Ask the Doc By Victor R. Prisk, MD
Q: I am a 38-year-old bodybuilder starting my diet for the NPC Nationals next week. I began having pain in my right elbow and it’s killing me. It hurts when I do lateral raises or even when loading plates on the bar. I saw my doc and he offered a cortisone injection, calling it “tennis elbow.” Should I do it? Is there anything else I can do? I need to train and this is limiting me.
A: It sucks to go into your contest prep with a nagging injury. Although many bodybuilders rely on Deca to relieve their aches and pains going into a contest prep, this is only masking the real problem and should be addressed prior to your prep. “Tennis elbow” is the affectionate name that we in the medical community give to lateral epicondylitis. Lateral epicondylitis occurs in up to 50 percent of tennis players, thus the given name. As you have discovered, this condition is not limited to tennis players and has been reported to be the result of overuse from a variety of activities. Lateral epicondylitis is extremely common in bodybuilders, weekend warriors and blue-collar laborers. Patients with tennis elbow often complain of severe, burning pain on the outside (lateral) part of the elbow. In most cases, the pain starts mild and gradually worsens over weeks or months. The pain can be made worse by pressing on the outside part of the elbow or by gripping or lifting objects. Lifting even very light objects such as a 10-pound plate can lead to significant discomfort. With increasing severity, pain can occur with simple motion of the elbow joint and can radiate to the forearm.
There are many proposed etiologies for this condition. Historically, the pain has been attributed to inflammatory processes of the radial humeral bursa, synovium, periosteum and the annular ligament. Nowadays, most agree that the condition is attributable to microscopic tearing with formation of reparative tissue in the origin of the extensor carpi radialis brevis (ECRB) muscle. This micro-tearing and repair response can lead to larger tearing and structural failure of the origin of the ECRB muscle. Surgical debridement of the ECRB degeneration is efficacious. Fortunately, in the majority of cases, surgery is not needed for this condition. Despite how much I love to operate, this condition should always be treated conservatively first. The best way to end this problem is to stop the offending activity and give your elbow and wrist rest. However, you’re a bodybuilder and staying out of the gym isn’t happening, especially around competition season. Wrist splinting and a counter-force brace can give relief. Icing post-activity with an ice-massage cup often helps (freeze water in a Styrofoam cup and peel the rim back to use in massage). Non-steroidal anti-inflammatory drugs like ibuprofen and naproxen can help with pain and inflammation despite their limitation of inhibiting muscle-building prostaglandins. A cortisone injection can often calm down the pain and get you on the track to recovery. Unfortunately, with an injection of cortisone, rest is an absolute must because there is a risk that the muscle origin can rupture. So, that being said, don’t have the injection unless you can strictly rest and rehab for two weeks. Don’t use the injection as a way to return to the weights tomorrow. Decreasing your weights for a short period of time and doing exercises that don’t cause pain is the best plan. Stretching and gradual strengthening of the wrist extensors with modification of activities is the key to recovery.
There are other alternatives to cortisone that are in the safety and efficacy research trial stages. These include Harvest and Symphony injections. These are autologous (meaning coming from yourself) stem cell and platelet-rich plasma injections, which supply growth factors to the degenerative muscle and tendon. Growth factors like VEGF, PDGF and IGF-1 show potential to heal degenerative tissues. Perhaps, direct injections of such growth factors may work as well. We will have to do some controlled clinical trials to evaluate the safety and efficacy of such treatments…
Q: I am a 270-pound powerlifter and I enjoy training very heavy. For the last few months, it has become increasingly more difficult to get out of bed in the morning. My knees and shoulders are very stiff. It takes me longer to warm up and I have a lot of shoulder pain with bench pressing. I have started taking two Aleve in the morning and prior to every workout. Will this get worse? Can I do anything else?
A: I feel your pain. As we age, it seems that our joints remind us of our mortality. Although getting underneath 700 pounds on the bench can make you feel invincible, the cartilage of our joints is not. Morning stiffness can be related to osteoarthritis (OA) and other rheumatologic conditions. If rheumatoid arthritis runs in your family, you should definitely see your primary care doctor or a rheumatologist. I suspect that this is early osteoarthritis that you are experiencing. The unfortunate aspect of osteoarthritis is that the changes in your joint cartilage tend to be progressive and lead to significant pain as you age. The heavier you lift, the more potential for cartilage damage and thus more rapid progression of OA.
The goals of osteoarthritis therapies are to decrease pain and to maintain or improve joint function. In recent years, numerous studies have investigated potential chondroprotective agents (cartilage protective)— substances that are capable of increasing the anabolic activity of chondrocytes while simultaneously suppressing the degradative effects of mediators on cartilage. It has been suggested that such agents may repair articular cartilage, or at least decelerate its progressive degradation. Among those substances that may possess chondroprotective properties are chondroitin sulfate, glucosamine sulfate, hyaluronic acid, corticosteroids and heparinoids. There are even doctors who prescribe hGH injections into joints (without any objective evidence of benefit or safety).
My suggestion for athletes with early osteoarthritis is to avoid injections and non-steroidal drugs as long as possible. Studies show that the marcaine anesthetic often used to suspend the cortisone injected into joints can be toxic to chondrocytes, which maintain healthy cartilage. Non-steroidal anti-inflammatory drugs are a leading cause of gastrointestinal ulcers and bleeding in America. Likewise, these medications can lead to high blood pressure, cardiovascular disease and kidney disease. If they must be used, they should be taken with food and you should be well hydrated.
Besides maintaining a lean bodyweight, I recommend supplementing your diet with omega-3 polyunsaturated fatty acids (omega-3 PUFAs) found in fish oils. They have been used to treat joint pain associated with several inflammatory conditions and limit morning stiffness. I recommend 2 grams in the morning, 2 grams before training and 2 grams at night. It is important to obtain fish oil without high mercury content and avoid it if you have a high bleeding tendency (bleeding disorder or on blood thinners). The addition of a glucosamine and chondroitin supplement has also been shown to relieve arthritis symptoms in a similar capacity to that of ibuprofen or naproxen. Further treatment of individual joints with documented osteoarthritis would include viscosupplementation with Euflexxa or Hyalgan. These are not FDA approved for all joints, but do have approval for the knee. More recent studies are also showing efficacy in relieving arthritis symptoms in hips, shoulders and ankles. Viscosupplementation acts like an oil change for joints. These are hyaluronic acid intra-articular injections, which help stimulate the synovial lining of your joints to produce healthier synovial fluid. They also have the ability to desensitize pain receptors in the joint and reduce inflammation.