Forget about your stack; take care of that sac!



This column first appeared in Ante Up Magazine in June 2009.

When Ante Up asked me to write a health column for its magazine (presumably because I wasn’t a good enough poker player to write an actual poker column), they suggested “Maybe poker players get carpal tunnel or something.” Well, generally, they don’t. But they do get something similar in a different spot.

Ante Up columnist Joe Navarro cured Phil Hellmuth of one of his most obvious tells, hugging himself when he bluffs. Now when Phil’s in a hand he plants his elbows on the rail and covers his lower face and neck with his hands.

His tell is gone, but he may be trading it for some elbow problems. Let me explain.
If you wiggle the skin overlying the boney tip of your elbow, you’ll notice that the skin is loose and slides rather nicely in all directions. The same thing happens over your knees, and to a lesser extent over your hips and shoulders. There’s a slippery sac just below the surface of the skin called a bursa that allows this movement to occur. There are places in your body you wouldn’t want loose skin, of course. It would be difficult to look cool shuffling poker chips if you had slippery bursas under your fingertips. But having bursas over major joints makes it easier to flex them smoothly.

Like any small, dark, moist, enclosed space in your body, if bacteria can get in they’re sure to like the accommodations. It turns out there are plenty of bacteria not very far away living in the folds of the skin you just wiggled in the last paragraph. Add a little bit of microtrauma from leaning on your elbows for 15 straight hours playing poker, and the bacteria can migrate into the bursa and set up shop. The resulting bursitis might be just a little extra fluid in the sac, but it can turn into a rip-roaring infection.

If the bursitis is not particularly painful and not red or hot it’s probably just inflamed and not infected and probably will resolve itself over time, especially if you leave it alone and stop leaning on it. Even a swollen bursa the size of a golf ball can be absorbed by the body.

But if it starts to get red, hot and painful, or if you’re running a fever, the strategy is different. Now you have a real infection. The physical structure of the bursa makes it difficult for antibiotics to get in to the actual sac where the bacteria are camping out, so the correct treatment is drainage. This is not something you should try at home. The skin needs to be cleaned, properly numbed and the bursa opened with a scalpel. Packing the cavity with gauze for a few days helps encourage drainage. With proper drainage antibiotics are not always necessary, but most doctors prescribe them anyway. Hot soaks will help this resolve even faster.

Internal medicine doctors usually shy from anything having to do with cutting, but family doctors, general surgeons, orthopedists and even walk-in clinics often handle this sort of problem. If you must you can always visit someone like me in the vast health-care safety net called the ER, but you’ll have to wait your turn among heart attacks, vomiting babies and drunks whose dogs ate their pain pills. The key point is do not heat up a needle and try to stab this thing yourself. You’ll probably do more harm than good.

This condition isn’t limited to brick-and-mortar rail-leaners. Internet poker junkies who prop up their head for hours at a time staring at their screens can get it, too. Just keep in mind that if you have a small painless collection of fluid then stop leaning on your elbow and it probably will get better. Once it gets red, hot and painful, seek help from a physician.

One more note for the real poker professionals out there: This clearly is a work-related injury and qualifies for workers comp coverage. You DO have workers comp don’t you, Phil?

— An avid poker player, Frank Toscano, M.D. is a board-certified emergency physician with more than 28 years of front-line experience. He’s medical director for Red Bamboo Medi Spa in Clearwater. Email your poker-health questions to

Ante Up Magazine

Ante Up Magazine