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severe Lateral/Medial elbow tendonitis - surgery?
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By Cotton
Jun 25, 2012
I'm late 20's, new to climbing (2nd year), and otherwise healthy. For about the past year, I've been battling tendonitis on BOTH sides of BOTH elbows. It's recently gotten so bad, that my PT told me today I may need to consider finding a new sport.

I can write a lot on what I've done up to this point to recover, but here's the short of it...
-PT 1-3x's a week (since mid-April)
-Eccentric loading exercises per Dr.J (rockandice.com/articles/how-to...
-Prescription strength anti-inflammatory
-Climbed moderates just a handful of times this year (took about a 6 week break at one point)

I got back into climbing about a week and a half ago, and climbed mainly slabby, foot-work climbs and nothing over a 5.9. Elbows started heading downhill and yesterday, they were nearly non-functional.

I only have health insurance through mid-September and trying to figure out if it'd be worth my while to get surgery. I want to try everything I can before throwing in the towel. I'm probably going to have to sit this year out, but shooting for a recovery goal for next year at least.

Anyone experience tendonitis this severe before and return to climbing? How did you deal with it and about how long was your recovery?

Cheers.

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By Julius Beres
From Boulder, CO
Jun 25, 2012
Rewritten
I developed severe lateral elbow tendinitis around the age of 30. I believe intense indoor bouldering is what caused it to start. I tried ignoring it for a while, but eventually it got so bad I couldn't even pick up a glass of water. (I had it in both elbows, but it was far worse in the left.)

I took time off, took ibuprofen, tried again and it still hurt. Took more time off, did some PT, tried again, and it still hurt. I had cortisone injections, more time off, more injections and it still hurt. After the last cortisone injection, I took over 6 months off and still pain. Growing increasingly frustrated, I tried acupuncture, ralphing, ultrasound treatments, etc. Two years passed that way and I finally gave up and got surgery. After surgery, I basically was forced not to do anything serious with my arm for 3 months. It hurt like hell to use the arm, but eventually, the pain was reduced. After 6 months I started easy climbing. I did a couple of years of easy sport, but mostly easy trad climbing which did not seem to bother my elbows much. Eventually, I started climbing harder and harder.

These days, I am climbing harder than before the problem. If I spend a day climbing 11s and 12s the elbow still hurts and gets sore, but it is tolerable, and more mild climbing doesn't seem to bother it...

So, I guess you can say the surgery worked... however, I'm not entirely convinced that had I put my arm in a cast for 3 months and simply not used it, followed by a couple of years of slow progress back, that perhaps I would not have achieved the same results. The thing with surgery, is that you always feel it.

I'm happy that I am climbing hard (for me) again. My elbow definitely will never be the same as it was before surgery, but it is allowing me to do the thing I love. It is a hard choice, and I'm not sure what I would recommend for anyone else faced with that choice...

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By Cotton
Jun 25, 2012
Thanks for your reply, Julius. I def have some questions for you, hopefully not too probing...



eventually it got so bad I couldn't even pick up a glass of water.
That's about my condition. My case sounds very similar to what you dealt with and the way you treated it.

You wrote that after your cortisone injections, you took six months off and then still pain, but then you had surgery and 6 months later started easy climbing. Do you think the primary difference here was the surgery or how you used the elbows during that 6 months?

After surgery, I basically was forced not to do anything serious with my arm for 3 months.
Can you give me example of you max capacity for use during the first 3 months? What was the most you used them during that 6 months?

I did a couple of years of easy sport, but mostly easy trad climbing which did not seem to bother my elbows much. Eventually, I started climbing harder and harder.
So it would be fair to say I'm looking at a 2-3 year recovery?

These days, I am climbing harder than before the problem. If I spend a day climbing 11s and 12s the elbow still hurts and gets sore, but it is tolerable, and more mild climbing doesn't seem to bother it... Do you still do tendon-strengthening exercises, ibuprofen, etc? Do you have to back off much?

So, I guess you can say the surgery worked... however, I'm not entirely convinced that had I put my arm in a cast for 3 months and simply not used it, followed by a couple of years of slow progress back, that perhaps I would not have achieved the same results.
Did you gt both elbows operated on or just the worse one?

The thing with surgery, is that you always feel it.

Do you mean scar tissue?

Do you or anyone know much about stem-cell trials?

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By Julius Beres
From Boulder, CO
Jun 25, 2012
Rewritten
"You wrote that after your cortisone injections, you took six months off and then still pain, but then you had surgery and 6 months later started easy climbing. Do you think the primary difference here was the surgery or how you used the elbows during that 6 months?"

It is very hard to say. Cortisone really didn't do much for me. It felt numb due to the anesthetic they inject along with the cortisone, but aside from that, it provided practically no relief.
The big difference with surgery is that my arm was confined to a cast for several weeks. After that it took months of PT to regain range of motion. I could not fully extend my arm for about 3 months (I'm guessing from a combination of scar tissue, plus they also cut off the end of the tendon, so the tendon needed to stretch to regain its proper length).
So, there was a pretty big difference between prior therapy where I did not climb, versus surgery where I did not use my arm at all. After surgery, due to the complete lack of use, there was atrophy of my arm muscles. I imagine having weaker arm muscles reduced the strain on the tendon as well.
Now, it is entirely possible that without the surgery I still would not be climbing... but it is also possible had I put my arm in a cast for a month but didn't have the surgery, it would have also healed.

"Can you give me example of you max capacity for use during the first 3 months? What was the most you used them during that 6 months?"

For the first couple of weeks I did not use the arm at all. Then for a couple of weeks, I started PT exercises just to regain range of motion (but no use of the gripping muscles). After a month, I did PT for 2 months doing all the standard tendinitis exercises with light weights. After 3 months I started very easy use of the elbow.

"So it would be fair to say I'm looking at a 2-3 year recovery?"

That was the time frame for me (about 3 years until fully using it again). But the first couple of years were spent pursuing other therapies. After the surgery, I was back to "normal" climbing in about a year (but I did not want to chance aggravating it, so I stuck with mostly trad climbs).

"Do you still do tendon-strengthening exercises, ibuprofen, etc? Do you have to back off much?"

I don't bother with the exercises... can't say I ever noticed them really helping much. I climb a lot these days... last week I climbed 6 days out of 7. Most of my climbing is trad, but I will pull hard on sport maybe once or twice a week and have not had to back off at all. On a recent sport climbing trip I climbed hard for 4 days straight. At the end I felt some soreness in my elbows, but it went away quickly after a couple of rest days (in other words, completely manageable).

"Did you gt both elbows operated on or just the worse one?"

I only had surgery on my left elbow. My right always got tendinitis, but would recover quickly with rest. After the long period off from climbing, it seemed to heal itself, which is why I suspect the surgery only helped by forcing me to take a long time off.

""The thing with surgery, is that you always feel it." Do you mean scar tissue?"

Hard to describe, but I suspect part of it is scar tissue. My elbow now occasionally "pops" when I straighten it (not painful, but feels annoying). It also seems to get sore or stiff after not using it for a while, especially if it is cold outside.

All in all, I would say the negative side effects are tolerable and I am happy to be climbing again. But, considering the other elbow is just as good without surgery, I remain unconvinced that the surgery itself fixed the problem, and perhaps tolerating the side effects is unnecessary.

"Do you or anyone know much about stem-cell trials?"

Don't know a thing about it...

I remember the first doctor I saw about my elbow. He was 80+ and basically said "as you get older, things hurt..." The implication was that I should stop climbing. I felt that was ridiculous... I was only just turning 30 and felt relatively young and in shape and did not want to give up on my passion. I know how frustrating it is going to doctors who just tell you to stop climbing. It is an awful feeling not only not knowing the best course of action, but also not even knowing what to expect. If someone had said "take a year off and it will be better" I could have dealt with that... the fear was, I would take a year off and still be in the same boat and time would just be slipping away. The desperation lead me to surgery. Unfortunately, I know of no studies that actually show it being effective, but it is what I ended up doing, and today I am climbing.

Good luck to you!

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By Matt Sedor
From portland, or
Jun 25, 2012
mmmmmmonkey
I have not had experience with the same issue you have, but right now I am dealing with some incredibly intense elbow issues from a previous surgery. I am pretty jacked right now. My advice to you would be to be sure and see an elbow specialist, if you go the surgery route. Seek out someone who has a great reputation and does sports medicine. I have some names if you are interested.

Best of Luck,
Matt

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By coppolillo
Jun 25, 2012
I did two "PRP" injections for a torn tendon in a tendon in my left elbow, at the medial condial...this is definitely worth investigating BEFORE surgery.

cortisone: avoid at all costs! once is fine, but over the long term it weakens connective tissue. it's a downward slope.

i'd see a SPORTS SPECIALIST...make sure your orthopod is not a run-of-the-mill guy....

you could also consider traveling--Dr. Andy Pruitt in Boulder has seen tons of athletes and tons of these. Dr. Karli at Steadman-Hawkins (Vail) has probably done more PRPs than anybody in the US...

tumeric is also a very potent anti-inflammatory (some studies suggest more effective than ibu without the risks to your stomach)....research it and take it...maybe it'll help?

best of luck, bruddaman. i'd say for now, don't climb...if it hurts it, it's probably not good for it. hang in there! RC

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By coppolillo
Jun 25, 2012
more info on PRP here:
elevationoutdoors.com/blogs/ma...

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By Clay Mansfield
Jun 25, 2012
I'm probably out of my element here, I've never had severe elbow pain, but have had bouts here and there.

I feel like the effect of muscle knots (trigger points) is often overlooked. If something is that chronic, it would make sense to me that there is a major imbalance somewhere in your musculature. To my understanding, imbalances lead to knots, which lead to pain due to aggravation/tension on certain soft tissue.

The pain can often be referred to another area of the body away from the knot. I dealt with a few months of bad shoulder pain only to find out it was was referred pain from a small city of knots in my back. When pressure was applied to those knots, my shoulder pain would magnify.

I figure a massage is worth it to try and probably isn't going to hurt you any more in the long run.

My thoughts are probably oversimplified and a bit linear, but it's something to think about.

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By Matt Sedor
From portland, or
Jun 26, 2012
mmmmmmonkey
Cotton, I just sent you a PM.

Matt

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By Matt Sedor
From portland, or
Jun 26, 2012
mmmmmmonkey
But in the case anyone ever looks up this thread for elbow advice, here is the info I sent to Cotton:


Dr. Mark Diebert from Alpine orthopedics is a friend of a friend. He does not do elbows but gave me some great advice. Dr Kelleher there would be a good place to start, he does elbows and looked at mine, which was beyond his scope. alpineorthopedics.com/staff/pe...

The Steadman-Hawkings Clinic in Vail, Colorado is one of the best orthopedic clinics in the country. I spoke with Dr. Viola there, and he is the man. Also, Dr. Hackett, I have heard, is a great elbow surgeon.
thesteadmanclinic.com/dr-randy-viola.asp

Dr. Shawn O'Driscoll at the Mayo Clinic in Minnesota is, arguably, the best in the country and is doing my surgery July 17.
mayoclinic.org/bio/10693483.ht...

Good Luck, elbows are so awesome but are notoriously difficult.

Matt

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By Cotton
Jun 27, 2012
Good information all around, everyone - much thanks.

I'll prob do a post in the "Training" forum, but any routines or resources that will allow me to maintain some upper body strength (particularly) without straining elbows (i.e. no gripping or pulling), that'd be sweet.

Cheers.

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By Jonathan Williams
From Minneapolis
Jun 27, 2012
Me.
this may sound obvious, but to anyone who has ever had an unsatisfactory result or even less than perfect result: you can never UNDO surgery. it should be truly the last, or only, option. PRP has shown some promising results in some patients.

jonathan (a physician)

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By Cotton
Jun 27, 2012
Jonathan, do you know much about stem-cell?

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By MJMobes
From The land of steady habits
Jun 27, 2012
modern man
Clay Mansfield wrote:
I'm probably out of my element here, I've never had severe elbow pain, but have had bouts here and there. I feel like the effect of muscle knots (trigger points) is often overlooked. If something is that chronic, it would make sense to me that there is a major imbalance somewhere in your musculature. To my understanding, imbalances lead to knots, which lead to pain due to aggravation/tension on certain soft tissue. The pain can often be referred to another area of the body away from the knot. I dealt with a few months of bad shoulder pain only to find out it was was referred pain from a small city of knots in my back. When pressure was applied to those knots, my shoulder pain would magnify. I figure a massage is worth it to try and probably isn't going to hurt you any more in the long run. My thoughts are probably oversimplified and a bit linear, but it's something to think about.


a GOOD massage therapist is all one needs to fix that shit. you are on track, the medical world is way too hung up on BS "fixes" and not nearly up to par on how to prevent. a GOOD physical therapist can do wonders too, its just hard to find either one. tennis elbow, golf elbow, its all the same. tight muscles from your calves can cause back problems.

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By coppolillo
Jun 27, 2012
Yo Cotton--

I asked Andy Pruitt (med director and founder of the Boulder Center for Sports Medicine) about stem-cell stuff and his exact words were "not ready for primetime." This was about a year ago. Dr. Karli at Steadman-Hawkins says they have had fantastic results in preliminary research stuff with dogs and horses, but as far as I know, it's a ways off for human joint stuff. Lemme know if you hear differently: I've got an ankle that might like it!

Hang in there, brudda.

RC

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By Mark Wyss
From Denver, CO
Aug 20, 2012
Mt. Baker
Has anyone ever had any experience with using dry point needling for treatment of Medial Epicondylitis (golfer's elbow)? I have had this for a while now and have had 2 cortisone injections for it. The first shot worked great, the second shot not so much. It has been a little over a year since the second shot and my arm is starting to hurt again. I am weary of taking the cortisone route again cause I know that the injections will ultimately give my tendons problems as I age. Someone at work suggested dry point needling. I have read up a little on it, and it sounds promising. Just wanted some feedback from fellow climbers before I go to the doc.

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By Rob Gordon
From Hollywood, CA
Aug 20, 2012
Tough Mantle Problem.  Haven't sent yet...
I have posted this many times before, but I'll post yet again. I have had horrible tendonitis, but by doing reverse wrist flexes I have found relief (not even that diligent, I just do one set till fatigue after warming up. I don't even use weight, but a bucket of sand might be worth trying). Get those tops of the forearms as big as the bottom. I also stretch both sides of my forearms and try not to climb in the gym. Gym climbing almost always brings it back. Seriously, before surgery try and get those tops of the forearms massively big and strong. Think about how much time you spend gripping. How is the opposing muscle supposed to keep up if you don't work it super hard? I don't find much benefit in resting. Maybe a week or two while focusing on the opposing muscles. If yours is really so bad as to consider surgery, maybe you need to wait for it to go away while building opposing and then start from scratch building strength evenly.

Good luck. Once you get it under control, don't get lazy, it can come back quick.

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By Christopher Barlow
Aug 20, 2012
I had lateral epicondylitus two years ago very severely in my right elbow. I've been a climber for nearly twenty years with no tendonitis, then BAM, I have a nearly debilitating case in what felt like overnight. Really, it was a few weeks of "I'll try to climb through it."

I saw some folks in Durango, CO, Quantified Performance, who are without doubt some of the best PTs out there, who totally cured my tendonitis (along with a few finger injuries, too). I took three weeks off from climbing and have had virtually no problems with elbow pain since. The treatments they did were dry needling/trigger point needling (that stuff is great, by the way), ASTYM, laser therapy, and the real kicker, ARP Wave. Look that stuff up on the internet to see what it is. They're too complicated to explain here.

In my personal experience with tendonitis and with several friends who've had it as well, here are a few kernels:

- Surgery seems somewhere between equivocal and bad. I have only met one person who had surgery and was happy with the results. As someone else mentioned, maybe if the climber took that much time off and dedicated that much effort into recovery (and returned back to climbing slowly), the pain wouldn't have been come back without getting cut open.

- Taking time off without treatment frequently results in increased pain. Just not climbing isn't treatment. Tendonitis is an overuse injury caused by poor patterns of muscle function. Without treatment, the problem will continue no matter how much you rest.

- Elbow pain (inside and outside) is almost always a result of or at least related to imbalances in the shoulder. Work on shoulder stability, and elbow pain usually gets better.

- Massage and icing are great. The eccentric exercises are good, but if the problem is starting in the shoulder, they won't do much. Your triceps need to be strong as well.

- My PT told me that Cortisone has been shown to basically rot the elbow tendons. The only soft tissue for which he would support Cortisone is in certain finger injuries.

- Several folks have mentioned avoiding the gym and bouldering as a preventative measure. I disagree. I see a proper regime of training that includes variable intensities and rest periods combined with diligent preventative exercises (eccentrics, shoulder stability, core strengthening, and stretching) as the absolute best way to avoid overuse injuries. The body hurts when it's asked to do something that it is too weak to do; being strong - in the right ways (i.e. not simply the "grab a tiny hold and pull the s--t out of it" strong) - makes injury much less likely.

I hope that helps.

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By SpokaneBob
Sep 5, 2012
Dear All,

I am like all of you, a long-time climber who has had his share of elbow issues. I am in basic agreement with the general tone of the discussion--i.e., surgery should be a last resort remedy. I have had one cortisone shot in my right elbow on the medial side and I think I benefitted. The one thing which has not been mentioned which could be of benefit is the use of ultrasound (US). I would not recommend US by itself, but rather as a supplement to proper work with a PT, strengthen and stretching exercises, ice, etc. In my experience if US is properly (key word of emphasis) integrated into the package of complimentary solutions, US can be beneficial. US can be done by the individual, but it is likely better to have US done by a licensed PT. I have benefitted from US. It is a non-invasive procedure. I hope this helps advance the discussion.

Cheers and safe climbing,
Bob Loomis, Spokane, Washington

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