Your nagging knee pain may be due to cartilage damage. Learn what causes it, what the symptoms are, and how it’s treated.
Call 281-633-8600. If you have pain on the outside of your elbow, you may have tennis elbow. We’re now offering a treatment called the Tenex procedure that can provide faster pain relief and quicker return you your normal activities, for certain patients.
This is a summary of Dr. Bennett’s video.
Hello. My name is Dr. J. Michael Bennett. I’m an orthopedic sports medicine specialist who works primarily with shoulder, elbow and knee injuries, and today I want to talk a little bit about tennis elbow and what are the newer technologies that’s available for the treatment of tennis elbow.
For those of you that are wondering what exactly tennis elbow is and whether or not you have tennis elbow, I’ll just go over a couple of the symptoms that people will usually display when they come into the office. Once again, this is a right elbow here. This is the anterior aspect of the elbow. This is what we call the medial side and this is what we call the lateral side out here. The lateral side has the epicondyle which is this bone here, and a lot of times you can palpate that bone directly if you just bend your elbow and just feel the little prominence over here on the outside of the elbow.
If you have repetitive activities such as lifting or if you’re locking your wrists or if you’re at the gym and you go out there and you do these flies and you got to keep those wrists locked and you start developing a lot of lateral elbow pain, these are typically symptoms associated with tennis elbow. If you go out and play a lot of tennis and you get pain with the back hand, any activity where you lock your wrist and you do a repetitive activity, that can irritate this common extensor tendon insertion site here.
So a typical patient will present in the office complaining of maybe two to three months’ worth of pain localized to the outside elbow, point specific pain. Typically if they touch this bone, it hurts. If they lift their wrist up, it hurts. If I hold their wrist and they try to lift up with resistance, it hurts and it’s isolated to this lateral epicondyle. There’s a really good test also called the piano key sign that we do in the office where you extend the fingers and you push down on this middle finger right here and it gives you direct pain on this lateral epicondyle. And the reason is that extensor carpi radialis brevis or one of the extensor tendons here inserts right through there at the base of that second metacarpal, so you can kind of isolate that area. Typically we’ll try things like a counterforce brace, a good stretching strengthening program, as well as anti-inflammatories, injections or even sometimes a topical anti-inflammatory.
You want to make sure that there’s also another pathology you got to be aware of or diagnosis you need to be aware of also that some people tend to or some doctors tend to overlap with lateral epicondylitis, and that’s something they call radial tunnel syndrome. So if you have that isolated pain here, more likely it’s a lateral epicondylitis or tennis elbow. Now, if the pain is more ambiguous and vague and tends to be over here in the forearm area and tends to give you a little bit more tingling or numbness on the top of the hand extending to the fingertips, that’s more of a neurologic issue and that actually has to do with a pinched nerve that goes in deep into this forearm area. So that is called a radial tunnel syndrome. Sometimes you can even tap that area and feel like a stinging or almost like a nerve sensation going down that forearm region or the top of the forearm area here. And that is a completely different diagnosis. It’s a completely different treatment for that.
But if you do have the symptoms associated with tennis elbow, I definitely recommend to have it evaluated. Make sure you’re doing the right treatment. Make sure you’re doing the right physical therapy. Make sure you got the right counterforce brace. A lot of the braces that you buy over the counter are pretty straightforward, but you got to know how to put it on and you got to know where to put it on. Typically we’ll recommend putting it on about a thumb’s breadth below where that pain is, and that usually helps unload that tendon so the tendon can actually heal.
Typically if you have tennis elbow pain for three months to six months, that’s when it’s termed as chronic tennis elbow and you definitely want to be evaluated and see an orthopedic specialist just to get the diagnosis and also to see exactly how bad that tendinosis is. Sometimes you can have a severity of the tendinosis that actually involves not only the tendon but it actually goes into the lateral collateral ligaments, which are the ligaments that help stabilize this lateral aspect of the joint. So if it gets to that point, then it actually becomes more of a complicated solution where this type of option may not be a good option for that patient.
However, for those specific patients that have tendinosis or degeneration within the common extensor tendon, this procedure, it’s called Tenex, is a very good procedure. The idea behind Tenex is to use a smaller incision than the typical incision for an elbow scope, which is one of the options we do for tennis elbow, and definitely a smaller incision than an open debridement of the lateral elbow. This is actually what we call a micro incision where we make a small poke hole or a small little poke hole or an incision into the lateral elbow and identify the degenerative tendon and the tendinosis with this little pinpoint needle here and specifically debride that area of tendinosis, removing the pain-generating tissue.
The benefit of this is that you’re preserving all the healthy tissue around that area and you’re specifically going after the diseased tissue, and we do that by identifying it with ultrasound guidance. So I drew over here a picture showing you exactly what the elbow looks like and what we’re seeing with the elbow. This again here is the elbow, looking at it from the anterior aspect. This is the lateral side. These are the common extensor tendons coming up here in the lateral epicondyle. And then usually you’ll get the degenerative tissue right here at what we call the extensor carpi radialis brevis, which is this tendinous insertion here in the lateral side of the elbow. That extensor carpi radialis brevis actually is underneath a healthy layer of fascia and soft tissue.
So it makes it very beneficial to be able to go in there with these micro incisions in this pinpoint accuracy with this little device and find this little area here with ultrasound and just debride it. And the beauty of this device is that it not only debrides the degenerative tissue but it also irrigates it and sucks it out. So it not only just debrides it but it actually removes it at the same time by sucking it out and removing it at that site. So we’ll evaluate it and ultrasound it. We’ll actually debride that whole area. This here is a larger picture showing you the tendinous insertion. This is the capitulum at the lateral epicondyle. Once again, that degenerative tissue is right here. With the needle, we go in and debride extensively. And looking at it from the side view here, the radiocapitellar joint, once again there’s the common extensor tendons that are responsible for the repetitive activities of the wrist and extension here. We go in there and we actually find this area and actually debride that area where the tendinosis is. This is the console itself here that actually gives us the setting and the cutting power for the device. With this specific device, it’s nearly impossible to damage the healthy tissue because it only really breaks up the degenerative tissue because of the ultrasonic frequency. It actually vibrates and actually creates a fragmentation of the diseased tissue, whereas the healthy tissue doesn’t respond in the same way.
So that’s another benefit that this comes into play. This is also a quicker procedure. It takes about 20 to 30 minutes. Sometimes you can just do it under a local where you just kind of use a little conscious sedation and you numb up the area. We typically prefer to do it in a sterile environment, but some doctors are probably using this in their office as well.
One of the questions we get about tennis elbow involves what happens if you ignore tennis elbow. Okay. So tennis elbow is a chronic thing. I mean people have had it for months, when it comes down to three to six months and when you start thinking you need to see somebody to get the diagnosis and the right treatment. Well, what happens if you don’t and you just continue to live with it? Well, you start to notice a lot of weakness, some swelling. The problem is that the tennis elbow is due to the extensor tendons here, the tendinosis from the extensor tendons that insert on the lateral aspect of the elbow. So if you look at the muscle here, it inserts right here at that lateral epicondyle. The problem is that there’s also some ligaments that come down underneath here, underneath this lateral epicondyle that help stabilize the elbow joint. In the model here, you can clearly see these ligaments here. They go from the lateral epicondyle. They sweep underneath this radial head here like a hammock and kind of support this radial head. This is called the lateral ulnar collateral ligament, and you also have the radial collateral ligament up here. So you have two important ligaments here at the lateral aspect of the elbow. So what can happen over time is that you can get some degeneration of these tendons, and let’s just say these tendons start to get torn and they degenerate and they become fibrosed or degenerative and torn. Sometimes these tears can propagate and they can extend down into the collateral structures which are the ligamented structures at the lateral elbow.
If somebody falls or lands on their elbow and then let’s just say they have some preexisting tendinosis or degeneration of those tendons and maybe even a partial tear of that lateral collateral ligament, that becomes a bigger deal and that can lead to instability across the elbow joint because once you lose those lateral ligaments here, this radial head here will pop out of joint and that leads to what’s called posterolateral rotatory instability. And so you typically do not want to. . . If you’ve had this for a long time and you’re starting to notice some symptoms for posterolateral rotatory instability, it’s popping and snapping with rotation of the elbow, pain when you’re doing a pushup or pushing up, you’ll feel like a clunk sensation on the lateral aspect of the elbow, that means that this bone here is sliding out because it no longer has the structural support here.
So if it gets to that point, that is something that cannot be treated with something like the Tenex. It cannot be treated arthroscopically, although there is one technique that is described, a tightening of these structures arthroscopically, and usually they are treated with an open procedure. And if it’s really chronic and it’s been going on for a long time and that lateral and collateral ligament is just completely torn and retracted, sometimes we’ll have to do a reconstruction of that ligament and actually reconstruct this whole area with a graft.
So from going from Point A to Point Z, there’s a lot of different steps to take into consideration when it comes to tennis elbow, the first step being get the diagnosis early. Number two, make sure to start engaging into preventative activities that you can do to kind of protect that elbow at least during the healing phases. And number three, making sure that you do not ignore a mechanical issue in the elbow such as a clunking, popping, locking of the elbow joint, especially if you have a preexisting history of tennis elbow. I just wanted to do a quick video just showing you the benefits of using the Tenex procedure. There’s more information on this on our website. . .to look up more information on the Tenex procedure that we’re offering in our offices and at our participating service centers at this time. Thank you.
Dr. Bennett offers his patients the Tenex tennis elbow procedure on an outpatient basis at the Elite Surgery Center on Travis Street in Houston and at the Memorial Hermann Surgical Hospital – First Colony in Sugar Land. Call Dr. Bennett’s office for an appointment at 281-633-8600 at his Sugar Land office and at 713-234-3152 for an appointment at his Houston clinic, located near the Houston Galleria.
Don’t wait! These tennis elbow issues need to be diagnosed and treated early to avoid long-term damage, and the need for more extensive and invasive surgery to repair that more extensive tendon damage. Call Dr. Bennett’s office today or send us an email through our contact form.
Dr. J. Michael Bennett is a Board Certified Orthopedic Surgeon and a Fellowship Trained Sports Medicine Specialist. He specializes in treating injuries of the elbow, shoulder and knee, and he also treats certain hand and wrist injuries like carpal tunnel syndrome. Dr. Bennett has been selected as a Texas Super Doctor® for several years running and he’s been recognized as one of the very best orthopedic surgeons and sports medicine specialists in the Houston area.
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