My Elbow Hurts!
Tennis elbow, or lateral epicondylitis, is a fairly common chronic pain condition. It’s a repetitive strain injury and associated with degeneration of the extensor tendons of the wrist, and for some can be pretty damn hard to treat. Usually the recommendation is to stop doing the activity that led to the injury and hopefully the pain goes away, or use a brace, or mask the injury with pain killers. Or cortisone shots. But what if you loved that activity? And what if that activity was your JOB? And cortisone is unsuccessful for many people, in addition to being associated with increased degeneration over time. Are there other treatment options other than these? The exciting answer is yes!
What’s happening in the tissue in people with tennis elbow is a lot of “micro tearing”, meaning little tears in the tissue from overuse or misuse that the body then has to heal with scar tissue. But that repair is weaker than the original tissue, especially where original muscle tissue and scar tissue join, and therefore at risk of having more micro tears. So, for example, you spend your adult life typing and your lateral epicondylitis (or the end of your muscles that control your fingers that insert around the elbow), that’s a lot of opportunity for micro tears that heal and tear again.
Evidence based injections
Tennis elbow usually arises in people aged 35-55 and for many can be self limiting, meaning the pain goes away. This is especially true if caught in the very early inflammation stages, or it was a temporary activity, but most people don’t seek treatment early on. One of the major difficulties the tendons and ligaments have when healing is that they don’t have good blood supply compared to tissues like the muscles. Which is how prolotherapy and ozone work for this condition.
Prolotherapy stimulates a local inflammatory response at the site of injection, causing an influx of blood and healing cells. Doing this repeatedly over a few treatments is like poking the body and telling it “heal here” every time it forgets. Ozone has a similar effect but with a different mechanism, and how it works depends on its concentration. At high concentrations is lowers blood flow and increases the concentration of inflammatory cells, but at low concentrations (30 gamma or so) it increases blood flow and is decreases inflammatory cells. Additionally, because it’s an incredibly powerful anti-oxidant, it helps the mitochondria (the powerhouse of the cell – thank you high school) produce more energy molecules. So together, prolotherapy tightens and strengthens the tendons and ligaments and reminds the body it needs to heal this area, and the ozone helps the body get out of its own way and gives the cells the energy it need to do the healing.
It’s also been shown that people with the chronic version of this condition have peripheral nerve changes and a sensitization of this spot in the brain. Meaning that there is a positive feedback loop of injury causing pain, then those nerves keep sending pain signals in absence of the original stimulus, and to make matters worse the brain is hyper-aware of pain signals from this area. A cool thing both prolotherapy and ozone do is reduce this pain positive feedback loop and treat the peripheral nerves, helping with the chronic pain.
A real patient’s experience!
The following case study is presented for informational purposes as an example of what prolotherapy and ozone injections have done for one individual experiencing a severe case of lateral epicondylitis using a very aggressive treatment schedule. This was documented and posted with this patient’s permission!
Most prolotherapy treatment plans for injuries are 2-5 sessions total over 2-6 months with touch ups just when the pain comes back. For most patients this is once a year, but for many it is never needed again! I also feel strongly that every patient do stretching and exercise or some sort of physio to address whatever movement dysfunction led to the tissue damage.
Not all treatment plans would be this extensive, and the patient always has a say in how their treatment progresses. Please keep in mind that each patient is unique, and this is in no way naturopathic medical advice and if you have a specific medical concern that you should consult your naturopathic or medical doctor for evaluation and treatment advice.
Case Study
LG is a massage therapist, and has been for 19 years. 2 years prior to treatment, she had to stop practicing for 6 months because of lateral epicondylitis (tennis elbow) in her right arm. She received two rounds of PRP, but only one injection site right at the tear site found on imaging in the tendon. This helped and she was able to return to work, but the pain became debilitating again, and one year later had to stop working a second time because of the pain. A few months after she started prolotherapy with me at CHMT where we injected in all areas of pain and dysfunction, instead of just the one site. These were the three areas of maximum tenderness when palpated (poked and prodded) and these were on the site of the tear, over the annular ligament of the radius, and in the tendon for the supinator muscle. In my experience, musculoskeletal problems are very rarely isolated issues, and once one muscle or ligament is compromised, the structures around it and that work with that compromised structure are likely affected. Based on how long this injury had been building up and that the PRP had limited success, I wanted to make sure that not only the site of injury but all the supporting tissues were healthy and strong. In addition, LG loves her job and her clients and was very, very motivated to continue working, so we decided together to be very aggressive with treatment.
We also supported collagen production with vitamins and minerals (like vitamin D and C) that the body uses to make collagen, which is the primary protein used to heal these types of injuries. After 2 months she was able to work with light shifts, and after 3 months she returned to using light weights during her workouts, both activities without pain. At this point I had introduced ozone injections into the clinic, so we added that into her treatments to maximize the benefit she was getting from the injections. I also noticed that I was feeling far less scar tissue during the injections and her tenderness decreased dramatically in 2 of the 3 sites.
After 4 months we entered a maintenance phase of occasional injections after she returned to work whenever she felt the pain come back. At this time she was continuing with exercise and physio as well. She was very determined to not have to take another few months off of work again. At six months, her massage therapists reported that her arm was starting to feel like it had before the initial injury 2.5 years prior, and there were far less adhesions and “crunchiness”.
LG was able to work her regular schedule without pain, and other activities in her life (like turning door knobs and using weights with workouts) are now also pain free. At this time of publishing, she has been working her regular schedule without any additional injections, pain free, for 4 years.
Prolotherapy and ozone therapy are amazing treatments for pain because they build the tissue up and stimulate repair, as well as healing the nerves involved in chronic pain. This case really highlights the power of prolo and ozone. Massage therapy is generally a very short career because of repetitive strain injuries like epicondylitis, but this therapy can help heal those injuries and help RMTs and others in careers prone to repetitive strain keep doing the jobs they love!
References
Ahmed Z. Lateral epicondylitis; a review of pathology and management. Bone Joint J. 2013;95-B:1158–64.
