Recalcitrant form of tennis elbow

[RiderJen]

I am still trying to resolve a stubborn case of tennis elbow which began in early January while trying to resolve my (still-unresolved) shoulder pain (presumably due to a torn RC). I have had several weeks of PT for tennis elbow, done stretches, tried heat, tried ice, ultrasound, massage, worn the elbow band, and avoided all my favorite activities that aggravate it ---- all to no avail. My PT and sports ortho surgeon are perplexed.

I have listened to and read about countless others who had tennis elbow but found relief by doing just one of the above measures including simple wrist extension/flexion, using the Theraband Flexbar (too painful for my elbow AND shoulder), and deep massage of the area.

My doctor wants to do an MRI of my elbow and may recommend surgery (fortunately, he is not a big proponent of cortisone shots). I had to postpone the MRI for several weeks after coming down with Shingles, which began 2 weeks after a bad cold.

I am wondering if anyone knows why some cases of tennis elbow go unresolved using the same methods that brought relief to others. I'm starting to wonder if I have a strange immune system disorder that causes soft-tissue disfunction. I don't want to have a surgery here, a surgery there, to fix the symptoms of what might be a bigger underlying problem.

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[physiobob]

Interesting you had shingles recently. that indicates a low immunity and you issue might be nothing more than that. i.e. Your body is not healing normally at present and needs time to get itself sorted. if you aren't getting anywhere with a tennis elbow approach one might propose that you don't have tennis elbow. What do you feel is the specific thing you did that has brought on this issue. You mention shoulder rehab. This may be a neurologically referred pain.

[RiderJen]

Thank you. I didn't do anything in particular to bring this on. I was active, riding my bike and going to the gym. I was careful to not overdo at the gym and allow my muscles 1-2 days of rest in between any weight work-outs, and allow recovery days after long bike rides. Though I recovered quickly after each ride, I was beginning to feel like I was pushing myself too much to train for long rides since I still work full-time and can't ride during the week. Overall, I felt like I "needed a break".

The shoulder pain began last September, out of the blue, at home, while I raised my arm to reach for something. First, it was thought to be RC tendinitis, then RC tendinosos. When several weeks of PT for that produced no results (the pain only got worse), doc ordered an MRI which didn't show a lot but some small tears in the sub-acromion space. Since I was not improving (unlike most of the other patients with the same dx at the PT facility), my PT believed I was in the minority who will need surgery, probably to scrape the acromion and open up the space.

By January, while still getting PT for my shoulder, I began to notice some minor pain on the lateral aspect of the muscle just below my right elbow. It worsened after a few weeks so I mentioned it to the doctor on my next visit for my shoulder. He did the standard tests and verified I have tennis elbow. He said he wants to fix the elbow before returning to the shoulder, and sent me back to PT for new exercises to address tennis elbow and also scapular function to support the shoulder. (This doctor is a very reputable shoulder/elbow specialist who works closely with the PT.)

In early April, I came down with a bad cold, and by mid-April, my elbow still showed no sign of improvement. My PT agreed to let me give my shoulder a rest, and talk to my doctor again. He ordered the MRI, which I had to cancel a few times when I developed Shingles (the MRI requires lying very still which is impossible with the nerve pain of Shingles). The pain is gone but the rash is still clearing up.

I have resumed some of my gardening activity just for the sake of my sanity. Being sick for 5 weeks, little exercise, and other stressors about sent me over the edge.

[RiderJen]

Interesting you had shingles recently. that indicates a low immunity and you issue might be nothing more than that. i.e. Your body is not healing normally at present and needs time to get itself sorted. if you aren't getting anywhere with a tennis elbow approach one might propose that you don't have tennis elbow. What do you feel is the specific thing you did that has brought on this issue. You mention shoulder rehab. This may be a neurologically referred pain.

Since recovering from Shingles, I have been resting and avoiding over-activity. However, I need to resume some type of moderate exercise to relieve stress and maintain my cardiac system. I also should start taking a multi-vitamin. I already eat a very healthy diet. My sleep is not good -- I tend to wake up at night every time I roll over, and have to get up very early for work (before 5:00 AM). Other than improving in these areas, is there anything else I could do, but give this more time to heal?

[physiobob]

riding my bike and going to the gym.....long rides

Your comments above could lead to the cause of the problems. I am an avid road cyclist and remember the elbow issues when I first began the long rides (Often to much load on the arms due to poor bike setup and fatigue in the torso). Also the bike setup is very important .

As for the gym there are also a number of exercises that can cause pseudo tennis elbow. Especially barbell work and triceps pushdowns with a flat bar. Perhaps the most important consideration here though is the neck/upper trapezius area. This needs more investigation and a treatment approach. All of your activities impact on that area. Unfortunately gardening might make it all worse.

Seems you need a more thorough assessment. You should not be diagnosed with 'Tennis Elbow' without due cause. This is afterall a chronic condition i.e. it takes a long time to develop and even longer to become painful. Maybe another opinion is worth investigating

[RiderJen]

Thank you for your very thoughtful reply.

With respect to my bike set-up, I've had 2 fittings and I'm certain the bike fits me very well. I have never noticed any elbow or shoulder pain while riding. The shoulder pain began last September but I didn't notice it while riding until December -- even during a challenging metric century ride in November.The elbow never bothered me while riding. However ---- I had Kienbock's disease in my left wrist, which was treated with a silicon spacer put in in 1978. My right wrist has had similar symptoms (poor ROM, popping when the wrist is immobilized) and I've gotten conflicting reports on the x-ray/MRI results as to whether Kienbock's is there or not. All of that to say -- my wrists are not 100%.

Could this be pseudo Tennis Elbow even if the standard strength and ROM tests for it are positive? Are the symptoms exactly the same in either case? Pain is on the lateral epicondyle. Oh -- and this is a recent development in the past few weeks --- now it also hurts to press on the medial epicondyl, but the 'tennis elbow' pain is much MUCH worse. I feel like I'm falling apart.

I will give serious consideration to my neck and upper trapezius -- but how do I find someone who sees outside the box and looks at the whole picture? Finding the right doctor is starting to seem as likely as winning the lottery.

[physiobob]

Maybe one of our USA members will notice this post and can suggest someone. What city/state are you in?

[RiderJen]

Maybe one of our USA members will notice this post and can suggest someone. What city/state are you in?

I am in Southern California, in eastern Los Angeles county. Someone in the San Gabriel Valley, Orange County or San Bernardino counties would be nice.

Is there another forum here where I should ask for a referral?

[RiderJen]

In my quest to heal my recalcitrant tennis elbow, I've run across many sources repeating the standard treatment for inflammation: rest, ice, anti-inflammatories.

And then there are recent sources saying that inflammation is good and the body's way of healing injured soft tissue, and to avoid anti-inflammatories and use heat instead of ice.

When I have taken Advil and used ice, I felt no improvement.

I mentioned this to a Vet friend of mine who explained that some inflammation is healing, but chronic inflammation causes scarring.

What is the truth? Does anyone know? The more I read, the more I think that soft-tissue injury is still very much misunderstood, and wonder if there's a definitive, proven answer.

[Dr Damien]

dear Rider Jen

Tennis Elbow is more degenerative than inflammatory, im not surprised ice is not working as there is very little inflammation going on there...you need a change of lifestyle to avoid irritating the tendon...

cheers

[RiderJen]

Thank you, Dr. Damien. See, this is my point. Most medical resources I've found on-line recite the "ice and anti-inflammatory medication" treatment.

[yelufem]

Inflammation in tissue is generally a cascade of process by which the body heal itself after an injury.At acute stage ,the tissue start to repair itself and this could be sucessful if the environment aroumd the the injured tissue is conducive.A frequent reinjuiry when the tissue is undergoing healing results in fibrous tissue and chronic pain ensue as we have in the case of tennis elbow.Over time ice application alone would not work.
Chronic injuiry repond well to heat atimes:it is believed,heat could trigger fresh inflammation and help the tissue to heal itself.
Clinically speaking inflammation is not bad.In fact,it is a way of body attending to it own problem at a critical time.
To butress Dr damien good point,a change of life style would drammatical reduce your pain.shall come back soon.yelufem.

[physiobob]

You can look on the Physio Directory on PhysioBase - the online physiotherapy community website. There may be some USA listings on there.

[RiderJen]

Thank you both.

By "change of lifestyle", do you mean stop the activities that cause pain until the elbow heals?

Or, my elbow may never be the same again, so kiss those activities bye-bye forever?

[Musculoman]

They mean, change activities until the pain is gone, then slowly return to light activities as tolerated. Further progress back to normal duties / activities as long as they remain pain free. Look at the aggravating activities and try to modify them to decrease the load on your tendon insertion. I.e. get an ergonomic assessment @ work etc. what activity causes you dramas?

What started the tennis elbow? If it is a sport, possibly try looking at your training / competitive schedule and modify it to allow greater time between the most stressful events / parts of the sport. Besically as per many soft tissue injuries, we want you to return to normal function as that will promote normal mechanics and decrease secondary changes (i.e. permanant scarring in the tendon in this case).

Regards,
Musculoman.

[taoist]

HI RJ

Having trained in Chinese acupuncture, the application of Cold is seen to restrict the flow of that which is needed to promote healing, in their terms "Qi and Blood". The normal treatment method is to improve local flow using heat (either Moxa or heat lamps) and needles, probably with electro-stimulation. Ice may be useful in the acute and sub-acute stages, but chronic injury seems to respond better to heat. Injuries such as TE are seen as "Overwork" which tends to cause a local "deficit" of Qi and Blood, leading to "Stagnation" that causes pain and inflammation, so stimulating the area would be the normal approach, depending on the type and age of the person involved. It's a fuzzy kind of logic, but certainly one that is based in years of continuous observation and refining.

I'n my clinic, I'd probably use a combination of heat, massage, needles and electro, and expect to see a positive result in around 6-8 treatments

[mcasus]

I agree that ice in acute and sub-acute stages, and heat in chronic is helpful for most people. But to be clear for the questioner, prior to returning to the activities that caused the TE in the first place, you want to be sure that elasticity has returned to the tissues, which means having some appropriate stretching exercises to do on a regular basis, and some strengthening exercises of the muscles which have no doubt lost some strength after months of inflammation. If you are being followed by a Physio, presumably these techniques have been suggested. If you aren't then I strongly suggest you consult a Physio for a home program of strategies to get you past this.

[RiderJen]

Thank you for your comments; I'll address each topic in a separate paragraph:

CHANGE OF LIFESTYLE:
Aside from my full-time job, my lifestyle activities (prior to onset of this problem) primarily involved cycling and gardening, amateur photography (using a DSLR), baking/cooking, and knitting. I also enjoy (er, enjoyed) fitness walking and trips to the gym to work out on the spin bikes, eliptical machine and/or treadmill, along with some of the arm and leg machines (NO barbells). I took rest days --- I'm NOT an exercise/activity fanatic, just try to have some exercise most days of the week. I haven't ridden my bike since last December when my doctor restricted me from riding, gardening, and every other fun activity that might cause pain in my shoulder (until February, I was getting PT for rotator cuff tendinosis/tears). I also stopped gardening and knitting and rarely took pictures of the garden since the garden was going to pot anyway. After months away from our cycling group (a MAJOR source of social activity and sunlight) and gardening, I was starting to feel depressed. Desperate, I started doing some "light" gardening, taking care to use good body mechanics, wear my elbow band, and use my left hand whenever possible. I've also been taking some garden pictures which I share and keep to record progress -- a hobby that brings me great pleasure. I stopped baking and knitting because they aggravate my shoulder and elbow -- but, so does taking pictures and gardening. Meanwhile, I caught a bad cold in late March, then Shingles in early April; sick for 5 weeks, I didn't do any exercise which led me further down the slippery slope of mental depression. I'm recovered from those now, but there are other signs of a weakened immune system. I have ALWAYS been a very healthy person and wasn't often sick. I had an ergonomic evalauation of my workspace, which seems to be fine (I also sit in an ergonomic chair which I love).

ONSET/TREATMENT
The tennis elbow pain began in early January while I was under the care of a physiotherapist and sports orthopedic surgeon for the treatment of rotator cuff tendinosis/tears. Shoulder PT began last November, and the pain only worsened each week while I obediently and religiously followed their instructions to the letter doing the exercises and stretches at the PT appts. and at home. They finally decided that PT wasn't really helping my shoudler and that things looked very likely I'd need surgery, so we stopped shoulder exercises until my next doctor appointment in mid-Feb. Meanwhile, the tennis elbow pain began in early January and by mid-February was much more painful than my shoulder; my doctor wanted to focus on healing the elbow before resuming treatment of the shoulder, so he sent me back to PT for new stretches/exercises as well as ultrasound, massage, and and the elbow band --- however, like the shoulder, the elbow continued to worsen. Perplexed, my doctor (a very reputable sports orthopedist who specializes in elbow/shoulder injury) ordered an MRI which I had to postpone 2x due to Shingles, and seemed ready to advise that the next step is surgery (he is not a proponent of cortisone shots and didn't seem to think it would help in my case). I stopped seeing the PT until the MRI to determine how to proceed, and the MRI is still pending while I decide what to do next.

ACUPUNCTURE
Funny you should mention that --- a member of our bike group asked if I've tried acupuncture. What do I look for in a good acupuncturist to treat tennis elbow?

OTHER
I am doing some stretching and mild strengthening exercises at home, using the book "Fixing You: Elbow and Shoulder Pain" (by Rick Olderman), to keep my shoulder flexible and improve scapular strength. I do them with care, following his instructions, to stay within the boundaries of pain. Pain has not improved (yet) but my shoulder ROM seems excellent. This Friday, I have an appointment to consult with a DO who performs Prolotherapy treatments. She is highly trained in the field. On the first visit, she will spend an hour assessing me which will include an ultrasound test of my elbow; if I qualify for Prolotherapy, she can do a treatment on that day. I need to get verification that my insurance will help pay for Prolotherapy; if not, I may seek another type of treatment.

Am I frustrated? Very much so. Every physical activity that I enjoy causes pain, including walking (due to the natural arm-swinging motion... nothing vigorous, just the natural movement causes intense pain in my elbow). One activity that also causes a lot of pain is getting ready for work in the morning --- it's impossible to put on make-up and style my hair with one hand. I vanpool to save gas $$$$$$$ and to also avoid stress on my elbow while driving (my car has a manual transmission); the van leaves at 5:35 AM, so my morning routine is rushed starting when I hurl myself out of bed after a poor night's sleep. By the time I'm on the van, my elbow is a wreck and doesn't settle down until a few hours later. So, I could say that the activity that causes the MOST pain is getting ready for work, but that's one activity I cannot curtail. :-(

[Musculoman]

Hey again Jen,

Your history sounds quite depressing, I hope things start to turn around. I would definately suggest getting the MRI. I would also query the diagnosis some more. Tennis elbow can sometimes be misdiagnosed, it stirs my curiosity in that your elbow aggravated following your shoulder rehab. Generally, the acvitiy in the upper limb on a whole is decreased while suffering with a primary injury up the kinetic chain. Sure, you may have been altering your activity in a way that caused overactivity of your wrist extensors ... but I would ask the specialist about things such as.. radial tunnel syndrome and possible neural impingement in the shoulder following the RC injuries causing referral? Clutching at straws, but it sounds as if you are doing everything right with no change in symptoms.

It would be quite amazing however for multiple physio / specialists to misdiagnose such a well known injury though.. :S? You could try a wrist splint to completely offload the wrist extensors for a period, especially at night? Just throwing ideas out there.

Chin up though, surgery has good success rates where conservative management has failed (this will likely be the next course of action following the MRI). Has the Dr. tried corticosteroid injections? Also another good idea before surgery...