My elbow is killing me
By Bruce I. Minkin, MD
“My elbow is killing me! It’s been going on for months and nothing I do is making it better. It keeps me awake at night. Even lifting a cup of coffee hurts my elbow.”
If you identify with these complaints, you just might have lateral epicondylitis or tennis elbow. If you do, you are not alone. In the US, over 200,000 people a year develop this painful elbow condition.
What is tennis elbow? This condition is a chronic tear of the fibers of the extensor tendons of the forearm. These are the muscles that lift up the fingers and wrist. Specially one of the wrist extensors develops a tear where it attaches to a bone prominence on the outer side of the elbow.
Unfortunately, this lateral epicondylitis represents an aging process. It is rarely seen in young adults under 30 years old. As the tendon insertion ages, the fibers become weakened. Sometimes the symptoms develop after an acute injury but more commonly occurs with repetitive activities that involve repeated wrist lifting and rotation.
I compare the process to a plastic lawn chair that’s left outside for months. The plastic fibers degenerate and become brittle. Then fat Uncle Mort plops down on the chair and the bottom falls out.
For lateral epicondylitis, activities like tennis can start the process. But you don’t have to play racquet sports. The condition is frequently seen with carpenters and factory workers who do repetitive twisting of the forearm. Recreational weight lifters who do exercises like curls and bench press can also develop the condition.
Medical epicondylitis is also a common elbow complaint. This chronic irritation occurs on the medial or inside aspect of the elbow. The flexors of the wrist and fingers insert on a bone prominence on the inside of the elbow. The flexors of the wrist and fingers pull down the fingers and wrist. Activities that involve forceful wrist flexion can rupture the tendon insertion similar to lateral epicondylitis. Golfers elbow is a common name for medial epicondylitis. It is also frequently seen with racquet sports like racquetball which uses the flexors more aggressively.
Symptoms of either lateral or medial epicondylitis are usually very localized to the bone prominence in an area the size of the end of your thumb. Other conditions that can cause elbow pain in the area are arthritis of the elbow joint or compression of the radial nerve in the forearm. These conditions are separate anatomical problems requiring different treatment protocols.
The frustrating aspect of lateral epicondylitis is that it can last a long time and not get better with standard conservative treatment. Some physicians suggest that the problem will go away with strict limits of activities and time. But it is difficult to totally limit activity for years and put up with the pain for a protracted period of time. A common practice for tennis elbow is a steroid injection.
Some people report relief but it is usually temporary. To me, steroid injections do not make physiologic sense. The condition is a mushy degenerated tendon and we know that steroid injections will degenerate soft tissue. What usually happens is a short period of decreased inflammation followed by return of symptoms after steroid injection. Forearm straps don’t help the condition and can cause compression of the radial nerve.
The treatment I have used for this condition is called a Blood Patch injection. I personally developed chronic lateral epicondylitis over 25 years ago. It bothered me for over a year and I had 3 steroid injections with no relief. I read an article on this technique in the medical literature. The Blood Patch injection relieved my symptoms within a month and have not returned in 25 years. I compare this technique to having a hole in your plaster wall. You fill it with spackling compound and when it hardens the hole fills in. When this happens the symptoms resolved.
Since I first did this procedure on myself, I have used Blood Patch injections for medial and lateral epicondylitis with good results. My patient’s response has been similar to reports in the medical literature. Over 90% of patients have relief of pain and return to normal sports and work activities without surgery. No procedure is 100% guaranteed. Patients who tend not to respond have had protracted pain for over a year, prior steroid injections, and massive extensor tendon tears.
Surgery for lateral epicondylitis is an option for refractory cases. But the concept of surgery is the same as Blood Patch injection. The object is to create scar at the bone insertion. The problem is that if surgery does not relieve pain, there is little else to do for treatment.
The procedure of Blood Patch injection takes about 15 minutes in the office. The painful area is identified and anesthetized with a small injection of lidocaine. About 2cc of blood is withdrawn from the arm similar to getting lab work. The blood is mixed with long acting numbing medicine and injected into the torn tendon that was previously anesthetized. I tell patients that it will hurt for a few days after injection. Improvement is usually noted in 3 weeks and commonly gone by 2 months.
There are other more complicated injection procedures like PRP (Plasma Rich Platelet) injections. I like my procedure because it is safe, effective, and inexpensive.
Why put up with pain when there is a safe, effective, non-surgical option? Blood Patch injection can help that elbow that is killing you, and get you back to the activity you enjoy doing.
Bruce I. Minkin, MD
with Carolina Hand
& Sports Medicine