Tennis and Golfers Elbow (Tendinopathy/Enthesopathy)
What is it? Tendons are tough bands of tissue that connect muscles to bones. There are several types and stages of tendon problems. Tendon problems at the elbow are quite common. ‘Tennis elbow’ also known as extensor tendinopathy refers to irritation of the tendons on the outside of the elbow. See figure 1. These muscles function Figure 1 to extend the fingers, hand and bend the wrist backwards. A tennis backhand is a classic example of use of these muscles and tendons. ‘Golfer’s elbow’ also known as flexor tendinopathy refers to irritation of tendons on the inside of the elbow. See figure 2. These muscles function to bend the fingers, hand and bend the wrist forward. A tennis forehand is a classic example of use of these muscles and tendons.
Figure 2
What are the painful following exercise. Along and more frequent. In the earlier with pain, stiffness or tightness in the stages, this pain during exercise may symptoms? elbow and forearm region may also initially disappear as you warm up, The primary sensation with elbow be experienced. Typically, these initial only to return when you cool down. tendinopathy is pain felt on the signs of tendinopathy are ignored, However, as you continue to exercise, elbow. Tennis elbow / extensor as they disappear quickly with use the tendinopathy worsens and your tendinopathy is felt on the outside of of the arm or applying heat i.e. a hot pain may begin to be present for the elbow and golfer’s elbow / flexor shower over the elbow and forearm longer periods during exercise until tendinopathy is felt on the inside of region. However, as you continue it is present all of the time. This may the elbow. Pain typically develops to exercise, the tendinopathy interfere with your performance and gradually. Initially, it may only be progresses and the pain within the even become debilitating. tendon becomes more intense
How did I get it? irritated with all the stress, pulling or strengthen the tissue. It is the becomes painful and eventually reason that tennis players develop Elbow tendinopathy is a common the tendon begins to break down. tendinopathy but bodybuilders do injury associated with activities Repetitive uncontrolled use of the not. Slow strength training promotes requiring repetitive use of the wrist forearm muscles and therefore tendon growth. This explains the and hand and results from overuse the forearm tendons can lead initial paradox that strength training of the tendons on the outside of the to microscopic tears within the is used to repair an overuse injury. forearm. The forearm musculature tendons and degeneration of the The body does not mount a very is a large muscle mass with high tendons begins. Slow controlled good inflammatory or healing forces and high repetition inserting movements are less likely to irritate response so this injury can take a on a small area of bone. The junction the tendon and more likely to build very long time to heal. of the tendon and bone become
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What should I do? ignore the problem. Your pain may improve as you exercise however, How is a Elbow tendinopathy generally does the exercise you are doing may be not improve on its own if the cause compromising the healing process diagnosis made? is not addressed and you continue and causing further damage. This A diagnosis is made based to exercise using these tendons. can lead to your injury getting on the history of the injury If you have or suspect you have worse such that your pain does and examination of findings. elbow tendinopathy, you should not disappear after ‘warm up’ and While not normally needed, consult your nearest sports medicine you feel it throughout exercise. If occasionally x-rays, Ultrasound professional. In the meantime, you this occurs, your recovery may be Scan and / or an MRI are ordered can begin initial treatment. This prolonged and it may take a number to rule out other injuries. should consist of icing following of weeks or months for you to return exercise and regular gentle to exercise and sport. stretching of the forearm muscles. Icing should consist of crushed ice Elbow tendinopathy does not wrapped in a moist towel applied for produce any long-term effects, as I5—20 minutes or ice in a paper cup long as it is properly diagnosed massaged over the outside of the and appropriately treated. If not, elbow until the skin is numb. it can lead to prolonged pain on the outside of the elbow and a If you have or suspect you have prolonged layoff from exercise and elbow tendinopathy you shouldn’t sport.
What does rehab treatments including injections such particularly effective for elbow as prolotherapy, PRP (Platelet Rich tendinopathy. A trial of anti- involve? Plasma) and ABI (Autologous Blood inflammatories or simple pain relief In recent years there has been a very Injections) and minimally invasive medication like paracetamol may significant shift in the treatment of surgeries such as percutaneous however be worthwhile initially or if tendinopathies. It is now recognised tenotomy are increasingly popular. the symptoms are severe. They essentially aim to injure the that there is not much inflammation Physical therapy: tissue to promote a healing response in tendinopathy so anti-inflammatory Exercise therapy in particular by the body. medications and cortisone injections strengthening exercise should be the are not considered effective. Often Activity Modification: mainstay of treatment. tendinopathy will persist for a long time. In fact often a large tendon Reducing provocative activities such Unloading braces: tear will heal quicker than the time as lifting (overhand for extension Unloading braces can help decrease taken to repair a tendinopathy. It tendinopathy and underhand for pain. They may certainly help with seems as though the body does not flexor tendinopathy) is essential for symptoms although it is unlikely that recognise tendinopathy as an injury recovery. For example someone who they help speed up healing. usually lifts underhand and has flexor and makes no attempt to repair the Splints: tissue. For this reason treatments tendinopathy may find it beneficial aimed at strengthening and or to adopt overhand lifting postures Splints can be used for extreme cases irritating the tissue are preferred. to give the flexor tendons a rest. where pain is unbearable. The reverse would also be true for Physical / exercise based therapy GTN Patch: must always be the mainstay of extensor tendinopathy GTN patches are a patch originally treatment. Tendon function and Pain Medication: intended for heart disease and blood strength must be preserved. Irritant Pain medication tends not to be
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pressure. They have been shown small risk of causing infection. One factors that promote healing. While to increase nitric oxide which is an theoretical side effect of a cortisone cortisone works well in the short important healing chemical. GTN injection is that it can weaken the term, PRP works more slowly but patches are relatively cheap and are tissue and result in a rupture. The risk long term outcomes have been non-invasive. Their main side effect of this is low, approximately 1/1000. shown to be better than cortisone. is headaches. The headaches are due A cortisone injection is usually used Shock wave therapy: to lower blood pressure and should in two groups of patients. The first only persist for the first 2 weeks. GTN Shockwave therapy can be group have milder symptoms or can patches may be worth considering considered. It may offer some alternate their duties so they can if initial activity modification and benefit. work around the pain. In this group exercise therapy has not improved an injection is performed when the Surgery: the tendinopathy. pain has been present for a long Surgery is rarely required and should Cortisone injection: period of time and an extensive be avoided in the vast majority of trial of physical therapy has failed. An injection of cortisone, which cases. The second group is patients with is an anti-inflammatory steroid extreme symptoms or who for some medication, may be given to relieve reason cannot wait for physical pain. Relief from a cortisone injection therapy to become effective. This is usually highly effective but group usually receives an earlier temporary in nature. Its effectiveness injection but must also engage in in controlling pain varies from many physical therapy or the pain will just months to as little as a few weeks. return when the injection wears off. There is some contention regarding how many times an injection can Irritant Injections: be repeated but generally it will be While often quite painful, irritant considered twice before pursuing injections such as PRP are surgical options. The injection can increasingly popular. It acts to irritate be painful and has an extremely the tissue and infiltrate growth
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