhance healing

o   The membrane undergoes a rigorous purification and sterilization process, and is stored as a dehydrated powder; sterile saline is added to become an injectable solution

o   Great option for plantar fasciitis (#1 use), tennis elbow, golfer’s elbow, small rotator cuff tears, small patellar tendon tears, high hamstring tendon tears and small Achilles tendon partial tears

o   PROS: very safe, with no significant reportable adverse effects; Dr. Holmes has used for 5 years; no rejection, despite not being one’s own tissue; no blood draw required; typically less post-procedure pain than PRP

o   CONS: probably not as effective for joint pain/arthritis; otherwise, same cons as PRP

·      Amniotic Fluid Injections (brand- Catalyst PDA-HAF)

o   Very similar to amniotic membrane injections, but often stored in a frozen form and thawed immediately before injection

o   Contain over 200 different growth factors

o   Great option for soft tissue as well as joint problems such as osteoarthritis

o   PROS: theoretically, a more powerful amniotic product than a dehydrated membrane

o   CONS: more expensive than the dehydrated membrane product

·      Alpha-2-Macroglobulin Injections

o   A natural substance found in our bloodstream

o   Blood drawn from the patient, centrifuged, manually separated and then placed in a separation pump to further isolate and concentrate the A2M

o   45-minute procedure done in one office visit

o   Functions as a “protease inhibitor,” binding the inflammatory proteins that cause the degradation of cartilage in the joint

o   Utilized to reduce pain, inflammation, halt the progression of osteoarthritis and provide “longevity” to the joint

o   PROS: very safe and natural substance; presumed long-term benefit, less post-procedure discomfort than other injections; two to three injection sites can often be chosen with one procedure

o   CONS: newest type of regenerative injection; very few medical studies proving effectiveness thus far, but studies are underway; frequency of injections not known at this point (likely every 6-24 months)

With any of these injections, all forms of ORAL and TOPICAL anti-inflammatories must be stopped for 1 week before and 2 weeks after, as to not interrupt the initial healing cascade initiated by the injections. This includes:

·      Advil/Motrin/ibuprofen

·      Aleve/naproxen

·      Aspirin- any doses above 81 mg

·      Mobic/meloxicam, Celebrex/celecoxib, Voltaren/diclofenac

·      Fish oils/Omega-3 fatty acids

·      Turmeric

·      Oral green tea

·      Glucosamine/chondroitin

·      Arnica

COST: Regenerative injections are rarely ever covered by insurance. Although we closely monitor their coverage status, in the current climate of healthcare and insurance companies reducing their coverage of even typical treatment measures, we do not expect these injections to be covered in the near future.

With rising deductibles, many patients pay out-of-pocket for traditional treatment measures as well. Thus, a regenerative injection may ultimately be a similar out-of-pocket cost to traditional treatments but more clinically effective and cost-effective over the long-term.

A patient should view these injections as an investment into the long-term health of their tendons, fascia, ligaments and joints.

We are here to serve you! 

F. Clarke Holmes, M.D. 

THE ANATOMY OF A LEADER: MY VIEW AS A SIDELINE PHYSICIAN, COACH & PARENT

Over the past 20 years, I’ve served as a coach for youth sports, a team physician working the sidelines & courtside and as a parent of two young athletes. It has been enlightening to observe those athletes who are particularly skilled in their leadership capabilities. I’ve learned that being a leader can take on many forms. There is not a “cookbook” formula, but it is obvious that every type of team needs leaders to succeed. Here are some of the various types of leaders and their attributes.

  • The Encourager - this leader can do so from the field/court or the bench. He (spoken generically, “she” can apply in all situations as well) may be a starter or rarely see playing time. Either way, he’s the one leading the cheers, picking up his teammates when they are down on the ground, congratulating one after a big play or consoling a teammate after a mistake. This type of leader is often an extrovert and tends to be less focused on his own performance.
  • The Leader by Example - this person is often on the quiet side. He doesn’t lead by cheers or many words, but is frequently a workhorse. She is obedient and respectful with her coaches and rarely steps out of line. A coach often asks her to demonstrate various drills during practice. Other players begin to emulate this athlete, and the domino effect has a very positive effect on the team.
  • The Star - this leader is a “gamer.” He wants the ball when the game is on the line. “Ice water in his veins” is a phrase often assigned to this athlete. She inspires her teammates as she does not hesitate to make a big play during a key portion of the game. Even though a excellent player, to effectively be a leader, the “star” must still remain humble and do things on the game or practice field to make his teammates better.

Every team needs leaders. A championship often team has all three types described above. Even if not a winning team, it’s still important to have various type of leaders emerge on each team. These leadership skills often spill into other types of endeavors, perhaps in the academic or business arena. During the formative years, these leadership skills may help your child resist some negative forms of peer pressure.

As a parent or coach, realize that leaders may be born, or they may be made. If you exhibit leadership in your own arena, your children will take notice. Recognize the personality of your child or player and tap into his skill set to develop their particular leadership style. Also, realize that a child or young athlete may be a leader in one field and a follower in another. That is not a weakness, but just a reality. If an athlete gives his best effort in all that he does, then one or more of these leadership styles will often develop as positive bi-product.

Get busy leading!

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics 

Should My Son Play Tackle Football?

"Should my son play tackle football" is a question I receive on a very frequent basis. Parents are more concerned than ever about the risks that come with playing this collision sport. The first question I ask the parent in return is "Does your son really want to play tackle football?" Football is a rigorous, gladiator-style sport. It often pushes boys towards their limits with regards to commitment, fear, body contact and fitness level. These "pushes" can be a positive thing for your son, but if he is not enthusiastic about playing this sport, then your question has been answered. I strongly discourage participation in football if your son doesn't want to be on that field. 

Here are the reasons your son SHOULD play football:

  • He becomes part of a team, something bigger than himself. Bonding is often very high among football teammates, as they adopt an "in the trenches together" mentality
  • Courage, dedication, loyalty, sportsmanship and confidence are valuable character traits that often develop with a successful football experience
  • Improved fitness levels- football is a sport requiring endurance, speed, quickness and power, with some positions emphasizing more of these traits than others
  • Mentoring- many football coaches become like father-figures to young men, teaching them important life lessons while teaching them football as well

Here are the reasons your son should NOT play football:

  • First and foremost, he doesn't want to play
  • The risk of injury. Here are some important injury-risk considerations:
  1. Size and strength deficits- if your son is physically less developed than many other peers competing in football, then his risk is increased. If the team or league is allowing 140 lb. boys block and tackle 225 lb. boys and vice-versa, then the smaller boy's risk is much greater. In the youth leagues, rules are often in place to reduce this effect. In the high school environment, it is up to the coaches to ensure the safety of the smaller athletes.
  2. Concussions- we could create an entire blog on this subject, but in a nutshell, concussions are common at all levels of football. Contrary to most conditions in medicine, concussion symptoms in younger football players often last longer than those more mature. New evidence is suggesting that the earlier the age one starts having concussions, the greater the risk of long-term problems such as memory deficits and depression, just to name a few. Also, the multiple concussions likely create a cumulative effect, meaning several concussions in a relatively short period of time create more long-term damage than one concussion or a few concussions separated by many years. Simply put, someone playing tackle football for 10 years is much more likely to have more concussions, whether diagnosed or not, than one playing for only 3 years. Improved equipment such as helmets and better tackling techniques may reduce the severity and risk of concussions, but no equipment or rule adjustment can significantly reduce or eliminate concussions. 
  3. Orthopedic Injuries- minor contusions and sprains are part of the game for nearly every player and heal without consequence. However, some fractures and ligament sprains, although appropriately treated, leave football players with long-term pain and dysfunction. For example, despite a successful ACL-reconstruction surgery after an ACL tear, 50% of athletes have knee arthritis within 12 years of the injury. In addition, repetitive microinjury to the back likely leads to an increased risk of disc problems in the cervical and lumbar spine. 

When weighing the risk of injury as it relates to football participation, consider not only the immediate impact of injury, but also the long-term implications of concussions and orthopedic injuries.

If there is an opportunity to play flag football, then I encourage one to play this version for as long as possible. In my opinion, tackle football is a sport that be re-joined or joined for the first time at a later age, perhaps 9th or 10th grade without a major roadblock to success. Years of tackle football does not necessarily guarantee success at higher levels such as high school or college. In fact, beginning tackle football at a young age can lead to burnout or injuries that derail one's ability and desire to continuing playing into middle and high school. 

In conclusion, the decision of whether your son plays tackle football or not must be one thoughtfully considered by and discussed among the athlete and his family members. Risks and benefits for your child should be carefully weighed.

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics, PLLC