The patient presents with recurrent pain about the outer aspect of the right elbow. He reports that the pain primarily occurs with forceful gripping and occurs with movements of his right upper extremity characterized as repetitive wrist extension and palm upwards rotation of his forearm (supination).

He reports that the symptoms are recurrent, associated primarily with periods of increased racquet sports activity and fitness training. He reports prior use of OTC and prescription NSAIDs, and receiving a number of local steroid injections.

On physical examination his right upper extremity appears normal, without focal redness or swelling. The soft tissue over the lateral epicondyle is mildly swollen and of a softer, fuller texture compared to that on the left. He demonstrates normal active range of motion at the elbow. He reports slight increase in pain over the lateral elbow (epicondyle) with resisted wrist extension and supination, with mildly decreased strength (pain limited) compared to the left.

Assessment

1. Lateral epicondylitis

Considerations

The diagnosis is not particularly challenging or uncommon. Of significance is that the label is only applicable for a limited period. Tendons attaching at the lateral epicondyle that are repeatedly inflamed may degenerate over time, epicondylitis transitioning to epicondylosis. As such, traditional oral anti-inflammatory treatment and local steroid injections will not be effective indefinitely. Moreover, excessive local steroid injections may hasten deterioration of the tissues.

Treatment

1. Educate the patient about the involved musculature, adjacent soft tissue and function.

2. The patient is to attempt to eliminate contributing causal/exacerbating activities as much as is possible.

3. We discussed his workout routine making adjustments to its content.

4. I recommended that he consider purchasing a lighter weight hybrid/composite tennis racquet and decrease backhand stroke frequency.

5. We discussed applying alternating heat, ice, mild friction massage and local electrical stimulation (TENS) to encourage local circulation with limited concurrent analgesic benefit.

6. I recommended twice a day application of a thin layer of topical DMSO overlaid with a balm composed of one or more of the following numerous substances: menthol, aloe, eucalyptus, cayenne, arnica, Emu oil, devil’s claw, c. indica (as allowed in his State); other agents are also applicable.

Presuming that the tissues have not already degenerated significantly and the patient can make appropriate lifestyle changes, I anticipate a positive response to the treatment plan over time. At follow-up we will address additional evaluation and treatment alternatives depending upon case status and how much of the plan he was able to fully engage.

Contact us with questions about this case and other issues of interest.

In America, opium was sold legally and conveniently and at low prices throughout the nineteenth century. Morphine came into common use during the Civil War for management of pain, heroin toward the end of the century. These opiates and countless pharmaceutical preparations of similar products were as freely accessible as our numerous over the counter products today. Five regular portals of legal distribution included:
• Physicians.
• Drugstores that provided products with and without prescriptions.
• Grocery and general stores stocked and sold opiates.
• Opiates that could be ordered by mail.
• Opium and morphine as common ingredients in hundreds of proprietary medicines and other products.
Most of the opium consumed in the United States during the nineteenth century was legally imported. Morphine was legally manufactured here from the imported opium and opium poppies were also legally grown within the United States.
Alternative herbs and medicines for pain care often face tremendous community opposition. Some would say rightfully so, because we now know better and do better by our population. But, if such were true we would make cigarettes and liquor illegal given all of the injury and disease associated with these products.

Effective and appropriate alternative pain management is a matter of perspective and merits our support.

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People present to clinicians every day with the objective of management. Presuming the validity of the pain, consider the following treatment options.