One ligament to bind them
April 28, 2013 5 Comments
Last Thanksgiving, I spent hours making a tasty onion recipe and then when I handled a turkey at arm’s length, I felt a “pop” and my neck and elbow started to hurt like crazy. I treated this on my own for a bit, and then eventually saw my regular physiatrist, who diagnosed me with tennis elbow, gave me an OT routine and a brace, and told me to otherwise rest (making me completely nuts).
Rest was making me nuts because it was no biking, no exercise, and worst of all, no drumming! Augh!
So after roughly four months of that, a cortisone shot, and some custom bracing, I still wasn’t getting better. I also was getting really frustrated because the treatments and descriptions of tennis elbow all referred to wrist-based flexion problems, and yet I was also having pain when I did things with my wrists In a neutral position (like tie my shoes, lift a glass, or pull my pants up).
So the OT gave me a referral to a different physiatrist who did sports medicine – Dr. Victor Ibrahim, who is the doctor for DC United, and of course his is a non-insurance practice.
But when we went in – I had asked Sarah to come with me as a second pair of eyes – I noticed a difference: I described my history and asked “what treatment should I be doing?”
His response was “well, when you have a treatment which isn’t working, either you need to change the treatment or you have the wrong diagnosis. Let’s confirm your diagnosis.”
And so we went to the ultrasound machine, the first imaging used in the $5000 of treatment I’d had for this elbow, and he said almost immediately “I see the issue- your tendon is inflamed, but the one below that – the one which controls pinching motions of the fingers- it’s torn through” and of course no amount of OT will rehab a torn tendon – it will generally make it worse! He kept looking, and also saw that the ligament at back of my elbow (the UCL) was also torn through- he showed this by pulling my arm while under ultrasound- you could see inflammatory goop shoot out (ew), and even visually you could see a radical difference between my right (bad) and left (good) arms- my right arm basically looked like it came out of joint. Dr. Ibrahim said that this sort of damage probably built up over a while, so it wasn’t like this was something which I had done in the last four months while attempting to rest.
So this is a spectacular misdiagnosis, and is exactly the type of thing which could have been prevented (along with spending thousands of dollars of my own money, and thousands of dollars of UHC’s money) if the diagnosing physician had used imaging. Now, I know that there is a push to do exactly the opposite in the name of cost reduction, and that’s one of the reasons why I thought it was so important to document precisely what happened here: lack of information at the outset led to an incorrect diagnosis, led to lots of expensive, ineffective incorrect treatment (and lots of patient suffering).
So back to Dr Ibrahim. He gave me some options, which he listed from most invasive to least invasive:
- I could have a Tommy John surgery, guaranteeing that I wouldn’t have a 95 mile-per-hour fastball ever again (because that is a worry- I’m certain I can get at least a 9.5 mile/hour fastball within a radian of my target…)
- I could have a stem cell transplant, where they perform liposuction, spin off the fat, do some magic and turn it into stem cells which regenerate the tendon and ligament. Science!
- PRP – he recommended against this because spinning my own plasma and injecting it into the joints could further spread babesia and Lyme, which meant that he got a gold star for caution in my book
- prolotherapy – this is an injection of dextrose into the ligament and/or tendon which can trigger an inflammation and cause healing. Mechanism of action is unknown, but hey, it is with aspirin too, so not such a shock.
Sarah has had both prolo and PRP, and they’ve done wonders as stabilizing her pelvis is concerned, but she described them as excruciating.
Dr Ibrahim offered me these choices, but recommended prolo- and amazingly, when I accepted that option, was willing to do it right then (!) and doesn’t even charge for it (!!) [his argument is that the cost of dextrose and a syringe is next to nothing, so should be included in the office visit]. So I had a few shots, and they hurt about as bad as you would expect a gigantic needle being shoved into a torn tendon to hurt- which is to say, OW. I’d put it about a 5 on my pain scale, but that’s only because the testicular torsion blows everything else out of the water as a 9 (I presume 10 would be my head spinning around Exorcist-style).
So after painful things it takes me a few minutes to recover, so I was lying down, and Sarah was talking to Dr I about the pain in her arms, and her Lyme disease. He said, “let me take a look at those” (!!!) and proceeded to ultrasound her arms (the first imaging ever done on her arms, which have caused her disabling pain for 7+ years) where he then said “I see a whole lot of scar tissue- this looks like the type of stuff that can be caused by infectious disease- this looks excruciating”. At this, Sarah started crying, because this was the first real validation she had ever gotten that there was an actual physical, measurable, objective source for the pain she has been in for most of a decade. The real kicker was when he said:
there is something we can do to remove the scar tissue and make you feel better.
Holy $h!7! Really?
The treatment is called a debridement, and basically it’s an injection of some goop which dissolves scar tissue and allows the body to function normally.
So we scheduled a follow-up- a joint appointment where Sarah would get a debridement and I would get another prolo if necessary (expected). That was last week.
I had my second course of prolo- it turned out that my UCL only needed one (yay!) and my tendon seems to be doing pretty well. Sarah, on the other hand got under the ultrasound, and her sinovium lit up like a Christmas tree – Dr I said that this was likely active Lyme. He said that the risk of doing the debridement when the infection was live like that was really high, and could leave her bedridden, which would be intolerable, so he had to delay her treatment. Mega-bummer.
But it does impress me all the more, that here you have someone who was all ready to perform a weird procedure on someone, and then didn’t, because he didn’t feel like it would be in the best interest of the patient. Yay Hippocrates!