Elbow tendonitis/tendinosis is an overuse injury resulting from repetitive motion events frequently found in certain sports or work related activities. Statistics show that nearly one half of all tennis players will suffer from this injury at some point, however this group represents less than 5 percent of all reported cases.

Through extensive published research the NOSC has found that what many doctors commonly refer to as tendonitis is actually tendinosis. Tendonitis is defined as an inflammation of the tendon. Tendinosis is an overuse injury resulting from multiple micro-traumatic events, which over time accumulate and lead to the eventual degeneration of the tendon. Dr. Nirschl describes this as tendinosis, a distinctly non-inflammatory, degenerative, avascular (lacks blood supply) process. This painful tendon abnormality might be thought of as heart attack of tendon. Our research has proven through examination of the tendon using a high-powered microscope that there is not inflammation in the tendon and therefore tendinitis is not present. This is an important distinction because it impacts how you treat and cure the injury.

Lateral Elbow Tendinosis (outside of the elbow)
(Commonly referred to as Tennis elbow or backhand tennis elbow)

This overuse syndrome is caused by continued stress on the extensor muscles (extensor carpi radialis brevis, extensor digitorum communis) of the forearm, as they originate on or about the lateral epicondyle of the elbow. The onset of pain is usually gradual with pain or tenderness felt on or below the elbows bony prominence (epicondyle). Heavy use activities including movements such as gripping and carrying tend to be troublesome. Lateral tennis elbow is a very persistent disorder that does not easily resolve itself.

Medial Elbow Tendinosis (inside of the elbow)
(Commonly referred to as Forehand Tennis elbow, Golfer's elbow, Baseball elbow, Suitcase elbow)

Medial tendinosis presents with pain and tenderness centered about the medial elbow. The medial epicondyle serves as a site of attachment for the flexor-pronator muscle group. Golfers elbow is similar to tennis elbow but the pain and tenderness are felt on the inside of the elbow, on or around the bony prominence. An additional factor may be a compression of the ulnar nerve (funny bone). It is typically seen in pitching a baseball, the trailing arm in golf and pull-through strokes of swimming. Typically it occurs in middle-aged people often involved in sports or occupational activities that require a strong handgrip.

In sports contributing factors include; over activity of the trailing arm in golf, opening up to quickly and dragging the arm behind the body when pitching a baseball.

Posterior Elbow Tendinosis

Posterior elbow tendinosis, sometimes referred to as boxer's elbow, involves the triceps at its attachment to the elbow. It typically follows a sudden severe strain to the triceps tendon as the arm is fully extended (javelin throwing, punching, serving a tennis ball, baseball pitching). Weightlifting has also been implicated in the pathology.

Symptoms

• Usually gradual onset
• Recurring pain
• May radiate down arm toward the wrist
• Difficulty extending or straightening the elbow fully
• Pain caused by grasping or lifting
• Dull ache at rest
• Sharp twinges during or after activity
• Pain related to activities using the wrist - grasping, tennis, and gardening

Treatment

Relief of Pain

• Protection, Rest, Ice, Compression, Elevation, Medications, Modalities (PRICEMM)

Control Abuse

• Modify Intensity, duration, and technique of forearm activity
• Use proper size and type of equipment
• Countr'R Force bracing

The first step is pain relief. We use medication in our clinic as a helpful means to enhance the healing process. Medication alone does not promote healing, but enables you to get comfortable and proceed to the rehabilitation or healing phase of treatment. Towards this end, Dr. Nirschl advocates the use of non-steroidal anti-inflammatory drugs (e.g. Ibuprophrin, Motrin) and restricts the use of cortisone injections to the rare case when the patient's discomfort is so pervasive as to preclude activities of daily living. It is important to note that steroid (cortisone) injections cannot be used long term because of potentially damaging side effects. You should never receive more than 3 injections in a one-year span. Rest and medication alone is not an acceptable form of curative treatment. Comfort or pain control alone does not specifically improve the injured tendon tissue.

Physical Therapy can be beneficial in the treatment of elbow tendinosis. Through our research we have found sensory level electrical stimulation the most effective modality. Tendons, which attach muscles to bones, do not receive the same amount of oxygen and blood that muscles do, so they heal more slowly. Electric stimulation helps increase blood supply to the tendon thus increasing healing and decreasing any swelling or discomfort.

Ice is also a very important element in the healing process and should be used any time signs of irritation or pain are present. It is important to use ice after exercise and after any activity that causes discomfort.

While rest is important to enhance the healing process, it is important to understand that rest is best define as the absence of abusive activity, not absence of activity. "Absolute rest is rust". All tissues, particularly injured tendons, require tension and motion to maintain health. Total immobilization is obviously contra-indicated as it results in muscle atrophy, weakness, and decreased blood vessel supply. More specifically, immobilization at the elbow results in limited extensibility, joint stiffness, fibrous adhesions and random alignment of collagen fibers.

Controlling Abuse with Bracing

It is often difficult for people to completely avoid pain-provoking activities. Our practice recommends bracing to help disperse forces that otherwise would be absorbed at the site of injury. The Count'R Force braces have proven very helpful in enabling individuals to begin a rehabilitative exercise program sooner as well complete their daily activities with less pain.

Count'R Force Lateral Elbow Brace       Count'R Force Medial Elbow Brace
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Bracing has also proven beneficial in enabling rehabilitating individuals to return to their sport. The principle of the Count'R Force brace is to give firm yet pliable anatomic support and protection for an expanding muscle and moving tendon, while at the same time allowing freedom of joint movement. The brace decreases internal muscle tension and lends support to injured tendons without pinching blood vessels or nerves or causing excess focal compression.

The goal of rehabilitation exercises is to promote optimal healing of the injured tissue. Absolute rest and pain relief by injection or medications offer no stimulation to the injured tissue. Injured tendons must be nourished by increase blood supply, in association with the production of new collage protein, which matures into healthy tissue. Rehabilitation exercises are the key to the curative process because they promote strength, flexibility and endurance to the injured area.

A major goal of rehabilitating the elbow is total arm strength and endurance including the shoulder. Incidence of injury increases as the body fatigues therefore; exercise of the elbow and shoulder muscle groups is an important concept to avoiding injury. Dr. Nirschl stresses to his patients that you should get in shape to play your sport, not play a sport to get in shape.

Why Rehabilitation Exercises

High school athletes not performing a strength-training program had an injury rate of 72.4% compared to only a 26.2% injury rate for athletes on a strength training program. Furthermore, the time required for rehabilitation from an injury was twice as long as those individuals not on a strength-training program.

It is important to continue the strengthening program followed by a maintenance program when the pain has resolved. Since regular activities of daily living do not maintain conditioned muscles and may actually be detrimental to some muscle (including sports activities), it is critical to continue a maintenance program.

Surgery

Surgery is warranted when patients fail a quality rehabilitative program. Failure to receive a quality program or months of rest without rehabilitative exercise does not justify surgical intervention. In addition if muscles are not strengthened prior to surgery it will prolong the post surgical rehab time, but a conditioned arm will recover much quicker after surgery. Surgical intervention focuses on excision of the degenerative tissue and stimulation of healing factors not the obsolete concept of tendon release. Post operatively the patient can expect to be treated in a sling for 3 to 5 days and thereafter a structured therapy protocol is followed.

Tennis Techniques and Racquet Design

It has been suggested that the techniques and conditioning in the skilled tennis player versus the novice player may be vastly different and explain the tendency to see a larger proportion of novice tennis players who suffer from tennis elbow.

The unskilled player may demonstrate a leading elbow with the backhand stroke, thus placing greater strain on the elbow area at the time of ball contact. Ball contact in the unskilled player may also occur too far from the fulcrum lever, i.e. the shoulder. This causes an increase in torque being absorbed through the upper extremity and greater arm fatigue. The one handed backhand requires greater coordination of movement from 5 body parts as opposed to 2 body parts with the 2 handed back hand. And again, the one handed backhand causes an increase in torque being absorbed by the upper extremity. Excessive spin has been implicated in causing tennis elbow as well as general deconditioning and lack of upper extremity strength. The novice player will also tend to have more miss hits occurring near the racquet edge, which leads to increased torque and vibration to the players elbow.

The skilled player tends to hit the ball in the center of the racquet head, also refereed to as the sweet spot, more often than the unskilled player. The sweet spot is the center of the racket or slightly above it towards the tip and is considered the ideal area of impact. The tighter grip only at impact used by the more skilled player tends to dampen vibrations more quickly. The skilled player has a relaxed grip throughout the stroke until impact and will also tend to use the more ergonomically efficient two-handed backhand.

When selecting the ideal racquet a number of options should be considered for the player plagued with tennis elbow. The frame should be of medium flex. Repetition of motion is the primary cause of tendinosis. Lighter racquets may result in more jarring and shock to be absorbed through the arm. The heavier racquets allow less recoil with the ball and there is less twisting associated with off center/off axis hits but has the disadvantage of more difficulty in proper positioning. Antivibration stoppers or clips placed in the strings will not prevent frame vibration or control twisting (torque). Low string tension is preferred over tight stringing.

Ideal grip size matches the working size of the hand. Look at the palm of the hand. Notice the palmer creases. Using a ruler measure from the bottom crease (running along the middle portion of your hand between the long and ring finger) to the tip of your ring finger. This determines the grip you need.