Tennis Elbow and Golfer's Elbow

Episode 30 - Tennis Elbow and Golfer's Elbow

[00:00:00] Dr. Chehab: Welcome to IBJI's Ortho-Inform, where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Chehab with Ortho-Inform. Our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day. Today it's my pleasure to welcome Dr.

Todd Remington, who will be speaking about common conditions about the elbow, specifically tennis elbow and golfer's elbow. So Todd, thanks for being here today on ortho form. And, , just tell us a little bit about your background. , where'd you grow up? What's your.

[00:00:31] Dr. Rimington: Yeah, sure. , it's, it's great to be here.

, thanks for inviting me, Eric. , happy to talk about elbow, issues. , so as, , as far as me, I grew up in a small town, , in central Illinois. , I started my training at University of Illinois where I did my undergrad. , thankfully I have my son going there, , now as well, so I'm happy about that.

, I started, , from there I went to University of Chicago, , did my, , M. D. there, and then following that, , I did an internship, , in general surgery at University of Chicago, , and then I went from there to, uh, Georgetown where I did my orthopedic surgery, uh, and then following that, uh, I trained in Pittsburgh at Allegheny General Hospital where I did a hand and upper extremity, , fellowship.

[00:01:07] Dr. Chehab: And after you completed your fellowship in hand surgery at Allegheny, you came back to the Chicago area and you joined Northwest Orthopedics, correct?

[00:01:16] Dr. Rimington: Yeah, that's correct. I, uh, started at Northwest Orthopedics and then we, uh, in about, about two years ago joined into Illinois Bone Joint. Great having you.

[00:01:25] Dr. Chehab: So, and then, um, what are some of the interests you have, , surgically with, the elbow and in particular?

[00:01:32] Dr. Rimington: Yeah. So, uh, my specialty is, , upper extremity. So I do from hand up to shoulder, , with, Elbow surgery, uh, I focus on, things like we're talking about today, like lateral epicondylitis or tennis elbow, , also golfer's elbow or medial epicondylitis.

I also do a lot of nerve surgeries around the elbow, cubital tunnel, which kind of plays into medial epicondylitis, which we'll get into, um, and, I do shoulder reconstruction as well, uh, and then I do all things hand.

[00:01:56] Dr. Chehab: Yeah. Okay. Great. And some of the societies that you're a member of? Yeah.

Great.

[00:02:00] Dr. Rimington: Yeah, so I'm a member of the American Society for Surgery of the Hand. I'm also a member for, of the Chicago Society of Surgery of the Hand, uh, American Board of Orthopedic Surgery, the American Academy of, uh, Orthopedic Surgery. Sure.

[00:02:11] Dr. Chehab: And then, finally, some of your special interests, your outside interests from orthopedics?

[00:02:15] Dr. Rimington: Yeah, so, uh, I'm a big, , basketball fan, college basketball fan. I love the Illini, uh, kind of live and die by them. We had a, uh, A good run this year to the Elite Eight. I'm a golfer. I play a lot of golf. I've gotten my kids involved in that as well, so that's been a lot of fun. Then I'm a big hiker. I always go to a national park every year.

This year we're going to Rocky Mountain, and I like to say Yosemite's my favorite place on earth, so we try. I've been there the past three years as well.

[00:02:40] Dr. Chehab: Okay. So, , let's get right into it. Let's start talking about lateral epicondylitis and medial epicondylitis. Let's start with the lateral epicondylitis commonly known as tennis elbow.

So, , what is it and what do patients feel when they When they have a lateral epicondylitis or a tennis elbow.

[00:02:56] Dr. Rimington: Yeah, sure. So, uh, lateral epicondylitis is a pain on the outside of the elbow. , generally comes from, , patients doing a lot of wrist extension. Uh, the muscles that extend your elbow startup or extend your wrist startup at your elbow.

 And so when you're doing activities that require a lot of that, and tennis is a common one. , when you're, uh, approaching a ball, getting ready to hit it, you're always holding your racket slightly cocked back. Okay. before you're ready to hit it. So you're using those muscles all the time. Um, and so that's a common one.

Also swinging a hammer can cause it. Uh, but basically it's pain. It's pain when you're extending your wrist. Uh, it's pain when you're doing those activities.

[00:03:31] Dr. Chehab: Okay. And obviously you don't need to be a tennis player to have a tennis elbow. Um, what's the most common, Person that you see who develops a tennis elbow.

[00:03:40] Dr. Rimington: Yeah, you know, it's, it's my patients always laugh about that. Uh, they're like, I don't play tennis. Why do I have tennis elbow? And I, you know, I tell them, look, tennis elbow is a common name for it, but it can happen in anything that causes you to extend your, your wrist. So, yeah, I mean, you can think about all the things we do.

Anytime you go to grab or twist something, you're always using your wrist extensors to set your wrist so that you can grip something. So really anyone can get it and it can happen from anything that you're, you know, kind of doing a lot of. So if you're, you know, even if you're doing crafts or. You know, anything that you're doing, grabbing things with your hand, extending your wrist can cause it.

[00:04:11] Dr. Chehab: Is there a demographic, age group? When does it usually come on?

[00:04:14] Dr. Rimington: Yeah, it can extend to any age group. However, it's normally sort of your young active population. You know, anywhere from 20 to let's say, you know, 40, 50, anybody that's doing something repetitively. And a lot of times it is an athletic or sporting activity.

[00:04:29] Dr. Chehab: Okay, and, and, so when do patients seek medical attention? What brings them into the office typically?

[00:04:34] Dr. Rimington: , generally it's the pain, uh, and it's the difficulty doing the activity. , when you get into, uh, patients such as my pickleball patients that, you know, they want to play it all the time, they just want to play it every day, it's an addiction I think.

 And so those patients, uh, are, are, can't do what they want to do. They want to play every day and they can't, uh, and they have this pain in their elbow and that leads us to, to seek treatment.

[00:04:55] Dr. Chehab: Okay, so pain is the number one driver for pain. Patients coming in with tennis elbow, do they have dysfunction of their hand?

Does their hand not work or their wrist not work?

[00:05:03] Dr. Rimington: So they, they can get some weakness, uh, because when you try to initiate extension or when you try to initiate a grip, you get pain and you let go of whatever you're gripping because your body wants to protect you from that pain. So, uh, there can be some, , weakness associated with it.

[00:05:16] Dr. Chehab: Okay. When they, what are you looking for on clinical exam when patients present with what you suspect to be a tennis elbow?

[00:05:23] Dr. Rimington: Yeah, sure. So the, , the pain occurs on the outside of the elbow, uh, right at the lateral epicondyle. That area will give you pain. Uh, when I have the patients, uh, extend their elbow fully and then bring their wrist up, , when they're resisting that.

So what I do is I have them extend the elbow, bring the wrist up, and then I try to force it down. And that generally will cause a lot of pain.

[00:05:43] Dr. Chehab: So that reproduces the pain. Any other maneuvers that you like doing?

[00:05:45] Dr. Rimington: It, Mostly that kind of checking to make sure that they don't have pain anywhere else in the elbow.

So I do my sort of usual spots that I press on also evaluate their ulnar nerve. The radial nerve is another nerve that runs in the area of the lateral epicondyle. So I'll press in the area where the radial nerve runs and see if they have any numbness or tingling to the back of their hand. Cause you can get something called radial tunnel, which is a nerve that can be involved with lateral epicondylitis.

Okay.

[00:06:09] Dr. Chehab: So a radial. Radial nerve compression can mimic, to some degree, a lateral epicondylitis, but usually lateral epicondylitis presents itself as pain with use of the hand, pain with extending the wrist back, right around the outside zone of the elbow, and troublesome for activities of the daily living.

We both see patients, they hate shaking hands, or hate turning doorknobs, or hate turning the caps on a bottle, and it's not disabling. But it's really, really troublesome. It's like a big nuisance in their lives.

[00:06:44] Dr. Rimington: Yeah, it's, it's super annoying. And, and as I said, everything we do, uh, when we reach to grab something, we're using those muscles.

So if you have. Pain in them and it can happen the first time of the day you go to stretch your arm out you get pain And then like you said any any minimal activity you're doing it's giving you pain. I was thinking about today I was blowing off my patio all the cicadas on it and my elbows started bothering me So maybe we're gonna come up to a cicada elbow now at the elbow with lateral epicondylitis.

[00:07:11] Dr. Chehab: So How are imaging studies helpful for the diagnosis of?

[00:07:17] Dr. Rimington: Yeah, so, , we'll generally start with x rays. Uh, you want to make sure that there's not, uh, any arthritis in the elbow. They could be, you know, causing it or could be coexisting with it, cause that'll affect how you treat the patients. , following that, , you'll look at, uh, MRI studies.

 The MRI can show, uh, if there's a partial tear of the tendons, the most common one is your extensor carpi radialis brevis or your ECRB if, if you hear those terms. , so that's the muscle that's generally involved and on the MRI you can see potentially a partial tear of that or a complete tear of that.

There's also a ligament, uh, that's in that area called the lateral collateral ligament and you can have a partial tear of that. And those are things that the MRI helps me if I'm thinking about, you know, getting towards a surgery for a patient. Okay.

[00:07:57] Dr. Chehab: But typically if you have a patient with a tennis elbow that you suspect.

MRI is probably not, you're not using it to make the diagnosis. That's a diagnosis you can make clinically, correct?

[00:08:06] Dr. Rimington: Correct. This is a, this is a condition where, , it's a clinical diagnosis. Uh, you generally will start treatment. And then when you get to the point where the patient isn't getting better or isn't responding to the conservative treatment, then you'll consider further imaging like MRI.

Right.

[00:08:20] Dr. Chehab: And for guiding further treatment. Correct. Okay. , so what are some of those initial non operative treatments that are used for, , for tennis elbow lateral epicondylitis?

[00:08:30] Dr. Rimington: Yeah, sure. , the first one and the hardest one is to stop whatever activity it is. Like I said, the pickleball players, the tennis players.

They don't want to stop playing. So rest, rest works, correct? Rest works. , so if you, if you, if you get pain playing tennis and then you never play tennis again, you probably won't have tennis elbow. Uh, that's pretty obvious, but the problem is, and I'm in this boat too. Life's for living. I live and die playing tennis.

So, you know, or I'm a golfer, but regardless, , my, whatever sport I'm involved, I want to keep doing it. So I certainly don't want to stop it. And we as orthopedists didn't go into this business to tell our patients to stop doing the things they love. We did it to fix them. We want to make them better. And so, you know, that, that is, it is something that would help, but, , it's not something that people really want to do.

[00:09:13] Dr. Chehab: Right. Right. And what are some of the other, um, modes of treatment that could be helpful for patients with tennis elbow?

[00:09:19] Dr. Rimington: Yeah, sure. So, um, you know, icing the elbow. I actually liked, , there's a technique, uh, that I'll tell my patients about with ice massage for this, where, , you take a Dixie cup, you freeze it, you unwrap the top third.

So you can hold onto the cup and not freeze your fingers. , and then you can rub that into the area of the elbow. Uh, if you do it for a few minutes, it'll make the elbow kind of numb. And then you can really get in there harder to actually massage the tendons and help to stretch them out. Uh, so icing it helps, , stretching helps, , and non steroidal anti inflammatories like Advil and Aleve help.

We generally will give patients braces. There's kind of two kinds of braces that we'll use. Uh, one's a strap that you put in front of where the area is bothering them. , the, the, one of the kinds that we use is called a bandit. Uh, so basically what that does is it puts pressure on the tendon so that when you're extending your wrist or when you're doing the activity, that force goes up to where the brace is at, and it doesn't go all the way to the area where there's pain.

So it tends to help while you're doing the activities. , there's also a sleeve that kind of does the same sort of thing. , The occupational therapy or physical therapy can be very helpful, too. , techniques, , stretching, uh, the muscle, the more you can get it stretched out, , the less pain you're going to have.

Uh, and then the therapist can do other modalities, , such as using ice, such as using heat, such as using ultrasound, electric stem. , the different modalities of therapy can help this a lot. , and then following that would be injections. , so injections for, uh, these types of epicondylitis issues, stem from steroid injections, , the steroid injections are designed to decrease the inflammation in the area.

So that's one technique we can do to try to decrease the inflammation, which is what's causing the pain. And then the other type of injections would be injections like, , PRP, uh, which is an injection that What does

[00:11:00] Dr. Chehab: PRP stand for, just for the listening audience?

[00:11:01] Dr. Rimington: Sure. The PRP Platelets that are in your blood, they have growth factors in them, and so we can use PRP, uh, to use those growth factors to try to stimulate healing, in, uh, that, , area.

So that platelet

[00:11:14] Dr. Chehab: rich plasma, that PRP, right? Correct. Okay. Yeah. So, um, there are lots of treatments. , you've mentioned, uh, rest, ice massage, stretching, anti inflammatories, , and Occupational therapy with different modalities including icing and, and ultrasound modalities, , and you've mentioned bracing with the straps around the forearm and the sleeves around the elbow.

, do the wrist braces at all, do you ever mobilize a wrist to help with a tennis elbow?

[00:11:46] Dr. Rimington: Yeah, I will sometimes, uh, And I'll do that sometimes actually after surgery too, , just to limit wrist extension because it'll protect those muscles.

[00:11:53] Dr. Chehab: And then, and then injections with cortisone, , as an anti inflammatory injection being a bit of a go to for those injections.

And then the platelet rich plasma or PRP injections being another mode of treatment for, , tennis elbow as a replacement. Reparative anti inflammatory type injection around the elbow.

[00:12:11] Dr. Rimington: Yeah, and the the platelet rich plasma, so I was actually involved in one of the original double blind studies on that at Georgetown and and interestingly in that study we showed that , we would needle, uh, the area.

So, and so one of the injection techniques is to actually put some holes into the tendon. So you'll actually insert the needle a couple of times into where the tendon inserts, , that helps to stimulate healing and also helps to stretch out the tendon. So in that study, we would do, uh, that to patients and then we would do that to patients and inject them with, , the platelet rich plasma, the PRP.

, and, uh, In the patients that had the PRP, , they were the same as the other patients at 12 weeks, but at 24 weeks, they were better. So what that's telling you is that the platelet rich plasma does have some reparative and healing techniques. It just takes some time for it to work. Yeah,

[00:13:00] Dr. Chehab: okay. So what's your go to injection, if I can ask?

[00:13:02] Dr. Rimington: Well, so, the problem with PRP is a lot of insurance companies don't cover it, so it's expensive for patients. So generally, I will do a steroid injection. I find that a lot of the patients I see initially, , The problem is, is they're inflamed and the inflammation is what's causing the pain. So generally I'll start with a steroid injection and I'll use PRP as an option B, um, for two reasons, cost reasons.

And then also because, , I think getting the inflammation out can sometimes then help the PRP later if you do that as a second option.

[00:13:28] Dr. Chehab: Yeah. Yeah. Okay. And so, , let's take the patient with refractory tenosylve, the tenosylve that's just not going away. So they've gone through all of these. Incremental treatments, I refer to them as, and they've gone with this in aggregate.

It's not like you're doing one of these treatments. We tend to sort of pile on all these treatments in order to get some effect for the, for the condition because it is a notoriously stubborn condition despite all these treatment options. So we've piled on all these treatment options, including injections, and, , we've gotten to a point where the patient just isn't getting any better.

So what are, what are the patient options at this point? What are the treatment options?

[00:14:03] Dr. Rimington: Yeah. So at that point is where you'd consider your MRI to look at it further. You decide whether there is any partial tears or complete tears of the tendons and the ligament that's there. So as I said, the ECRB and the lateral collateral ligament are what we look at.

, and then following that you'd consider surgical treatment for these patients. The, uh, the types of surgeries that I, I do for this, uh, I can, they kind of fall into two categories. Uh, so the first, uh, would be an arthroscopic treatment. , so, uh, through two small incisions around the elbow, I can insert a scope into the elbow.

 And, the ECRB, which is the muscle that's traditionally involved, actually sits in the elbow. Just pass the capsule in the elbow. So by going in through the elbow with a scope, I can remove the capsule, which can be a source of pain. I can debride any damage that's around the elbow and the, in the lateral side of the joint.

 And then I can release that tendon and the releasing of the tendon. Uh, is what, uh, will eliminate the pain because that's the area where the damage is at. , so I can approach that through the elbow joint, through two small incisions, , a very minimal, , surgery. Um, there's also a way to do this through an open technique, which is a little bigger incision.

, you actually split the muscles that are overlying the ECRB. , there's an, a, a longest, uh, muscle that's there as well, which you split, uh, and then That technique can allow you, if you need to repair a ligament, you can do a ligament repair at the same time. So if you need to repair something, I generally approach that open.

If I'm just doing a release, uh, through a more minimal technique, I can do that arthroscopically.

[00:15:29] Dr. Chehab: And do you notice, do you have a preferred go to procedure for tennis elbow? Do you prefer doing it arthroscopically or open?

[00:15:36] Dr. Rimington: Yeah, I mean, I think if it's, uh, if it's a patient, , That, uh, doesn't have, , any, uh, significant ligament tear, uh, then I'll, I'll err on doing the, or I'll, I'll choose to do the arthroscopic technique.

Yeah.

[00:15:47] Dr. Chehab: Okay. And then, , what can the patients expect after surgery? What, what are the, what's the typical recovery like?

[00:15:53] Dr. Rimington: Yeah, so I, you know, this is where it gets hard because again, like I said, these patients want to get back to their sports right away and, and, you know, when you're releasing a tendon, , or repairing a tendon or a ligament, it really does take about 12 weeks for that, that tissue structure to heal.

And so you need to keep the patients away from doing those activities for that period of time. So generally we'll use, , like we discussed a wrist brace, , to eliminate a wrist extension. Uh, I'll use a soft dressing, uh, on the elbow. The dressing stays for two days. , then I let them take the L the dressing off.

They can take a shower, they can get the area wet. , they can start moving the elbow so the elbow doesn't get stiff. Uh, they'll protect. the, the wrist, uh, with the wrist brace and eliminate, uh, uh, you know, repetitive wrist extension activities. , we'll eliminate that for an, and, um, you know, not have them do any of that for the first two weeks.

I'll then see him back and take out any sutures at that time. , then we'll still have them eliminate activities, but I'll, I'll be a little more lax with the brace. They can start moving their wrist. They should start doing light activities. I'll generally start them into some physical therapy or occupational therapy at that time at two weeks.

Uh, and then, uh, we'll work on stretching and range of motion activities for the first six weeks. Then after six weeks is where we can start talk about getting into activities and so.

[00:17:07] Dr. Chehab: So those first two weeks are most restrictive with the bracing, then it becomes a little bit more, um, lax on the restrictions.

By six weeks, that's when patients can start doing a little bit more, , physical activity. Activities of daily living without any restrictions, but you're not getting back into sports until about that 12 week period where the, generally speaking, the, the, the soft tissue will have sufficient time to heal and recover.

[00:17:28] Dr. Rimington: Yeah. If I have a patient who plays, you know, tennis four or five times a week, we're not going to get to that level until that 12 week mark. Uh, and if we do, they're just going to be painful again. And that's the frustrating part about this problem.

[00:17:38] Dr. Chehab: Right. And so let's go over some of the potential complications of the They're slightly different for arthroscopic and for open procedure.

So what are some of the complications that you forewarn patients that can occur but rarely do?

[00:17:52] Dr. Rimington: Yeah, so I think that with any surgery we do, infections are risk. That's very low in upper extremity surgeries. Nerve issues are ones that with both medial and lateral epicondylitis that we worry about. As I said, the radial nerve is in the area of where the extensor is.

And so That's something that as you approach this both open or with an arthroscopic technique, you need to know where that nerve is and avoid that. Sometimes there could be some irritation to that as a result of the surgery. The retraction around the area of the open techniques can sometimes put a little stretch on that nerve.

So you could have a little weakness, you could have a little numbness in the dorsal aspect, the top of your hand, where the radial nerve goes. And then the biggest thing is, um, That you might still have some pain and the problem with this disease process is that, uh, even though you fix it surgically, uh, if you go out and you play 15 times a week, you play tennis, you might get, you know, the pain again.

And so that, so that's the problem. You need to know that even though you've had this fixed. You may need to think about how you're doing your activities and you might need to, you know, turn it, dial it down a little bit so that you don't get these symptoms. You don't have to go through another surgery or another course of stopping your, your activity.

[00:19:03] Dr. Chehab: And then any, any treatments that you see on the horizon that are going to be making a difference in tennis elbow?

[00:19:08] Dr. Rimington: Yeah, I'm a big proponent of wide awake surgery, , and so I do the vast majority of my hand surgeries, uh, under local anesthetic and I keep the patients awake, , which is just safer for the patients in general.

 I have done some of the open, lateral epicondylitis surgeries, uh, under local anesthetic, so I'm trying to push the envelope a little bit about where I can, , use local anesthetic for patients, uh, to make, uh, surgery, , less risky for them. , so I think that's one, , you know, number two is refining those arthroscopic techniques.

It's something that we've been doing for a while, but, uh, it's also something that, we're getting better at, , with the arthroscopic techniques.

[00:19:42] Dr. Chehab: So let's switch gears. Let's go to the other side of the elbow. Let's talk about golfer's elbow. There's obviously a lot of overlap. , but what are patients presenting with?

Is it pain again? Same idea?

[00:19:51] Dr. Rimington: Yeah. So it's pain. So, , we have a different muscle involved here. So, uh, this is the muscles that flex the wrist and, and pronate the forearm. So what pronation is, is where you turn your hand from facing up. Uh, and that's kind of where the golfer's elbow, moniker comes from.

The, uh, patients that play golf normally in your dominant arm. So it'd be the back arm, , in golf. So the, the arm that comes back in your golf swing, once you initiate your downswing, you're going to pull it back. Pull on that, those muscles and you're going to try to flip your wrist at the end, especially if you're hitting a chip, you're trying to flip the ball high.

And so you use those muscles to flex your wrist, to turn your wrist around. And so the inner aspect of the elbow is where the pain's at.

[00:20:32] Dr. Chehab: Okay. And then, so patients have similar symptoms, pain with activities of daily living, different things probably triggered, , the pain. And so on that. For tennis elbow, it's extension of the wrist, for golfer's elbow, it's usually bending the wrist down or pronating the arm, like you were mentioning, from turning the palm up to down.

Um, and, and again, what are you looking for in your clinical exam?

[00:20:53] Dr. Rimington: Yeah, so with, with, um, medial epiconylitis or golfer's elbow, um, you want to evaluate the inner aspect of the elbow, you want to Palpate on the areas on the muscles. So generally it's, it's the flexor pronator muscles. They come together at the medial epicondyle, which is the bone on the inner aspect of your elbow.

So that'll be tender in that area. It'll be tender when you have the patients, uh, fully extend the elbow and then you resist flexion of the wrist. Uh, and then also when you resist pronation. So I'll have the patients turn the palm down and then I'll try to pull it back up and that generally causes a lot of pain.

Okay, on the inner elbow. That's correct. That's correct.

[00:21:27] Dr. Chehab: And then likewise, x rays you're using to evaluate for the presence of arthritis, because that might guide your treatment. MRIs, probably for a later time, because you can make the diagnosis typically, um, on the exam. What are, what are some of the other These are issues that can mimic a golfer's elbow.

[00:21:44] Dr. Rimington: Yeah. So then the other study that we will sometimes do is, is called an EMG, an electromyogram. So that's a test that a neurologist does to help tell us if there is a nerve issue. And so with medial epicondylitis, you have an ulnar nerve, which is a nerve that goes down and does feelings to your fourth and fifth digits in your hand.

And that exists right behind the area where you can have the medial epicondylitis. So in the back of the elbow, the ulnar nerve runs. That can get irritated, uh, and that can give you symptoms. So these patients can have a lot of pain, uh, because the ulnar nerve is involved and they can get numbness and tingling in those fingers.

[00:22:18] Dr. Chehab: And those are cubital tunnel patients? Is that typical for the medial epicondylitis patient to also have, uh, cubital tunnel type symptoms or ulnar neuritis symptoms?

[00:22:26] Dr. Rimington: Yeah. And so the, the ulnar nerve symptoms are generally in your patients that have worse medial epicondylitis. Those patients have a lot more pain and then also get the numbness.

[00:22:37] Dr. Chehab: So the nerve involvement is a little bit more common on the inside zone, golfer's elbow than it is on the lateral epicondylitis on the outside.

[00:22:43] Dr. Rimington: Yeah, that's

[00:22:44] Dr. Chehab: correct. For the tennis elbow. Yep. Okay. And then likewise, non operative treatments for, , golfer's elbow. Yeah. So similar list.

[00:22:51] Dr. Rimington: Yeah, exactly.

Similar, , anti inflammatories, rest, uh, using the same braces, uh, they actually have buildups on both the inside and outside of the elbow. So you can use the similar brace just in a little different spot, uh, therapy, , modalities, and then the injections we talked about as well. Same injections. Same

[00:23:09] Dr. Chehab: injections.

Cortisone or both. Or platelet rich plasma, PRP injections. That's correct. And then surgically, um, uh, what are the options surgically? Also arthroscopic and open for the medial epicondyle, or do you take one approach over the other?

[00:23:22] Dr. Rimington: Yeah, I don't do this surgery arthroscopically, um, mainly because of that nerve.

And so the issue The proximity of the nerve is what Correct. So there's patients that their ulnar nerve, , can subluxate, which means that the ulnar nerve can run up onto the medial epicondyle. And so, uh, the issue with that is, is if you approach that arthroscopically, you can put that nerve at risk because you don't know where it's at.

You don't see it. Right. And so, , I prefer to do this surgery open. Uh, I will address, , , any ulnar nerve issues, and that could include either just decompressing the nerve, so releasing it from the tunnel that it runs in, which is called the cubital tunnel, , which is again right behind the medial epicondyle, uh, and so I'll open that, , area, and then sometimes you need to move the nerve to the front, which is called transposing it.

 You can do that fairly easily when you do a medial epicondylitis surgery because you're, you're basically Uh, removing the damaged portion of the medial epicondylitis of that tendon. And so you're opening it and then that allows you to then move the nerve to the front. Uh, so I'll address the nerve if I need to.

If I don't need to address the nerve, I will always expose it so that I know where it's at and I'll release the tunnel of it. , but if it's not giving the patient a lot of symptoms, I won't move it, uh, and then I will, um, at that flexor pronator mass, I will debride any damaged tissue there. I generally do a, a lengthening of that, , muscle so that I can stretch that muscle out so that it won't cause as many symptoms going forward.

[00:24:49] Dr. Chehab: And then, again, talking about, the recovery, similar recovery, uh, three months before getting back fully into sports. First two weeks being the most restrictive. Bracing for about six weeks, but getting more lax with the bracing as that time period goes Yeah, that's correct.

[00:25:03] Dr. Rimington: It's, it's very similar to lateral epicondylitis.

And as I said, the biggest thing is just modifying your activities during that first six weeks.

[00:25:09] Dr. Chehab: Okay. And then, um, potential complications of, of both procedures?

[00:25:13] Dr. Rimington: Yeah. So, the issue with, uh, the medial epicondylitis would be the ulnar nerve. And so, uh, to eliminate that, uh, complication of ulnar nerve injury, uh, the way I approach the surgery is to expose that nerve.

 So I know where it's at, , and that will prevent it from any damage occurring to it. , and then it'll also address some of the pain that's associated with the nerve being involved in the condition. , and that's the main, that's the main thing. And then just like, uh, a tennis elbow. If you go back to playing golf a lot and that was the cause of it, , you may need to curtail how much golf you're playing, you know, don't play five days a week, play three days a week.

So the

[00:25:47] Dr. Chehab: most common complication on the inside zone of the elbow is potential nerve irritation, which you can minimize by your surgical approach. , there's the potential for, , the surgery essentially not working because patients get recurrent pain, but They most commonly get recurrent pain because they're going full bore right back into the same old activities that may have brought it on in the first place.

And then, , infection's always a risk with any of the surgeries that we do and, um, those need to be treated sometimes with further surgery or antibiotics or a combination of both.

[00:26:16] Dr. Rimington: Yeah, the reason for recurrent surgery would be, you know, as he said, if there's an infection, which again is a very rare thing, , but if there's recurrent symptoms, , and it's, it's, it's.

It's rare, I was trying to think in my head here, how many times I revised this, uh, it would be a few, you know, in 12, 15 years.

[00:26:33] Dr. Chehab: Are you doing surgery commonly for tennis elbow or golfer's elbow, or is it in the distinct minority of patients who require surgery?

[00:26:40] Dr. Rimington: Well, so, uh, it's certainly a diagnosis where we will do surgery.

Do conservative treatment for three to six months first. And so it's a, a more unlikely condition to require surgery. And you have a lot of modalities, which we talked about all of them. They're numerous. And, and we generally will try to get through all of those before we go to surgery. And so this is something you're going to treat three to six months.

You're going to do all the things we talked about, the different injections, the therapy, uh, activity modification, the anti inflammatories, you can do all of that. And then if that doesn't work, and it sometimes does, but it's rare, then you need surgery.

[00:27:15] Dr. Chehab: Okay. All right. Any other pearls or advances in prevention or techniques for surgeries that you see on the horizon?

[00:27:24] Dr. Rimington: Yeah. I mean, I think that, , We are, we talked about PRP. I think using different types of injections, this is where, , some injections, uh, that may involve stem cells may involve more advanced growth factors, , will be utilized. Um, because I, I do feel like in, uh, epicondylitis symptoms, there are ones where, , repairing that tissue and using those advanced techniques can help.

And so there's a lot of research going into that.

[00:27:49] Dr. Chehab: Okay. , so, uh, this was a question asked by my cohost, which I, , Cory Lehman, which I thought was a great question, , what are some things that you do to help you move better, live better?

[00:28:00] Dr. Rimington: I, I like to, um, I have actually, in the past, , three months I've actually lost 30 pounds.

So I, I've started getting really active, uh, in watching what I eat and trying to help, to, uh, become more active. I think I'm trying to keep up with my kids, uh, which is part of it. But, uh, I've started into some more, uh, working out programs. I started, , an app called Noom where I basically count my calories every day and I just started doing that and it started working and so I've kept at it and so that's something that, uh, has helped me the past, , three to six months, uh, and I get, I've got more energy and, And, , I've gotten stronger and, you know, I can keep up with my kids a little bit better.

They're getting older and into more advanced sports, so. You're a

[00:28:40] Dr. Chehab: college age kid and then what are the other ages? I

[00:28:42] Dr. Rimington: have three, so I have one in college, one in high school, and one's going to be in eighth grade. So, uh, they're all super active and they love sports and I love doing it with them and I want to keep doing it for the next, you know, 20, 30 years, so.

[00:28:53] Dr. Chehab: You mentioned they were your three souvenirs.

[00:28:55] Dr. Rimington: That's correct, yeah. So I like to joke that, uh, my training was Chicago, , Washington, D. C. and Pittsburgh, and I gathered souvenirs from each of them, which are my three children, so.

[00:29:05] Dr. Chehab: Well, uh, I'm with Dr. Todd Remington. Thank you so much for, uh, being a part of OrthoInform.

[00:29:11] Dr. Rimington: Hey, no problem, , happy, happy to, , be here, and, uh, we love taking care of patients. Hopefully this, helps all you patients out there as well.