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Melanie Cole (Host): Tennis elbow or lateral epicondylitis is a painful condition of the elbow caused by overuse. Playing tennis or other racquet sports can cause this condition. However, interestingly, several other sports and activities can also put you at risk. My guest today is Dr. Craig Kimmel. He’s the Director of Primary Care - Sports Medicine at Lourdes Health System. Welcome to the show, Dr. Kimmel. So, let’s discuss tennis elbow. What is it?

Dr. Craig Kimmel (Guest): Well, that sounds great. Well, tennis elbow is actually inflammation which can eventually lead to scar tissue at the elbow. It is in the area of the extensor tendon. It’s on the outside of the elbow and it is an inflammation which usually happens from overuse.

Melanie: So, overuse meaning if they’re playing a racquet sport or in some sort of activity that makes them move their elbow? People don’t always understand if this is something they’re doing with their wrist and forearm or with their elbow itself.

Dr. Kimmel: Right. So, that’s a great question. Most often, the overuse is actually at the wrist and not the elbow. Today, although my practice is sports medicine, the most common thing I see causing tennis elbow is typing without having the arms or wrists supported, where you’re extending or causing the wrists to go back in a typing motion repetitively. That can be typing on a keyboard, typing on a text message with your thumbs. It can be from holding up an electronic device like an iPad or other tablet reader. That tends to be a really common source of tennis elbow when the arms aren’t supported. Of course, we still see it in a lot of racquet sports like tennis if the technique is not good, or racquetball. You can even see it in things like golf--if the golfer is a newbie and will ground his racquet into the turf, that can also cause tennis elbow.

Melanie: I've seen that myself when golfers hit the ground and that causes that pain. So, what can you do if you start to feel the pain? Is this a chronic condition? And, can it go away?

Dr. Kimmel: Well, most of the time, luckily, tennis elbow does not become a chronic condition. Most of the time, it will go away on its own. As soon as people feel the pain, most of the time, they’ll stop doing the offending activity. They’ll associate, “I do this and it hurts so I’m not going to do it.” So, most of the time, people will stop that. People oftentimes will apply ice to bring down the discomfort. They’ll oftentimes try anti-inflammatory medications such as Motrin or Aleve, again, which can bring down the discomfort. Online on many websites like WebMD and Mayo Clinic and our own Lourdes website, we have lists of eccentric exercises to do which are stretching exercises where you’re actually lengthening the muscles of the forearm as you move them. That stretches out that tendon and can help relieve it, and most of the time, that’s going to be enough to get you feeling better.

Melanie: So, we see some braces on the market, and people put them just below the elbow. Do these do any good?

Dr. Kimmel: Well, the braces for the most part, make you feel better. They take a little bit of the pressure off of the insertion of the tendon, where the tendon attaches to the bone, and they can make people feel better. There are literally hundreds of different varieties of these. Some of them are better than others, and what I find is some are tight like tourniquets, and people will get them on and they feel like their circulation is cut off and, obviously, that’s not helpful. And, others are too loose so if they try to wear them during their sport, they flop and come off. So, it’s important to get one that has Velcro and fits well, and has a little bit of softness to it so that it won't be uncomfortable when you wear it. Many people now are using full length elbow sleeves instead of those little straps and the longer length elbow sleeve can give you a little bit of more gentle compression and cover more of the muscles towards the wrist which can actually be more comfortable than those little bands.

Melanie: What about steroid injections? Are those helpful? And, how often can you get them?

Dr. Kimmel: Yes, steroid injections are something that is highly debated. I guess the bottom-line on steroids injections is, I think all doctors would agree that they’re not great. Steroids basically bring an anti-inflammatory dose right into the area where the discomfort is. And, if you have acute tennis elbow which is a tendonitis, an inflammation of the tendon, an injection could be done under ultrasound where the physician can see that inflamed area, inject a little cortisone around it, and it can give you dramatic, quick relief of the symptoms. In an inflammatory condition, the first several weeks of the problem, that tendonitis can go away, that inflammation, and then, with some stretching exercises we discussed, it can get better. The problem is that many people don’t slow down and don’t stop their activity, and get a more chronic condition, and seek multiple doctors or a single doctor to give multiple shots, and that can cause weakening and damage to the tendon, and weakening and damage, potentially, to the bone as well.

Melanie: Can physical therapy help with this?

Dr. Kimmel: Physical therapy can be very helpful. There is massage called “Graston massage” which is vigorous rubbing which can break down scar tissue and increase circulation in the area. There are other types of that vigorous massage that can be done by them. They also can teach you how to do those eccentric exercises where you’re going to be lengthening the muscle as you move it, and that will help stretch it out, as well as some strengthening exercises that can be very good.

Melanie: What about PRP? That’s another thing that people are hearing about. Is that being investigated for its effectiveness? Does that work?

Dr. Kimmel: Sure, absolutely. PRP or “platelet-rich plasma” uses the theory that the body’s bloodstream has healing chemicals in the platelet-rich section of the blood. So, if you think about it, if you cut your skin, you bleed, and that blood has chemicals which tell the skin to mend. If you break a bone, the bone bleeds, and the blood has chemicals which tells the bone to mend. Well, we can take the blood from your arm like you would get from a cholesterol test but instead of spinning it 30 times a minute, we could spin 5000 times a minutes, concentrate those platelets 500 times greater with the healing chemicals that they contain. We can then inject that into the damaged tissue which can help it to heal when your own body couldn’t do it. There have been a couple of studies sponsored by the National Institute of Health that have actually shown this to be safe and effective. The downside for this, of course, is that currently very few insurances are covering it, and it can be somewhat on the expensive side in the neighborhood, on average, of around $500 per shot. But, it does work.

Melanie: What about surgical intervention? When does tennis elbow require that?

Dr. Kimmel: Well, surgical intervention is always our last resort. There are things like stem cells, there are things like Botox injections. There are, as you said, the physical therapy, and those things work. If surgery is necessary, which is rare--and it does happen in those people who, despite all the conservative things, it doesn’t work, and they continue to have significant pain and disability. The procedure which we like the best is something called Tenex, T-E-N-E-X. Tenex was invented by Mayo Clinic, and is a complete revolution in the treatment of tendinopathy. Basically, you make a little numb area in the sore area by the tendon. Under ultrasound guidance, you make a tiny little incision about the width of the end of a pen, and through that tiny incision, you take the Tenex instrument under ultrasound guidance in an outpatient setting, and point it at the tendon. It vibrates the tendon and, just like a singer can vibrate a glass and break it without breaking the glasses of the window because it’s the correct frequency, the Tenex can break down the scar tissue which traps the nerve tissue in the tendon, break it down, and then it’s rinsed away. They put a little steri strip tape on there. You don’t need any stitches or anything. You walk in and you walk out. You don’t need any anesthesia. Ninety percent of the people who are treated with the chronic tennis elbow get complete relief with this Tenex procedure. It’s covered by insurance, it works very well, and people maybe need a little Tylenol or Advil after. That’s the worst pain, if any, because the only cut is a tiny cut in the skin. The traditional surgery is almost never needed these days--the Nirschl procedure—and where the Tenex people have it on a Friday, go back to work on Monday, the open surgical procedure people are often out of work for two to three months. So it’s big deal that’s rarely done today--luckily not necessary.

Melanie: Such great information, doctor, so important. In just the last few minutes, please wrap it up for us. Give your best advice for people that are starting to feel that pain on the outside of their elbow, they’re not sure what to do about it, and why they should come see you at Lourdes Health System.

Dr. Kimmel: Well, again, I think that the important thing is to try to discontinue the activities that are causing the problem. If that and a little bit of pain medication over-the-counter and ice do not solve the problem, coming to see us is a good idea because, a lot of times, the issue is not just that you have the pain in the tennis elbow but the activity that you’re doing incorrectly causing it. And, we can help-- whether it is a tennis stroke that’s improper or the tension of tennis strings, the mechanics of your stroke, whether it came from your job or texting, and how do I get a workspace that works right. So, our whole thing is not just about getting you over the acute injury but trying to prevent futures injuries, and allowing you to do those activities that you want to do, the way you want to do them, for the rest of the your life.

Melanie: Thank you so much, Dr. Kimmel, for being with us today. You’re listening to Lourdes Health Talk. And for more information, you can go to lourdesnet.org. That’s lourdesnet.org. This is Melanie Cole. Thanks so much for listening.