Brevard Orthopaedics

It began as a dull ache on the outside of her elbow. As best she could recall, there was no beginning, other than the time she bumped her elbow against the car door when lifting a heavy bag of groceries. The pain wasn't bad, just annoying. Over the counter pain medication would take care of it and she thought little or nothing about it. Perhaps some arthritis was setting in. She took her own advice, "If it hurts when I do something, then just avoid doing it and the pain will go away. For a while it worked.

Then came the big weekend. Hosting a dinner party for twenty was enjoyable except that the nagging pain decided not to leave. She noticed she could not lift pots and pans without significant discomfort. She even dropped her favorite crystal serving dish- and watched it shatter on the kitchen floor. That night she could not sleep with the pain. The next day she called her physician who referred her for orthopedic care. She saw Dr. Mark Lemel, an orthopedic surgeon with a passion for the elbow and its problems. She relayed her complaints. Pain on the outside of the elbow was now constant. Each morning she would feel a little better. However even simple yard work would start a throbbing pain. She told him of the difficulty lifting and her inability to sleep. What was worse, she could not hold her neighbor's newborn, in her arm without significant pain and fear that she would drop him. "Isn't it arthritis?" she asked. When she heard the reply, she was confused. "Tennis elbow! I don't play tennis."

In fact, 80 to 90% of all people that suffer from tennis elbow have never played a set of tennis in their life. The common name for lateral epicondylitis , an inflammation of the tissue on the outside of the elbow, originated in the 1960s, when orthopedic surgeons noticed an association between poor racquet fitting and pain on the outside of the elbow. Any trauma or overuse of the muscles extending the wrist and fingers may lead to the pain of tennis elbow. It has been estimated that one person in ten will feel pain in the same area at some time in their lives. When it is brief and does not interfere with work, hobbies, or sleep, little needs to be done. However, if the pain lasts longer than a few weeks, many things can be done to help alleviate the problem and return an individual to more normal activities.

The Problem
Tennis elbow develops on the outside of the elbow, just above the joint itself. You can feel the bony bump where the muscles that extend the wrist originate. Anatomists have found that this area does not have the best blood supply. When an injury occurs, it takes longer for this area to heal- sometimes healing just does not occur. This leads to the pain and loss of function associated with tennis elbow. As time goes by, the normal strong fibrous tissue in the area becomes replaced by soft, thick, weak tissue that does not support the muscles of the wrist and hand leading to characteristic swelling and loss of strength.

The Office Visit

Most people with tennis elbow can point exactly to the spot where the pain started. The physician will often wait to examine this area last to avoid extra pain as well as avoid other causes of elbow pain. Dr. Lemel performs an examination of the neck, shoulder, and wrist each time he evaluates elbow pain. He looks for loss of motion in addition to pain. Pressing on the outside of the elbow reveals a soft swollen area where the muscles attach to the bone. Two characteristic positions also reproduce the pain. Dr, Lemel will have the patient hold the wrist extended while he pushes down on the top of the wrist. He will also have the individual hold the forearm in the palm up position while he tries to rotate the forearm palm down. Both of these positions reproduce the pain of tennis elbow and confirm the diagnosis. Dr. Lemel also looks for other sources of pain in the elbow by pressing the joints, nerves, and blood vessels in the area. An X-ray of the elbow evaluates the joint for arthritis and the remote chance of a bone tumor. Occasionally, the X-ray demonstrates a small calcium deposit on the outside of the elbow, further confirming the diagnosis of tennis elbow. An MRI is helpful if there is some question of the diagnosis.

Treatment
Many people are concerned that visiting an orthopedic surgeon guarantees that they will have an operation. Dr Lemel does not believe that. "As much as I enjoy helping people with my operative skills, I enjoy curing with nonoperative treatments as well. I believe that the decision for surgery is a team effort between the patient and the doctor. The physician has the technical ability and the knowledge of the risks and benefits of the surgical procedure. The patient has to live with the results and should make the decision based upon the options discussed with the doctor. In my practice, the patient has 51% of the vote no matter what treatment is discussed!" Tennis elbow is one problem that is often cured without surgery. At the first visit, Dr. Lemel will discuss the diagnosis and treatment alternatives such as activity modification. Many people have started a new activity such as yard work and simply stressed the tissue. Rest, some anti-inflammatory medication, heat, and ice after activity significantly decrease the symptoms especially in the early months of the problem. Dr. Lemel often makes suggestions as to how to modify a tool or technique to quiet the elbow. It is not infrequent that people are seen in the waiting room with racquet or club in hand waiting to show him exactly how the problem occurred. Dr. Lemel works closely with therapists on the treatment of tennis elbow. Use of exercises including stretching, strengthening, and modalities have been shown scientifically to decrease and even eliminate tennis elbow. Dr. Lemel often visits with patients in therapy to monitor their progress. He emphasizes that the exercises learned in therapy, if done on a regular basis after the pain resolves, will help prevent the pain from recurring. Cortisone injections are helpful when pain is significant- especially if a patient is losing sleep at night. While the medication is good for controlling pain, it does not cure the problem and should be combined with an exercise program to keep the pain away. The medication works by decreasing the pain causing substances in the area of injection and lasts from 6 weeks to about a year. Cortisone should not be given more than two or three times over a year. Dr. Lemel often abandons this treatment if pain returns after two injections as some complications may occur if too many injections are given.

Surgery
Dr. Lemel feels that surgery for tennis elbow is beneficial if all other treatments have failed and the problem has persisted for at least six months. Results are generally good with 80-90% of people reporting near full resolution of pain and full return of function. Yet the 10% less than perfect results makes it extremely important for the patient to understand the risks and benefits prior to surgery. The procedure itself is performed in an outpatient setting under local anesthesia and mild sedation. A small incision over the painful spot reveals the degenerative tissue. This is removed and the normal tissue repaired to the bone. This promotes a strong scar that is painless and stable. Postoperative rehabilitation is often done at home. Full recovery occurs in six to twelve weeks. Recurrences are rare. Overall, patients are pleased to be back in control and pain free. People report that the ability to get a full night's sleep is especially important. Dr Lemel is excited to join Brevard Orthopedics and looks forward to many years helping the people of the area.