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corticosteroid injections??

mclard

4-May-2005
6:48:03 PM

hey there. I'm currently suffering from some medial epicondilytis and, after trying all the other treatments with little improvement, my G.P. is wickedly keen to inject my elbow with some steroids. BUT, I've received mixed opinions on the benefits/disastrous effects of this treatment. Has anyone out there had corticosteroid injections?? Good/Bad?? Cheers...

LittleMac

4-May-2005
11:51:19 PM

Certainly have had them before, my advice would be this. Only get one if it will actually assist you in getting over the injury, sometimes these injections can be used as a band aid type fix and we all know what happens to Band Aids. I had one for my shoulder and it did the trick, sped the recovery process but like any injury do the hard work to get it right and you will have no regrets.

hansh

5-May-2005
9:20:08 AM

some facts:
!) the natural history of epicondylitis is that it will get better - no matter what you do!
2) steroid injections can speed recovery up (e.g. few weeks vs a year)
3) risks of injections are: infection (very small), nerve damage (small as long as one stays well away from ulnar nerve), tendon tears (very little risk at elbow - bigger risk at shoulder - great risk at heel)
cheers - from a climbing doc

LittleMac

5-May-2005
9:56:24 AM

For the layman out there, epicondylitis is also commonly known as golfers or tennis elbow and a corticosteroid is an anti inflammatory steroid and comes in several forms, possibly it's most well known name would be cortisone. Whilst there is some evidence to suggest that repeated dosages of such drugs can have a degenerative impact on injuries, single doses used in conjunction with suitable rehabilitation/treatment programs usually have no ill affects.

Julian

5-May-2005
11:16:09 AM

Hi there. How are going? I am not sure of your name- "mclard". How about Lardy for short!

Have a read of my article in Rock regarding elbow tendinopathy; it was a couple of issues ago. If you have had elbow pain more than a few weeks it is likely not all tendinitis, but rather tendinosis. This is not an inflammatory condition and as such will not respond to cortisone. Tendinitis is inflammatory and is very sensitive to cortisone, as it is a strong anti-inflammatory. That said, it would go away in a short while if you stop pissing it off; this would negate the need for an injection. The longer you have had it the more likely it is to be tendinosis. Either way there are things you can do regarding your climbing habits; stop crimping for instance. Crimping requires a muscle called flexor carpi ulnaris much more so than open handing, and is usually the main offender in either of the aforementioned conditions.

I would be curious to know what you have tried regarding treatment. I have treated well over 100 climbers with this condition and never had a failure. I agree with the advice that it will go away, though it usually requires you to stop the aggravating activity. There is minimal risk involved but an injection will mean a rest period.

Not climbing is a rather unsatisfying step. I do not normally recommend this as it is not necessary, and normally sees my patients progress to more advanced states of disrepair! Strengthening the tendon using very specific exercises, depending on the muscles involved, is very effective (ulnaris is the most common, but there are others).

Many GP’s will now not inject cortisone (a catabolic steroid- opposite to anabolic) for elbow tendinopathy, as it is more likely to be tendinosis, for which the injection will be ineffective treatment. The underlying pathology for this condition is a strength differential between the muscle and its tendon insertion.

If you stop the aggravating activity, muscle strength will reduce, thereby reducing the strength disparity, and the problem will resolve. Conversely, you can increase the tendon strength. Both steps will address the pathology, rather than applying a bandaid. A combination of the two (the first by altering your climbing style rather than stopping) will fix the problem- guaranteed.

Kind regards.

Julian

chris

5-May-2005
11:27:51 AM

I have had pain at the distal end of my biceps for a few months, since I have increased my training.
Often made worse by doing steep juggy routes, and it can actually hurt when I straight arm hang from jugs for a rest. I suspect I have a biceps tendinitis/osis, but am not really keen to cut down the training, because it might mean getting weak fingers!!
I have heard of oppositional exercises (in this case pushups seems the right thing)..... anybody with any experience re this?
I also have some long standing right shoulder pain which I just ignore (several years now!), so maybe that has something to do with it, plus have recently turned 35.... is it just a case of being too old to train a few times a week?

Mike

5-May-2005
11:52:58 AM

Gee's Chris, it sounds like we have the exact same injuries, though I suspect mine is from weights rather than climbing given I haven't been climbing much this year. Doggy left elbow, particularly painful during bicep curls, been that way for the last two weeks, and a more long term (last few months) right shoulder problem, particularly painful during lateral raises, which I've been trying to fix with rotator cuff exercises (from http://www.climbinginjuries.com ) and avoiding laterial raises, upright rows, or anything that involves lifting over the head. I'd be interested in your treatment solutions for both.

Julian any chance of disclosing the elbow strengthening exercises? That sounds a lot better than simply resting. I hate not exercising. My solution for the elbow thus far has been to ignore the pain and continue as normal, but I suspect that might be the wrong approach.

LittleMac

5-May-2005
12:33:54 PM

I love it when Julian steps into these conversations, he always makes everything so much clearer, manages to draw my ramblings together anyway.

Thanks Julian.

mclard

5-May-2005
8:19:14 PM

Hey Julian. Things going well thanks mate, except for the elbow condition. Thanks for asking.
I'm scoring a copy of the Rock issue with your article in it and will give it a read. I was already kind of clued up on the fact that it was tendinosis rather than tendinitis and have had some time off work (bloody carpentry) and a lot of time off climbing/training, all the while stretching the elbow out and performing reverse wrist curls (only on the eccentric tho, lifting it out with the good hand) and had zero improvement. Which makes me wonder if it could be something else entirely?? So, have organised elbow specialist appointment and hopefully iron clad diagnosis. Will then be confident in treatment for whatever the problem is. Definitely not keen on the cortisone personally, so I really appreciate your opinion.

Thanks again for advising us plebs on our injuries.
Cheers mate.
Lardy Mclard,,,

Eduardo Slabofvic

5-May-2005
8:42:49 PM

Say "No" to drugs. Say "Yes" to tape. Tape fixes everything.

Have had tendinowhatsitdowhatcomeagain for a few years. I heard right elbow go "shhhpth" one day on a closed crim. I blame too much alcohol, late night dancing, and other things I can’t quite remember for the issue. altered climbing style to open palm = yes. No crimping (it's so '80's anyway). Tape helps manage pain. Elbows tucked in, no chicken wings.

Roids give you zits.

what sort of exercise strengthens tendons but not muscles? High reps low weight? Arm curls aggravate it no end, no matter what weight.

julian

6-May-2005
5:10:49 PM

Hey mike, how are you?

As you could imagine, treatment involves more than exercises. Nobody is the same, in that their condition may involve different tendons (thus, different exercises), they may respond differently to treatment, joint angles at the time of aggravation can vary for the same tendinosis condition, etc etc. Treatment for this condition, which is one of the more recalcitrant affecting climbers, is a combination of advice, manual therapy, exercise prescription and altered climbing style. And all of this may change from week to week depending on progress. The approach needs to be personally tailored for success, and closely monitored.

Ignoring the pain is definitely not the correct approach. As a general rule, half the time you have had it and this is how long it will take to resolve with treatment. Personally, I find this does not often go over a few months for complete resolution. Resting will work in that the disparity in strength between the muscle and its tendon will reduce, but as soon as you start climbing again (assuming the same intensity) it will increase and you are back to square one.

Give me a call if you want to have a chat about it.

Julian

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