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June 1999 Issue
Tennis Elbow ... What a Pain!
by Michael Fick
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Go ahead ... cripple your arm ... permanently and irreparably. It's simple; just gut out your tennis elbow pain like a MAN. Ignore that nagging, sometimes searing, pain in your elbow, or take pain pills to cover it up, and keep on doing whatever hurts. Then every stroke of that hammer, screwdriver, racquet, golf club or other toy or tool will further damage the arm, causing more pain, increasing the inflammation, etc., until you run screaming to the doctor, unable to turn a door knob. Maybe you'll get your surgery in time to prevent permanent, crippling damage.

Tendons connect muscle to bone, and can get inflamed (tendonitis) by overuse, especially with repetitive impacts, with that muscle. In the case of "tennis elbow" -- whatever its cause -- the tendons involved are just below the outside or inside bony points of the elbow.

Hold your elbow against your side and lay your affected forearm out in front of you, palm and inner forearm facing up. With your other hand, locate the prominent bony side points of the elbow, one on the outside (lateral side) of the elbow and one against your ribs (the medial side of your elbow). The point where your funny bone is, which is now pointing down, is not involved. The affected tendons (epicondyls, in this case) and muscles run from those points down the forearm towards the wrist at the thumb, one down the outside of the forearm and one down the inner forearm. These muscles are involved in many hand and forearm motions, and when they get inflamed, those motions hurt like blazes and cause more harm.

Excruciating pain is nothing to laugh at, and suppressing the pain allows pathological damage (the kind a surgeon can see inside your arm) to progressively erode the tendon and its "bed" ... possibly permanently.

It's simple to determine whether your tennis elbow (epicondylitis) is lateral or medial (so you know how to treat it). If the pain is on top of your forearm, running from the lateral bony elbow point towards the thumb, and hurts when you raise your middle (finger) finger against resistance while palm-down, that's lateral epicondylitis. If your pain is just above the medial bony elbow point (the point which brushes your body when you walk), and hurts when you use that arm in many activities from walking to making the bed, that's medial epicondylitis. It's easy to find the exact spot of medial epicondylitis just by pressing a finger even gently into the soft tissue just above that inner bony point. You'll know when you find the sore spot.

To prevent tendonitis from progressing to intense pain, tissue damage, and ultimately disability you must take four steps:

  1. stop the pain;
  2. minimize using those muscles;
  3. cure the inflammation;
  4. rehabilitate the muscle so the cycle does not repeat.
If you take these steps early, the cure is cheap, simple at home or the office, and painless; takes little time or effort; and is highly effective. Let it go too long, and you're in expensive, painful, prolonged, recurring, deep kimchi (I knew I'd work food in here somehow).

Step 1: stop the pain. Options: take drugs and/or put a Velcro tennis elbow strap on the arm just below the elbow. The arm band switches off the pain instantly, and may reduce tendon irritation somewhat. Simple analgesics (pain killers) such as Tylenol hide the pain without combating the inflammation, thus invite further injury and permanent tissue damage (pathology). Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) ranging from aspirin to Motrin to the new Celebrex attack the underlying problem -- the inflammation -- but also attack thousands of patients' stomachs to produce pain, ulcers, hemorrhage, even death, with long-term use. (No, Celebrex doesn't stop this threat; it merely reduces it.) Besides, NSAIDS can interfere with the tissue repair process in the long term. Step 1 must be used with Steps 2 and 3 to avert worse problems.

Step 2: stop irritating the muscle involved. Whatever produced the problem, stop doing it so the body can heal itself. Sound simple? It is ... if you can spare that arm for many months -- maybe even a year -- while it heals passively.

Uh, I think you want to include Step 3: actively heal the inflammation. Along with rest and maybe drugs, you want to stretch, exercise, and ice the muscle properly. Here's your Step 3 -- your healing -- regimen of stretching, exercising, and icing.

Stretch the muscle for 20-30 seconds, shake out the stiff wrist caused by the stretching, and stretch again, repeating as many times you can in five minutes. Stretch by holding the arm out in front of you with its elbow locked straight, palm down for lateral and palm up for medial. Then use your good hand to bend the limp wrist downward until you feel the stretch in the sore area. Once you learn the stretch, you can press the hand/wrist in the proper direction by just sitting on the floor and pressing the hand against the floor with the elbow straight to achieve the same stretch.

After stretching for five minutes, sit on the couch, rest your forearm on your knee and do 20 slow wrist curls, palm up for medial or palm down for lateral, using just a pound of weight -- no more than two or three pounds even for muscular men. Hold each curl at its top for 5 seconds. This is not meant to build strength yet; that's why the weight is so light. It is meant just to align and move the inflamed tendon, not stress it.

Then massage the painful spot firmly with ice, keeping the ice moving to prevent frostbite. Freeze water in little Dixie cups for this purpose, and tear off the top half of the cup to expose the ice. Icing should be done for 5-10 minutes for lean arms, 10-20 for fatter arms that may insulate the tendon.

Repeat Step 3 two or three times a day for a few weeks, depending on how bad it is. Your physical therapist (PT) can tell you when the time is right to start Step 4, rehabilitation, with strengthening exercises s/he will recommend. Start rehab too soon, and your problem can get worse.

Step 4 -- strengthening and rehabilitation -- will prevent reoccurrence. Work out with increasing effort to strengthen the muscle, then keep it strong with moderate long-term exercise as prescribed by your PT, and the problem should not occur again.

No, I didn't forget to mention local corticosteroid injections. They ease the pain only temporarily, and repeated injections permanently weaken tissue, impairing tendon integrity and strength.

Don't rely just on this brief advice. See your doctor for proper diagnosis and perhaps to try some NSAIDS under medical supervision (OTC dosages won't do much to heal the inflammation, and prescription doses can be dangerous). And see a PT for detailed evaluation and treatment. This is no time to be macho.



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