Cortisone vs. PRP for Elbow Pain (revisited)

Why are doctors still injecting cortisone in tennis elbow? 

Here’s yet another paper showing the difference between cortisone injections vs Platelet Rich Plasma which I have discussed previously.  This 2023 study by Kamble is entitled:  Is Ultrasound (US)-Guided Platelet-Rich Plasm

Injection More Efficacious as a Treatment Modality for Lateral Elbow Tendinopathy Than US-Guided Steroid Injection?: A Prospective Triple-Blinded Study with Midterm Follow-up” (2 years). 

This graph pretty much sums up the findings.  You can see the patient rated disability scale on this graph.  The cortisone shot gives an initial improvement in symptoms, but it quickly starts to return toward the baseline.  In the PRP treated group, the pain graph is initially much flatter,  but starts gaining traction as time goes beyond the 4 week mark.  

So to repeat my earlier question, why are doctors injecting cortisone for tennis elbow or golfer’s elbow?  When we consider the many reports like this recent one (see these links as well https://pubmed.ncbi.nlm.nih.gov/37247780/, https://pubmed.ncbi.nlm.nih.gov/35031496/ https://pubmed.ncbi.nlm.nih.gov/34123513/ https://pubmed.ncbi.nlm.nih.gov/31860992/ https://pubmed.ncbi.nlm.nih.gov/30899764/ https://pubmed.ncbi.nlm.nih.gov/26362783/ )

, we see yet again that cortisone has a short term effect but it quickly wears off.  We also know that cortisone has many undesirable side effects such as the blunting of the healing inflammatory response.  It also has been shown to weaken tendons and potentially lead to tendon ruptures.  I personally feel that cortisone injections make elbow tendon problems last longer since they shut down inflammation  but in so doing, they counteract the body’s attempts at healing.  

It has become quite commonplace to hear inflammation held up as the cause of a host of problems.  However, remember that inflammation is also a natural physiological response to injury.  It is part of the natural healing process.  As a result, we need to be careful about using anti-inflammatories indiscriminately.  

Let's discuss naming and its consequences.  Tennis elbow has been long known as lateral epicondylitis, and every doctor learned in medical school that “itis” means inflammation. So like for appendicitis (inflammation due to an infection in the appendix) and hepatitis (inflammation of the liver), epicondylitis must be inflammation of the elbow.  Right???  

Well actually, we know from Dr. Nirschl’s study from 2003 (over 20 years ago) that tennis and golfer’s elbow is not inflammation at all.  In fact, it is the utter lack of inflammation and healing that accumulates, allowing tendon damage to become chronic.  Inflammation is the first stage of healing, so taking powerful antiinflammatories like cortisone can be very detrimental to any delicate healing that the body is trying to start.  

Kamble’s paper compared cortisone shots to Platelet rich plasma.  If you look at this graph, the blue line follows the pain scale over time.  You can see that Platelet rich plasma takes longer to see an effect.  However, over the long term, after the cortisone effects have worn off, the Platelet rich plasma effects are starting to compound.  Ultimately leading to healing.  

So what is platelet rich plasma?  In a nutshell, platelet rich plasma or PRP is a cell based treatment that uses a patient’s own blood.  The platelets are isolated and then injected into the damaged tendon.  PRP causes a number of processes to take place, many of which are inflammatory in nature.  These processes result in a more robust response to the accumulating tendon damage allowing the tendon to heal and return to normal strength again.  

Of the options we have, I find that platelet rich plasma is the most straightforward and effective way to get rid of the elbow pain associated with golfer’s or tennis elbow.  Cortisone injections may give some short term relief, but PRP has a better track record of fixing the problem for good.  

Frozen Shoulder - How To Avoid And Treat It

A frozen shoulder can sideline you , sometimes for over one year. This can affect any adult causing a really stiff and very painful shoulder, often without any memorable injury. So what is a frozen shoulder,  how can we avoid it? And how do we treat it?  Keep reading and I’ll give you my two best tips. 

The medical term for frozen shoulder is adhesive capsulitis. It’s just a fancy way of saying that your shoulder is stiff and the ligaments around the shoulder (aka the capsule) are scarred and thickened. People with frozen shoulder struggle to reach up, out, or behind their back. It can be downright painful to stretch the shoulder when frozen shoulder has set in. 

Nobody knows the exact cause of frozen shoulder. Certain medical conditions like diabetes and thyroid disorders can make you more prone to the issue. however, the most common cause for frozen shoulder is lack of movement for any reason. If you sprain your shoulder or if you have a chronic tendinitis, the natural response is to protect the shoulder and avoid the things that cause pain. While that may seem like the right thing to do, it actually allows the problem to happen.  You may think “it hurts to raise my arm to head height, so I’ll just raise it to shoulder height”. But if you do, the shoulder capsule will tighten down and soon, you will find that it hurts even to go to shoulder height. As you give ground, your pain free comfort zone keeps shrinking. 

So the first tip is this. If you have a sore shoulder, make sure that even while you rest it, you take it through a full range of motion every day at least once. The shoulder ligaments need constant stretching to remain balanced and supple. By reaching up like this, out like this, and up behind your back, you will not give any opportunity to the ligaments to tighten up. We can fix almost anything with the shoulder. However, stiffness makes everything harder to recover from so do yourself a favor and stay flexible. 

Let’s say that you are already in the freezing or frozen stages of frozen shoulder. Here’s a second tip. Like I mentioned before, it can take well over a year for the shoulder to thaw out on its own. But, you can speed up your recovery with a consistent stretching program. We often send our patients to physical therapy and encourage them to work diligently on their stretches. 

In many cases, I will also offer my patients a hydrodilation procedure. This is an injection of fluid, cortisone, and an air bubble. We give this injection into the joint under ultrasound guidance.  This is followed immediately by a stretching program.  

 

The additional fluid and air bubble act like an air spring to push into all the stiffened crevices of the shoulder and to magnify the stretch. combined with a formal stretchign program, Most people find that they start to make progress within 4-6 weeks of a hydrodilation.  It can still take several months to recover, but the procedure can speed up the process significantly. 

Side Sleepers Do This.

 I’ve been meaning to make a video about hope to sleep on your side. I finally got around to it!  I hope these tips help you. 

PABST Lesion

 Whoever came up with this one had a sense of humor. 

PABST stands for partial bursa side supraspinatus tear. It papers well with the PASTA lesion. 

Latarjet Procedure

When the shoulder dislocates, it damages the labrum and the ligaments that stabilize the

ball and socket joint.  Further dislocations can damage the glenoid socket and make the shoulder

prone to more dislocations.  

We can stabilize the shoulder using a transfer of the coracoid process of the shoulder. 

This helps by adding width to the bone socket and by creating a muscle sling. 

The bicep muscle sling stabilizes the shoulder dynamically when the shoulder is elevated.

Reverse Total Shoulder Replacement Mechanics

 

What is a reverse shoulder replacement?

When the shoulder wears out, we sometimes have to place an artificial joint called a reverse total shoulder.  It involves placing a new "ball" where the socket used to be.  It's called a reverse shoulder because we put the socket where the ball previously sat.  

What does a reverse shoulder replacement look like?

This is an example of what the new shoulder looks like when we place a reverse shoulder replacement.

Why would you reverse the mechanics of the shoulder?

Sometimes we need to do this because of severe wearing out of the socket bone. Other times, we need to use this implant due to a chronic rotator cuff tear. Traditional or "anatomic" shoulder replacements don't work well in these scenarios since the implants get unstable and/or loosen from the bone. The reverse total shoulder replacement allows us to put a deep dish ball and socket liner in place. This creates a much more stable arrangement than the native shoulder, which is quite prone to instability.

In addition to creating a stable socket, the reverse total shoulder replacement medializes the shoulder's center of rotation. This gives the deltoid a longer lever arm. In cases where the rotator cuff is torn, the reverse total shoulder replacement restores the shoulder's strength by optimizing the mechanics of the remaining muscles.

Chronic Rotator Cuff Tear

What is the difference between acute and chronic rotator cuff tendon tears?

"Acute", in the medical sense, means something that happened very recently.  Acute rotator cuff tears, typically happen due to an injury or accident.  People with those types of injuries can often remember how they hurt the shoulder and exactly when the pain started.  "Chronic" means something that has been there for a prolonged period of time.  Chronic tears of the rotator cuff happen over the course of time due to wear and tear.  Folks who have a chronic rotator cuff tear describe the onset of their pain as gradual.  They don't usually remember a specific injury.  Instead, they will tell me that the pain has been getting worse in recent months.   

How do you diagnose a chronic rotator cuff tear?

Many people come to me complaining of shoulder pain that has been present off and on for several years.  We often obtain an MRI of their shoulder and the MRI shows what appears to be a chronic tear.  Chronic just means the tear has been there for quite some time, resulting in some signature changes to the tendon and muscle.  Specifically, the tendon is detached and retracted far away from its normal attachment point on the humerus.  We also see shrinkage or atrophy of the muscles.   In late stages, the muscle is actually infiltrated by fat, resembling the marbling of fat we see in kobe beef.  

When a rotator cuff remains torn for several years, it begin to atrophy and scar down to the surrounding tissues. 

What are the treatment options for a chronic rotator cuff tear?

These changes are important to note because it helps us to decide what the viable treatment options are.  While many people can improve with a course of physical therapy, about 30% of people with such a tear are unable to fully return to normal function.  In these folks, we need to do something more to help them get their lives back.  

One such option is to transfer an expendable or "extra" tendon and attach it to the shoulder.  The most commonly used tendon is  the lower trapezius.  We can detach the lower portion of the muscle and tendon from the scapula.  We can then connect the tendon to the humerus using a tendon allograft.  This restores the strength and ability of the shoulder to lift and rotate.  The tendon allograft we use is usually an achilles tendon from the tissue bank.  These tendons are carefully prepared and tested to avoid transmitting diseases such as viruses or bacteria.  Thankfully, this type of tissue transplantation does not require any type of anti-rejection drug.  

After surgery, patients wear a special brace for 6 weeks.  After that, they begin physical therapy and generally can resume all normal activities around 4 months after surgery.  

Coming soon...

We will discuss other options such as superior capsule reconstruction and reverse shoulder replacement.  We will also discuss newer options such as the balloon spacer that has been recently approved by the FDA.  

What Is It Like To Have A Shoulder Replacement?

 

Dr. Sohn discusses the process of getting a shoulder replacement.  Thanks to newer implants and better anesthesia, this surgery can now be done as an outpatient procedure.  Dr. Sohn also discusses the Postop recovery and restrictions.

SLAP Tear Revisited

 SLAP tear:

The long head of the bicep tendon attaches to the top of the shoulder socket.  It looks a bit like the trunk of a tree with a flared out base that attaches to the rim, also known as the labrum of the shoulder.  When the "roots" of the tree are torn, this is called a superior labrum anterior to posterior (SLAP) injury.  Injuries of the bicep and labrum complex can feel like a deep pain that radiates down the front of the shoulder.   

Lateral epicondylitis

Lateral epicondylitis, (aka tennis elbow) is a common cause of elbow pain.  People describe the pain as an ache located in the lateral side of the elbow.  Normal activities such as gripping or lifting can become extremely painful.  

Although the “-itis” in the name would suggest it, this is not an inflammation problem.  In fact, it is the lack of healing that accumulates and causes pain in the tendons of the elbow.  Naturally, you don't want to take anti-inflammatories or cortisone injections because those would discourage inflammation which is the first stage of healing.  This problem will tend to go away on its own, but it can take over a year.

By using ultrasound, we can see the damaged areas of tendon. These appear as dark “hypoechoic” areas of tendon near their insertion on the bone.

One treatment option is a platelet rich plasma (PRP) injection.  This is a procedure where a person’s blood is drawn and spun in a centrifuge to isolate the the healing factors and platelets. By injecting those healing factors back into the elbow area, it is possible to stimulate the tendon to regenerate.  Results can be varied but recent studies suggest it is about as effective as surgical procedures. Here is a video from one company who makes a PRP system.

Arthrex ACP System Video

Listen To Dr. Sohn's Recent Interview On The Doctors' Podcast

In this interview, Dr. Sohn discusses shoulder health, recent advances in shoulder replacement.  He also answers the question:  "Are cortisone injections bad for you"?  

Listen here.  

Bicep Tendinitis

 Bicep Tendinitis:

This is by far the most common shoulder problem I see.  As you can see in the picture, the long head of the bicep tendon has to curve sharply as it enters the shoulder.  This is one of the only tendons in the body that bends at a sharp angle.  It probably explains why people get irritation and swelling on the portion of the tendon that rubs on the "corner" of the shoulder.  This causes a sharp pain in the front of the shoulder.  The pain can radiate down into the bicep muscle and occasionally into the forearm.  

These symptoms can be relieved with a bicep tenodesis surgery.  This is an arthroscopic surgery that fixes the damaged bicep tendon to the humerus so it can no longer rub and cause pain.  

Rotator Cuff Tear

 Rotator Cuff Tear:

This is probably the second most common injury of the shoulder I see.  The deep layer of shoulder muscles is called the rotator cuff.  People can tear one or more of these tendons leading to pain and weakness.  Patients describe this pain as a sharp or achy pain that emanates from the lateral side of the shoulder.  

We use an arthroscopic technique to repair the torn tendon.  We place bone anchors with sutures that secure the torn tendon back to the original position on the bone.  The tendon is held there by the suture tape while it heals.  It takes about 12 weeks for the tendon to fully adhere to the bone.