Can Botox injections offer relief from the pain of Tennis Elbow?

June 6th, 2010 Comments Off

Botulinum toxin, which irons out facial wrinklesthrough injections of the drug Botox, can provide relief for “tennis elbow”, claims a new study.

But the injection of botulinum toxin needs to be injected properly to avoid potential paralysis, states the research article in CMAJ (Canadian Medical Association Journal).

The study, a randomized controlled trial of 48 patients, was performed at Imam Khomeini Hospital Complex, affiliated with the Tehran University of Medical Sciences that serves patients from all over Iran. It was conducted to introduce an easy and effective method for injection of botulinum toxin to be used in routine practice. Instead of a fixed injection site physiciansdetermined the injection site based on each patient’s forearm length. All participants’ used in the study had undergone previous therapeutic interventions that failed.

It is very important when paralyzing a muscle to know the appropriate injection site. Injection at a fixed distance from anatomic landmarks, as was performed in previous clinical trials of botulinum toxin for the management of lateral epiconylitis (tennis elbow), could result in inadequate paralysis.

“We found that pain at rest and pain during maximum pinch were significantly reduced in patients with lateral epicondylitis [tennis elbow] after botulinum toxin was injected at the site based on precise anatomic measurement of each patient’s forearm length,” write Dr. Mortazavi, Iman Khomeini Hospital, Tehran University of Medical Sciences, Iran, and coauthors. “However, this method caused a decline in maximum strength and resulted in extensor lag.”

The authors conclude that precise measurement to guide injection of botulinum toxin can be effective in the management of chronic “tennis elbow”. However, it should be used for patients whose job does not require finger extension.

So, Botox can assist people.. but not if they need to use their hands due to the paralysis.

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Tenease – effective treatment with vibration therapy

June 5th, 2010 Comments Off

A short video from a company called Win Health who stock Tenease, a vibration therapy device for treating tennis elbow. Tenease has slowly become the recognized treatment at home for the condition.

You can purchase a Tenease device from the website at http://tenease.com

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Strapping and bracing – what is it best for?

June 5th, 2010 Comments Off

How Do Tennis Elbow Straps Work?

The theory behind counter-force bracing is similar to the mechanics of a guitar.  When a finger is placed on a string along the neck of the guitar, it reduces tension on the string distal to the fret where your fingers are located.  A counter-force tennis elbow strap can be thought of as your fingers on the neck of the guitar (your forearm) and the extensor muscles, especially the extensor carpi radialis brevis, would be the guitar string, thus reducing tension of the muscles as they attach to the lateral epicondyle.  The authors of the study review this concept well.

Counter-force Bracing is Effective

Results indicate that strapping was effective in allowing subjects to produce significantly more pain-free force.  Subjects were able to produce 16% more strength without pain using a strap.  There was no difference between two of the devices they used (a strap vs. a sleeve with a built in strap), indicating the strap itself is likely the significant factor.

One of my original concerns with the study involved the rest time between repetitions of grip strength.  As anyone that routinely assesses grip strength knows, the amount of force produced can drop significantly if the rest time between repetitions is not adequate.  However, the study design used a mean of 4 repetitions for each device and allowed 5 minutes of rest between testing sessions.  This was adequate for me and I was happy to see this methodology.

Clinical Implications

  • I like this study because bracing is simple, cheap, and effective.  People can go to any CVS or Target and get a nice tennis elbow strap these days.
  • Counter-force tennis elbow straps are effective at allowing patients with lateral epicondylitis to produce more grip strength with less pain.
  • The strap should be placed around 2.5 cm distal to the lateral epicondyle.
  • While it is unclear if the size of the strap is important, the study used straps that were between 5-8cm in width.  Considering there is some conflicting results in the literature, I would recommend you try to replicate the width of the strap.  There are some straps on the market that are very skinny.
  • Straps can be an effective way to allow people with lateral epicondyltis to return to athletics or weight lifting when painful gripping can severely limit activities.

Read the research

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The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis.

June 5th, 2010 1 Comment

STUDY DESIGN: Controlled laboratory study using a randomized crossover design.

OBJECTIVE: To determine the immediate effect of 3 common types of orthoses (2 elbow counterforce orthoses and a wrist splint) on grip strength in individuals with lateral epicondylosis.

BACKGROUND: Lateral epicondylosis is a common cause of pain and upper limb dysfunction. Although the effectiveness of orthoses has been reported, comparisons of effectiveness among orthoses are limited.

METHODS AND MEASURES: Fifty-two subjects with lateral epicondylosis were recruited (20 men, 32 women; mean +/- SD age, 41 +/- 8 years). Maximum and pain-free grip strength were assessed using a digital hand grip dynamometer immediately after the application of each orthosis. The 4 testing conditions included a placebo orthosis as a control condition, an elbow strap orthosis, an elbow sleeve orthosis, and a wrist splint. Data were analyzed using a 1-way analysis of variance for each outcome measure.

RESULTS: Pain-free grip-strength was greater when using the elbow strap or the elbow sleeve orthosis compared to when using the placebo control orthosis or the wrist splint (P<.02), but there was no difference between the elbow sleeve and strap orthoses (P>.05), nor between the wrist splint and placebo orthosis (P>.05). Maximum grip strength was less when using the wrist splint compared to when tested with the elbow sleeve or the elbow strap (P< or =.003). Use of the elbow strap, elbow sleeve, or wrist splint did not change maximum grip strength compared to the control placebo orthosis condition (P>.05). There was also no difference in maximum grip strength between the elbow strap and the elbow sleeve conditions (P>.05).

CONCLUSION: The use of the 2 types of elbow orthoses (strap and sleeve) resulted in an immediate increase in pain-free grip strength. No differences between the 2 orthoses were found, suggesting that either can be used. A wrist splint produced no immediate change in pain-free or maximum grip-strength, indicating that it should not be used as a first-choice orthosis based on those outcome measures.

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How many steroid injections can I have?

June 5th, 2010 Comments Off

How Many Can You Have?

There is no rule about the number of cortisone injections a person can have, but there are some concerns with repeated cortisone injections to one area of the body:

  • The cortisone injections are not helping
    If one or two cortisone injections into one region do not help a problem for a sustained period of time, then it is unlikely that more cortisone injections will be of any benefit.
  • Repeated cortisone injections are not healthy for tissues
    Small amounts of cortisone in the body are probably reasonable, but repeated injections can cause damage to tissues over time. Sometimes this is of little concern. For example, if a patient has severe knee arthritis, and a cortisone injection every 6 months helps significantly, then the number of injections probably does not matter too much. On the other hand, if a patient has shoulder tendonitis, but an otherwise healthy shoulder, the number of injections should probably be limited to prevent further damage to these tendons.

So what is the bottom line?

There is no hard and fast rule that says how many cortisone injections can be given over time. However, cortisone injections can have side effects, and repeated use of cortisone injections should be done with caution. Patients should understand that there are reasons not to use cortisone injections, even if they may help some symptoms. Because of this, most orthopedic surgeons will limit the number of cortisone injections they will offer to a patient.

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Steroid injections for tennis elbow pain relief

June 5th, 2010 Comments Off

Cortisone injections are very safe to perform. Side effects tend to be rare and minor. However, there are a few potential side effects of a cortisone injection that patients should know about.

Systemic Side Effects

Systemic side effects occur as a result of a small amount of the cortisone entering the bloodstream and affecting your entire body, not just the location where the cortisone was given.

Systemic side effects of a local injection of cortisone are rare and usually minor. Unlike taking oral steroids, or having cortisone injected directly into the bloodstream, only a small amount of a local injection is absorbed by the body. And since the body actually produces cortisone naturally, most people do not experience systemic effects. Those who do may experience:

1. Elevated Blood Sugar

The most common systemic reaction is seen in diabetic patients. Patients with diabetes should carefully monitor their blood sugar as cortisone can cause a temporary rise in their levels. Patients taking insulin should be especially careful, checking their blood sugar often and adjusting the insulin doses, if necessary.

2.  Facial Flushing
Patients may experience flushing sensation and redness of their face. This reaction is more common in women and is seen into up to 15 percent of patients. This can begin within a few hours of the injection and may last for a few days.

Local Side Effects

Local side effects are those that are only experienced in one area of the body. The local side effects of a cortisone injection are also rare.

1. Pain

Some patients have discomfort after the injection and may experience an increase in pain 24 to 48 hours after being treated. This usually subsides quickly and can be aided with an ice pack and anti-inflammatory medication.

2. Infection

Whenever there is a break in the skin, like when a needle is used to administer cortisone, there is a chance of infection. Your doctor will sterilize the skin to minimize the risk of infection.

3. Skin Pigment Changes

Patients with darker skin should also be aware that cortisone may cause skin around the injection site to lighten. This is not harmful.

4.  Loss of Fatty Tissue

High doses of cortisone can have detrimental effects on some tissues in the body. When injected into fatty tissue, cortisone can lead to a problem called fat atrophy. Fat atrophy causes loss of fatty tissue, which can lead to dimpling of the skin or the thinning out of fat. Patients who get cortisone injections in the heel to treat plantar fasciitis may find walking painful as fat that usually cushions their steps may thin out.

5.  Tendon Rupture

Cortisone can also cause weakening of tendons. This is one reason your doctor may limit the number of cortisone injections administered. Cortisone can also lead to tendon rupture, as is the case when cortisone is injected for Achilles tendonitis.

Are Cortisone Injections Safe?

Cortisone injections are extremely safe, but they do still carry potential problems. If you are concerned about having a cortisone shot, talk with your doctor. While cortisone is a powerful treatment for many orthopedic conditions, there are usually other options that can also be tried.

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