Common extensor tendon; high-grade tear

On February 20, 2012, I injured my common extensor tendon while playing squash.  After two cortisone shots and three weeks of physical therapy, my orthopedist recommended imaging for further evaluation of my problem.  The MRI showed a high-grade tear in the common extensor tendon.  This type of tear means that more than 50% of the tendon fibers were torn.  Because it often cannot heal on its own, my doctor recommended a surgical repair.  I wasn’t experiencing any pain, but my elbow felt unstable, and I had less strength in my forearm muscles.  I continued to try playing squash, but my elbow just felt funny and I didn’t want to make things worse.  However, I was also reluctant to have surgery, so I scheduled an appointment with a different orthopedic surgeon to get a second opinion.  He took a different approach.

Physical Therapy to Prevent Surgery

Physical therapy can reduce pain, and improve flexibility and mobility as an injury heals.  The second orthopedist who evaluated my arm recommended three additional weeks of physical therapy, after which he would assess whether or not surgery was still necessary.  I took his advice and resumed physical therapy three days a week, then supplemented these sessions with additional exercises at home.  After the three weeks, I had made so much progress that the orthopedist recommended continuing physical therapy.   Two and a half weeks later, however, I began experiencing pain that traveled from my elbow up to my neck.  I had spasms in my biceps, deltoid, and rotator cuff muscles that hurt so badly that I could not sleep at night.  

Because of this unexpected issue, I scheduled a follow up appointment.  The orthopedist thought that my pain may be associated with a neck injury.  He did x-rays of my neck in his office which showed bone spurs and a loss of intervertebral disc space at C5 C6.  He suspected this was due to an injury that had occurred many years ago.  I told him that, when I was 16, I had been in a car wreck where my head hit and broke the windshield.  He agreed that my x-ray findings were consistent with such an injury.  To further evaluate for soft tissue damage, he ordered an MRI of my neck.   For the pain and inflammation, he prescribed a Medrol dose pack.  This is a type of steroid medication that is taken orally, not an injection.  

At my follow up visit, I learned that the MRI of my neck was normal, and showed no nerve impingement or soft tissue damage.  It, however, did not indicate why I had pain in my shoulder and bicep muscles.  Unfortunately, I had an adverse reaction to the Medrol dose pack, known as serotonin syndrome.  My blood pressure increased to 220/100, and my skin felt as if it was “crawling with ants.”  This occurred as I was on my way to the MRI follow up appointment, just in time for my orthopedist to see it.  I was worried about my high blood pressure, and had considered going to the ER.  My orthopedist, however, advised me to see my primary doctor.  Before I left his office, he also arranged for me to see a neurologist for a nerve conduction study.  This test would check for any nerve damage in my neck.   This is something my physical therapist had also mentioned.  Nerve damage could have caused my biceps muscle to contract abnormally which led to the common extensor tendon tear.

Common Extensor Tendon Tears

The common extensor tendon attaches the forearm muscles to the lower end of the humerus, the bone of the upper arm.  It is injured during either acute trauma such as an elbow dislocation, or from repetitive overuse.  In the latter case, arm movements while playing tennis, squash, and similar sports cause “wear and tear” of this tendon over time.   It is a common injury among those who do physical work such as plumbers, auto mechanics, butchers, and chefs.  It may also be a complication of receiving too many steroid injections to relieve pain.

Common extensor tendon tears are characterized by the thickness of the injury:

  • Suspected  – the location of the tear is not detected on imaging studies
  • Low-Grade  –  less than a 50% tear
  • High-Grade. –  more than a 50% tear

How Long Does it Take for High Grade Common Extensor Tear to Heal?

It takes six to 12 months for a tendon tear to heal, and longer if surgery is required.  There is a limited amount of blood flow within tendons to transport oxygen, new cells, and nutrients needed to repair the tear.  When non-surgical management is chosen, the tendon attaches itself to surrounding tissues with scar tissue.  It will eventually “tighten up” and heal close to “never having happened.”  

High-grade common extensor tendons typically require a surgical repair.  After surgery, a splint is used to stabilize the arm during the first week of recovery, followed by two or more months of physical therapy.  Normal activities may be resumed after four to six months.

My Reaction to Cortisone

After leaving my orthopedist’s office with serotonin syndrome symptoms, I contacted my primary care doctor.  He informed me that I could do nothing but let the medication “run its course and get out of my system.”   He recommended that I continue to check my blood pressure at home, and prescribed a medicine to take if it went above 160/95.  He also gave me a prescription for Ativan to reduce the agitated feeling and “skin crawling” sensation.  He said my symptoms could last up to two weeks!  

Currently, it has been a week.  Although I no longer have daily blood pressure spikes, I have felt the “skin crawling” sensation and still worry that something bad will happen.  It’s a really crappy feeling, and I’ll be glad when this is over!  I have not yet seen the neurologist, or been doing physical therapy.  I don’t feel like doing anything that might aggravate my symptoms.  Hopefully, they will resolve soon, and I’ll decide whether or not to keep my appointment with the neurologist.  Despite the adverse reaction, the steroid medication did reduce my neck, shoulder, and elbow pain.  At my last visit with the orthopedic surgeon, he felt there was no need for surgery on my elbow.

To sum up: My common extensor tendon tear is healing without surgery.  For 12 days, I experienced blood pressure spikes every few hours, sometimes as high as 220/100.   I took Clonidine and Ativan, but often sat in the parking lot of my local ER while waiting for my blood pressure would go down.  On the tenth day of symptoms, my tremors were so bad that I finally went into the ER.  Now, after 14 days, my blood pressure has stabilized.  The slight tremors and muscle spasms continue, just not nearly as severely.

A Cortisone Warning

So, as a warning to anyone who takes cortisone shots, a Medrol dose pack, or similar medications, it is possible to develop serotonin syndrome.  If this occurs, contact your doctor immediately, or go to your local emergency room.