LIVING WITH CHRONIC PAIN
Over the last 10 months, I’ve been living with chronic pain in my elbow. It was formally diagnosed as lateral epicondylitis (LE), aka tennis elbow. I’m not sure what exactly caused it, but in almost every case it’s an overuse injury, much like carpal tunnel syndrome.
The pain isn’t exactly debilitating, but it does limit a lot of every day activities. Any gripping motion with supination (turning of my wrist) hurts. Basically, everything. The worst part is, the LE affects my right arm. I’m right handed. You get the picture.
WHAT I’VE LEARNED
Lateral epicondylitis, commonly known as tennis elbow but does not necessarily affect tennis players, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons anchor the muscle to bone. With lateral epicondylitis, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.
Lateral epicondylitis hurts. A lot. And, contrary to the traditional RICE (rest, ice, compression, elevation) approach to soft tissue injuries, RICE isn’t the approach to take when dealing with LE. In fact, LE isn’t improved with rest. While some rest may be necessary following certain treatments, eccentric exercises have been proven to be beneficial in treating or alleviating pain associated with LE.
WHAT I’VE TRIED
When I first started feeling pain in my arm, it started at my wrist. As with most muscle ailments, diagnoses and treatments are exploratory. So, with the help of a talented team at Pivot Sports Medicine in Bloor West, Toronto, Dinah Hampson, Jennifer Costa and Dr. Peter Lejkowski, using a combination of physiotherapy, active release therapy, and acupuncture, we embarked on a long road to recovery.
I was given wrist braces, arm braces, nitro patches, used light weight dumbbells, a flexbar, kineseology tape, acupuncture needles attached to an electrical stimulation machine, dry needling (aka intra muscular stimulation), thermal heat treatments, and shockwave therapy. Needless to say, I am pretty much an expert when it comes to understanding lateral epicondylitis and its varied treatments.
Let’s break it down…
WHY: I was initially prescribed the use of a wrist brace before I was diagnosed with lateral epicondylitis. The pain started at my wrist.
VERDICT: While the pain started at my wrist, my wrist wasn’t the problem. Also, the brace was cumbersome and impossible to wear at work.
WHY: In the beginning it was thought I had “gymnast wrist”, an overuse injury of the distal bone in the wrist. This made sense, as all the symptoms I had pointed to this condition. So, we taped it up, as gymnasts would to protect their wrists.
VERDICT: As with the wrist brace, the issue wasn’t with my wrist. Also, this was pretty noticeable and became a talking piece everytime I wore it. I quickly stopped wearing it in public.
WHY: There are no end to the different bands available. Armbands are suppose to provide a sort of counter-pressure on your extensor muscles, thereby reducing the “pull” on where the tendon attaches at the epicondyle (elbow bone). I tried two different types – one that was filled with air, and another that was designed with a gel pad. Both applied pressure between the meaty part of the extensor muscles and the elbow joint.
VERDICT: Neither worked for me. I tried to use them while working out, to reduce pain with any gripping motion (basically, any and every exercise). They wouldn’t tighten enough to create an effective counter-pressure, and both limited my range of motion because of the proximity to my elbow.
WHY: Nitroglycerin patches are typically prescribed to old people with heart conditions. They are used to draw blood to the area they are applied to. This comes at a cost: low blood pressure elsewhere in the body, and severe headaches from the low blood pressure.
VERDICT: I couldn’t give it a fair trial. Waking up at 3am with a pounding headache was far worse than any potential benefit. Besides, studies have yet to show any real benefit from this type of therapy for lateral epicondylitis. With LE, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. Because of this, some research suggests anti-inflammatory therapies are ineffective.
WHY: By the time I reached this therapy option I was desperate. I had been living with lateral epicondylitis for more than 6 months. That’s 6 months of chronic pain, even at resting. Life was hell. The research surrounding working with a Thera-band Flexbar was pretty convincing.
VERDICT: Completing 3 sets of 15 reps with 30 seconds rest between sets was painful to begin with, and it was hard to complete the full required reps. I did notice that as the tendon became stronger by using the Flexbar I was beginning to have full days pain free. Only one or two here and there, but after 6 months of constant pain, a full day here and there was heaven!
If you do decide to try this method, have ice packs on hand to use between and after the sets.
WHY: Blood is your friend when trying to heal injuries. Without getting all technical, blood brings in all the good healing stuff inside your bodies to the affected area and works its magic. The problem arises when inflammation caused by lateral epicondylitis prevents blood flow to the tendon, which in turn slows the healing process – if you follow the belief LE is an inflammation problem. Acupuncture works to draw “energy” to an affected area along the body’s meridian lines. Attached to a transcutaneous electrical nerve stimulation machine (TENS) there is further agitation to the area which tricks the body into thinking it’s being injured. Your body responds by sending all that good blood to the area in an attempt to heal it.
VERDICT: While on paper it seems like this would be the answer, however it didn’t work for me. I had approximatley 10-15 acupuncture needles peppered down the length of my arm, from elbow to my thumb (that one hurt!) attached to an electrical box that sent tingling shocks down the needles into my arm, but it wasn’t enough. The pain was much deeper, and beyond this surface stimulation.
Time to try this next method…
DRY NEEDLING (INTRA MUSCULAR STIMULATION)
WHY: This isn’t a well-known therapy and it really should be! I live and swear by intra muscular stimulation, but it’s not for the faint-hearted.
Unlike acupuncture, which works along meridian lines with the body’s energy, IMS goes straight to the heart of the matter. Long acupuncture-like needles are repeatedly stabbed into the tense muscle or trigger point, until the spasming muscle relaxes and surrenders to the needle. Sometimes it surrenders immediately, while other times the muscle contracts so hard that it grips the tiny needle making it virtually impossible to remove until the muscle relaxes. I’ve bent a few needles in my time.
The “trauma” that the repetitive stabbing creates cues your body to send blood to the affected area, it also works to trick your brain into signalling the affected muscles or tendons to relax. The pain caused by IMS sort of short-circuits the pain signals and scrambles them. This in turn changes the way your brain thinks about the pain at the affected area. Win-win! Relief is almost immediate.
There are very few phsyiotherapists that offer IMS. Dinah Hampson at Pivot Sports Medicine in Bloor West is one of them – and one of the best!
VERDICT: Once I went through all the above, and finally arrived at IMS, only then did I start to really get anywhere as far as pain relief.
Piggy-backing it with shockwave therapy was when I really started to feel I was actually on my road to recovery…
WHY: When you have an internal injury, the body’s response is to throw calcium at it. That’s what my body did and I ended up with calcific tendonitis in my extensors. This was in response to the lateral epicondylitis. Well, that small amount of calcium frickin’ hurt. It caused pressure build-up in my arm, so that when I supinated (turned over) my arm, it hurt. Dinah and I decided to try shockwave to break up the calcium deposits, so that it could be better and more quickly re-absorbed by my body.
Shockwave is painful, and it isn’t cheap. Make sure your benefits covers that sort of treatment before you sign up!
VERDICT: Piggy backing IMS with shockwave once a week seemed to steer me on the right path to pain free. I was experiencing several days in a row without pain, but it would come back – and it still always hurt when I was lifting – which was every day.
With CBBF Nationals to train for, and being at my wits end, it was time to step up my game. It was time to move into the realm of injection therapies.
WHY: When all else has failed, I ultimately arrive here. The cortisone shot. A steroid, cortisone is injected into the tendon – and, in my case, also along my extensors where the calcium deposits were – to reduce swelling.
The only downside to cortisone, and why it is usually the last resort, is you can only get up to three injections of cortisone a year because it weakens the tendon. Also, studies have shown that, despite the immediate relief of pain, symptoms often return 4 to 6 weeks after the injection. This supports the argument that LE is a degenerative tendon issue, over an inflammatory one.
VERDICT: I turned to Dr Tim Galea at the Institute of Sports Medicine, in Toronto, for a cortisone injection. And, since that fateful day, March 5, 2014 – 10 months after the onset of symptoms – I have been pain free (knock on wood!)
However, at the time of writing this blog post, I am only two weeks post injection. And, over the last two days, I have felt small twinges at my elbow. Not pain, but a squeezing sensation. Enough to concern me.
I continue to get weekly IMS treatments along my extensor muscles, to keep them loose and supple. If they are happy, that means less tension on the tendon. I am hopeful the cortisone injection is successful, but as anyone that knows me will tell you, I won’t let it rest. Since I’ve regained full strength in my arm again, I have been hitting the weights pretty hard. I only need my arm to get me through to August 9, my final national competition this season. Only then will I be able to give my arm the pampering and full rest it needs.
If the cortisone injection doesn’t work, there is one more ace up my sleeve…
WHAT: Dr Galea is the Godfather of Platelet-Rich Plasma (PRP) therapy. He’s helped the likes of World champion figure skater, Patrick Chan, and other high profile athletes with this ground-breaking treatment.
The process involves extracting some of your own blood, mixing it with a super-concentrated solution of platelets, which contain growth factors, and re-injecting it into the affected area. The so-called “blood patch” triggers the body’s ability to repair muscle, tendon and other tissue.
Dr Galea promised me that he’s never had a patient who has undergone this therapy for their lateral epicondylitis return for treatment.
VERDICT: It isn’t cheap and is not covered by most insurance plans, which is why I opted for the cortisone shot first.
Watch this space…