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Tennis Elbow May Not Be Tendinitis

The path to pain relief may be surprising

My doubles partner and I lead the final set, my elbow on fire. Self-diagnosis: severe lateral epicondylitis, an inflammation of an extensor tendon commonly known as tennis elbow. I ignore the pain and hit a series of high-bouncing slice serves. With that, we win our first match since July.

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Jumping Joints

Photo by Adam Voorhes

Tennis elbow sufferers can choose from cutting-edge treatments to at-home rehab exercises.

My elbow, alas, refuses to join the celebration, and a week later I'm perched on the exam table of Gary Chimes, M.D., Ph.D., a specialist in musculoskeletal injuries at the UPMC Rehabilitation Institute in Pittsburgh.

I explain how tendinitis has so inflamed my elbow that home remedies no longer work. Perhaps he could give me a prescription NSAID (nonsteroidal anti-inflammatory drug) more potent than the over-the-counter versions?

Chimes smiles good-naturedly, no stranger to know-it-alls whose orthopedic knowledge is based on TV commercials for analgesics. Before I can babble further, he explains that inflammation is indeed the signature sign of tendinitis, but it's doubtful my elbow will show signs of it.

To find out, he holds an ultrasound device against the inside of my wrist. With each heartbeat, small red flowers bloom on the monitor. "This is what blood flow looks like," he says. Next, he moves the wand to my elbow. No flowers here. "If your elbow were really inflamed," he says, "we would see much more blood flow in the affected area."

As you may recall from high school biology, tendons are tough, inelastic bands that connect muscles to bones. They can be damaged in two basic ways: sudden trauma or long-term overuse.  

"We used to think that both kinds of injury caused tendinitis," says Robert Dimeff, M.D., director of the sports medicine program at UT Southwestern Medical Center in Dallas. "Instead we're learning that the deterioration from accumulated small tears and frays in tendon tissue causes a condition better described as tendinosis."

The difference here is more than just suffixes. Tendinitis boosts blood flow to the injury, raises the local temperature and unleashes a pharmacopoeia of natural healing factors, dubbed the inflammatory soup. Some of these factors clear away the debris caused by trauma. Others sensitize nerves to induce protective pain, keeping us from more damage. Still others slowly rebuild what the injury has broken.

Tendinosis, by contrast, doesn't provoke a tidal surge of inflammatory soup. Instead, tendinotic tissues languish in a state of near neglect, as if our bodies don't fully recognize that an injury has taken place.

A small handful of tendons are especially susceptible to tendinosis, including the rotator cuff (swimmer's shoulder), the patellar tendon (runner's knee), the Achilles tendon (Achilles' heel), the medial epicondyle (golf elbow) and my own nemesis: the lateral epicondyle (tennis elbow).  

Different sports may have led to the popular names for these conditions, but they aren't restricted to athletes. Tennis elbow, for instance, can be instigated by any repetitive motions that stress certain muscles in the forearm and wrist. Gardening, hoisting trash bags, wringing out towels, and even typing are frequent triggers. Likewise, washing windows, painting a ceiling, or other chores requiring prolonged overhead use of the arms can lead to swimmer's shoulder as easily as a Michael Phelps workout.

Fortunately for today's tendinosis sufferers, innovative treatments designed to rally the body's innate healing response are now becoming available at specialized orthopedic clinics and sports medicine centers. These include:

Shock-wave therapy. Shock waves are delivered via a handheld device placed directly against the injured body part. "It literally feels and sounds as if you're getting hit by a jackhammer," says Alfred Cianflocco, M.D., director of Primary Care Sports Health at the Cleveland Clinic. Cianflocco underwent the procedure after a bad case of golfer's elbow failed to respond to ice, anti-inflammatory drugs, wrist splints and elbow straps. A typical session can last about five minutes; the more discomfort you endure in that time, says Cianflocco, the better your long-term results. Within weeks of his own treatment, Cianflocco threw away his elbow straps and returned to golf and gardening pain-free.

Needling. In a procedure called prolotherapy, a doctor uses a hypodermic needle to inject a known irritant, from talc to dextrose, into the injury site. This therapy stems from the realization that one longtime orthopedic staple — cortisone shots — works not so much because of the cortisone, but because of the micro-trauma caused by the needle itself. Cortisone, it turns out, may help relieve your pain in the short term, but it often weakens tendon tissues in the process, making tendinosis worse. Researchers have reported better long-term results by simply poking around with the needle. "This is called dry needling," explains Dimeff, "and it's another technique that causes a little bit of tissue damage so the body will wake up and respond to the injury." Adding safe but irritating compounds, he says, increases the volume of the wake-up call.

Nitroglycerin patches. Nitroglycerin has long been given in pill form to treat the heart pain known as angina. It does this by expanding blood vessels that supply the heart, allowing more oxygen and nutrients to reach starved heart muscle. Over the past few years, doctors have found that when it's applied via skin patches over painful tendons, nitroglycerin significantly increases tendon strength and function in patients suffering tennis elbow, swimmer's shoulder and Achilles' heel.

Platelet injection. Although platelets are best known as clotting agents that seal cuts and stop bleeding, they also contain powerful tendon-healing growth factors. To better concentrate these growth factors in a region of tendinosis, doctors remove a small amount of the patient's blood, spin it in a centrifuge, separate out the platelets and then re-inject these at the injury site. Another similar procedure called autologous blood injection (ABI) skips the platelet separation and simply injects the patient's whole blood back into the damaged area. Though research has yet to prove one approach works better than the other, both work for many patients: Reported success rates range from 80 to 95 percent.

In the pipeline. Stay tuned for a host of other promising treatments. For instance, researchers recently reported positive results for tennis elbow following injections of joint-lubricating hyaluronic acid (HA). Other studies have found that certain blood pressure meds have a serendipitous side effect: They reduce scar-tissue formation, promoting a more natural, youthful healing response in older adults. Still other investigators are using vessel-choking "sclerosing agents" and minimally invasive surgery to put the kibosh on tendinotic pain.

As for me, after zeroing in on the tendon fibers, Gary Chimes finds nothing significantly abnormal — just the low-grade wear and tear that's impossible to avoid in an active guy on the cusp of 60.

"It's not that there's something structurally wrong," Chimes tells me. "It's that you're asking a body part to do more than it was designed to do." To remedy this, he gives me two prescriptions.

"First," he recommends, "see a tennis pro about improving your technique, particularly your serve and one-handed backhand." Powering these shots with the arm alone concentrates a huge amount of stress on the elbow.  

Second, visit a physical therapist for rehab exercises. "A well-designed program of physical therapy will help you learn to use your whole body more effectively," he says. "That way, you won't always be asking little muscles to do the big muscles' job, putting more pressure on tendons."

Two months later, I can't believe my improvement. A local pro has taught me how to hit a two-handed backhand, effectively eliminating the major source of on-court elbow twinges. At the rehab center, my physical therapist has shown me a series of exercises that has not only further aided my elbow's recovery but provides significant relief for my other chronic tendinosis problem: swimmer's shoulder, the bane of diehard swimmers like me.

So while it's comforting to know that cutting-edge treatments exist for my tendinosis, I'm happy that I don't need them quite yet — or maybe ever.

Pennsylvania freelancer Jim Thornton writes for Men's Health, Field & Stream, and Swimmer, among other magazines.

Do-it-Yourself Physical Therapy

Here are just two of the many exercises my physical therapist taught me. Now that both my shoulder and elbow tendons feel good again, I continue performing these exercises daily to keep the problems from coming back.

  • Rotator and Scapular squeezes (shoulder).
    Hold a stretch cord with both hands, a foot apart, keeping your upper arms against your sides and your forearms extended at right angles straight ahead. With your elbows fixed by your side, slowly extend your hands outward, hold several seconds, then return to the starting position. Concentrate on squeezing your shoulder blades together during the exercise. Do 15 reps daily, gradually working up to 30.

    How this helps:
     For each muscle that moves us one way, an opposite muscle moves us the other. Repetitive exercises like swimming can lead to imbalances by strengthening one muscle more than the other. Stretch-cord "squeezes" help restore balance by working the external shoulder rotators and scapula stabilizers — key muscle groups that help stabilize the shoulder.
  • Wrist curls (elbow).
    Holding a 2- to 3-pound dumbbell or large can of soup, curl your wrist up and down. Go slowly, particularly while lowering — the "eccentric contraction" phase of the curl. This lengthens and strengthens the muscle. Repeat 30 times with your palm up. Rest a minute, then repeat 30 times with your palm down.

    How this helps
    : Eccentric contractions prompt tendon-producing cells called tenocytes to deposit healthy replacement tendon fibers at the injured site.