My Elbow Really Hurts, and I Feel Like a Wimp!

We hear this comment or one very similar to it on a frequent basis. Good ole’ tennis elbow, also know as lateral epicondylitis. Despite these names, this is not a problem limited to tennis players and does not typically involve the bone on the outside of the elbow named the lateral epicondyle. It is actually a tendon problem. The common extensor tendon on the outside of the elbow is highly involved in gripping, grabbing and lifting. When you shake someone’s hand, this tendon is under a lot of stress. When you lift the coffee mug with a handle, the positioning of your wrist transmits stress to this tendon. When you pull your sheets up to you when in bed, the position and action of the wrist and forearm send stress to this tendon. Finally, when this tendon is inflamed and/or partially torn, it HURTS! I mean, it really hurts. You are not a wimp for complaining about tennis elbow. Fortunately, this is one of my favorite conditions to treat. Why? For many reasons: we usually can cure this problem. Patients are so grateful to see this pain go away. Finally, it’s gratifying to see patients return to things they love to do after successful treatment such as tennis, golf, weight lifting, gardening and even typing!

Turning our attention to treatment options, there are traditional and innovative options. At Impact Sports Medicine and Orthopedics, we 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, typically covered by insurance and a 90% success rate. How does that sound? We've loved this procedure for 7+ years.

2) Orthobiologic/”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 always appreciate 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.

-F. Clarke Holmes, M.D.

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.

My Heel is Killing Me! What is This and How Do I Get Rid of It?

In middle-age individuals, 90% of the time, heel pain is caused by plantar fasciitis. The plantar fascia is a soft-tissue band, technically a ligament, that supports the hindfoot and midfoot. It is quite prone to inflammation, degeneration and tearing. Let’s quickly dive into this common cause of heel pain.

How Does it Present?

·       Heel pain, often sharp, with the first few steps out of bed and after a long day on your feet

·       Pain when rising from a seated position after prolonged sitting, such as in a car

·       In endurance athletes, pain during and after exercise

·       Tenderness on the bottom of the foot, specifically at the heel where the plantar fascia originates

Why Did I Get This?

·       Age- middle-agers are prone to this, as they are very active, but their rate of tissue breakdown exceeds their body’s repair rate. This is why younger individuals do not typically get this problem. They have a faster healing rate.

·       Poor footwear- shoes that are flimsy, too old or generally unsupportive contribute

·       Weight- gaining weight or being overweight overloads the tissue at the lowest point of our body

·       Too much activity/overuse- runners, walkers, and athletes repetitively load the plantar fascia, and at times, are in a situation of overuse or too much, too soon

·       Poor biomechanics- tight or weak calf muscles, a high arch or flat foot or a foot that excessively pronates or supinates can all contribute

How Do I Treat It?

Patience is the key. This condition may require a month or a year of treatment. Recovery can be slow. The underlying risk factors listed above must be corrected. What works for one patient may not be the best treatment for another. Care must be individualized.

·       Rest- yes, this is a dirty, four-letter word for many patients. Plantar fasciitis will NOT improve as long as one continues to run, walk or exercise to the same degree. Sometimes, activity modification will work- fewer miles, less frequent high-impact exercise and/or trying something lower impact such as biking or swimming

·       Improve the footwear and minimize going barefoot- remember with shoes, you often get what you pay for. Don’t go cheap!

·       Physical Therapy- helps most patients, can be curative for those with mild cases. Will not get the job done by itself for moderate to severe cases

·       Orthotics/Inserts- over-the-counter or custom. OTC ones are less expensive and worth a try for mild cases. Custom are more expensive but more beneficial for most patients. Orthotics alone will not cure plantar fasciitis. Other treatments must be combined

·       Anti-inflammatory medications- helpful in mild cases caught early. Not helpful in more severe cases or in patients that have had the problem for months or longer

·       Cortisone injections- occasionally helpful, occasionally harmful. We rarely utilize these, as they don’t promote healing, only reduce inflammation and can increase the risk of further tearing of the fascia. NEVER get a series of 3 cortisone injections as recommended by some.

·       Regenerative injections- very helpful for most. These are meant to “heal the heel!” Platelet-rich plasma, amniotic and umbilical cord injections introduce numerous growth factors to the area to promote tissue regeneration. These are game-changing injections and ones we have provided under ultrasound-guidance successfully now for many years.

·       Surgery- we favor a minimally-invasive procedure called the Tenex procedure. Tiny incision, local anesthesia only, no stitches required with minimal healthy tissue disruption. The “old-school” surgeries require larger incisions and involve “releasing”/cutting the fascia off the bone, are less successful, higher risk and have been abandoned by most orthopedic surgeons

In conclusion, heel pain affects a high percentage of middle-age Americans and can range from a nuisance problem to a disabling one. The key here is to seek care early and from someone who can customize a well-constructed treatment plan for you that has a variety of quality interventions. We are here to help!