Heart Attack of the Elbow? 
Yes, that’s the term Dr. Robert P. Nirschl, MD, MS a true pioneer in the diagnosis and treatment of elbow problems used recently at the American Society of Hand Therapy Conference. He pioneered many surgical techniques for the elbow many years ago and has continued to refine his theories and clinical treatment of the elbow. He is also an associate professor of orthopedic surgery at Georgetown University School of Medicine. Dr. Nirscl is well qualified to lecture on problems with the elbow but what does he mean describing tennis elbow as a heart attack of the elbow? ANATOMY AND PHYSIOLOGY First of all, he was describing the condition of the tendon. After a brief acute inflammatory phase the tendon that attaches the muscles to the elbow suffers blood loss and becomes disorganized immature collagen. He describes it as grey in appearance with no viable vascular supply. It has the consistency of jelly according to the doctor. This is a degenerative tissue problem which is in fact tendinosis not tendonitis. This is a very important distinction because it affects how we treat and cure the injury. Lateral Elbow Tendinosis (Tennis Elbow) (Illustration #1) is caused by continued stress on the extensor muscles of the forearm. This is a very persistent disorder that is not easily resolved. Medial Tendinosis (Golfer’s Elbow) (Illustration #2) presents with pain and tenderness about the medial or inside part of the elbow. This may have an additional complication of compression or irritation of the ulnar nerve (funny bone). TREATMENT According to Dr. Nirschl the first step is pain relief. He advocates medication to get the patient comfortable for the rehabilitation phase. Medication alone does not promote healing. He restricts cortisone shots to the rare case when a patient’s pain is so pervasive as to make activities of daily living too difficult. It is important to note that steroid (cortisone) injections cannot be used long term because of potentially damaging side effects. He states you should never give more than 3 injections in a one year span. Rest and medication in his view is not an acceptable form of curative treatment. Comfort or pain control alone does not specifically improve the devascularized tendon tissue. Dr. Nirschl strongly advocates the use of electrical stimulation which helps increase blood supply to the tendon thus increasing healing and decreasing swelling or discomfort. Ice can be used after exercise. Rest is advocated but he defines rest as the absence of abusive activity, not absence of activity altogether. Total immobilization is definitely contra-indicated as it will only further the decreased blood vessel supply. It will also stiffen the elbow. Counter force braces can also be used in conjunction with a stretching and strengthening program. This helps to distribute the force over a wider muscle area, decreasing tension on the tendon without pinching nerves or blood vessels. A major goal of rehabilitating the elbow is to strengthen the whole arm and shoulder. Incidence of injury increases as the body fatigues therefore this strengthening phase is critical to avoiding injury. Surgery is only used when patients fail a quality rehabilitation program. In addition, if muscles are not strengthened prior to surgery Dr. Nirschl has found it only prolongs the post-surgical rehab time. Post operatively he expects the patient to be treated in a sling for three to five days and then a structured therapy protocol is to be followed.. REVIEW In conclusion, Dr. Nirschl has found through clinical research that it is tissue degeneration (tendinosis) not inflammation (tendonitis) that dominates ttreatment decisions. He strongly advocates therapy and specifically electrical stimulation, pain control with judicious use of anti inflammatories and a pain control transition to strengthening approach. Call us at TriState Hand & Occupational Therapy if you have any questions about this approach to managing these problems. |
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