Tendonitis (Tennis Elbow) |
 What is it?
Almost every athlete at one point or
another in his or her career will suffer from tendonitis.
Tendonitis is a diagnosis, which is often made but less often
understood. To fully comprehend what the term means, you
must first break down the word tendonitis into its two word
basic parts, which are joined together to form the word.
The first word, of course, is tendon.
This is the strong band of tissue, which is at the end of
the muscle that serves to anchor the muscle onto bone.
When the muscle contracts it pulls on
the end of the strong band of tissue, which is the tendon.
This in turn pulls on the bone and provides movement across
the joint. For all intents and purposes a tendon is really
part of the muscle itself, which is devoid of the muscular
fibers and allows the muscle to attain a greater length across
the joint.
The second term is "itis." This
is a term, which is attached to a specific word and simply
means inflammation. It does not, as is commonly understood,
mean infection. The use of the term can change with the piece
of anatomy. When it is a tendon, it is tendonitis, but it
can also refer to the lining of the abdominal cavity (peritonitis)
or the thin lining of the brain or spinal cord (meningitis).
 Some
sites of the body are much more prone to tendonitis than
other sites, and in particular, the elbow and shoulder. Probably
the most commonly known form of tendonitis is tennis elbow.
This term is a synonym for lateral epicondylitis (see diagram).
This is simply the site where all the muscles on the back
of an athlete's forearm join together to form one strong
tendon which finds its origin onto a small spot just above
the elbow joint on the outside of the elbow (lateral spicondyle).
When the tendonitis represents an inflammation of this tendon
as it inserts onto this lateral epicondyle of the elbow it
is known as tennis elbow. These strong muscles on
the back of the forearm serve to cock the wrist up and back
which is, of course, the starting position for the tennis
stroke. If this is done repetitively it can cause a tendonitis
of this muscular origin at the elbow. Although the common
term for this condition is tennis elbow, it can of course
be obtained in any sport requiring repetitive motion of these
muscles. For that matter, it can also be work related with
manual tasks in the work place.
The actual pathology of what is the underlying
cause of tendonitis is something, which is debated in orthopedic
literature. Some researchers feel that it is a true inflammation
of the tendon itself while others feel that it is micro hemorrhages
(bleeding) into the fine tissues of the ligament itself.
Still other researchers have postulated that it is not the
tendon at all but rather an inflammation of the periosteum
(outer lining of bone) and is therefore more truly called
a periostitis. These arguments are somewhat academic in nature
because the end effect to the athletes is the same, pain.
There are many factors that together
contribute to the cause of tendonitis. Probably the most
common is repetitive overuse of the joint, and you can see
how easily this could happen in a racquet sport with the
repetitive stroking of the ball with the wrist in the cocked
up position. In the racquet sport of tennis itself, it has
often been thought that it comes from improper stroke technique
in the majority of players. This is particularly true in
the backhand. Researchers have broken down the two most common
faults into two large categories. Unfortunately, most of
us probably fall into the larger group, which represents
the category of players who are less than world class athletes.
For these players the most common problem is in an overuse
syndrome while coming down hard for the overhand serve. The
repetitive hyperpronation of the wrist with a vigorous overhead
stroke causes recurrent stress on the lateral epicondyle
of the elbow. Other common problems are the use of an incorrect
grip size on the racquet or a racquet that is the wrong weight
for the player's ability.
Signs and Symptoms
The symptom patients most often complain
of is a diffuse ache around the elbow joint which is usually
able to be tracked down to one small local area which is
quite tender on palpation. It is particularly worse with
active use and usually after the sport the athlete will complain
about stiffness and a sensation of swelling, although objectively
the swelling is hard to document. Interestingly, if the tendonitis
is not on the outside of the elbow but rather the inside
of the elbow, this is known as "Golfers' Elbow." The "Golfers'
Elbow" or medial epicondylitis is less common than the
tennis elbow but just as painful.
Treatment
The treatment of chronic tendonitis most
often begins with simple rest, i.e. cessation of the activity,
which has brought on the problem. Most athletes are not comfortable
with this as being the only treatment, and they can therefore
use certain types of splints, which are worn around the forearm
and limit the ability of the forearm muscle contraction.
Other forms of non-aggressive treatment consist of phsiotherapy
with modalities such as ultrasound and icing the affected
area before and after a sport. Non-steroidal anti-inflammatory
drugs such as Aspirin, Motrin, and Naprosyn can also be added
to the treatment region.
Surgical intervention is another option,
but this should be a last resort after all other treatments
have failed. Before surgery is contemplated, the area is
usually injected with cortisone if the patient has been refractory
to all other treatment. Cortisone should not be given repetitively
into the same area, however, because it can cause permanent
damage to the tendon if it is performed too often. It is,
however, for one or two usages a very effective treatment
and can often remove the need for surgery. If the patient
remains symptomatic or has only a brief period of relief
with the injection, then the patient often has to consider
a surgical intervention. This usually consists of a release
of the common extensor origin of these muscles from the lateral
epicondyle and removal of some of the scar tissue in the
area. This can be performed as day surgery, and the results
are usually excellent.
The risks include infection, damage to
nerves and blood vessels, stiffness, recurrence of symptoms,
anesthetic problems, etc. Make sure you understand these
risks prior to having surgery. It would be better, however,
if the whole problem could be avoided completely by simple
avoidance. This consists of a reasonable approach to the
sport and using proper stroke technique. It is not advisable
to pick up a racquet and try to learn how to play tennis,
or any other racquet sport, by playing every day non-stop
after never having played the sport before. If you do pick
up the sport so rapidly, this will almost guarantee an overuse
syndrome and tendonitis. The player can also switch to a
two-handed backhand, and this will usually relieve most of
the elbow problem. Obviously, this is not possible in squash
or racquetball.
The best approach to tendonitis is to
avoid it in the first place with techniques previously mentioned.
If it does occur, however, the best thing to do is to get
rid of it as soon as possible because once it has become
a chronic tendonitis it can be very difficult indeed to cure.
Athletes should seek the advice of a qualified medical doctor
who can best advise them and prescribe the appropriate therapy
or medication.
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