Tennis Elbow: Pain in the Wings

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By Kevin R. Stone, M.D.

Tennis elbow, golfers’ elbow and pitching elbow, all describe the pain felt at the outside or inside of the elbow joint where the tendons insert on the bone [1]. The syndrome is misnamed “epicondylitis” — misnamed because it is not an “-itis,” which means inflammation, but an injury. It can be caused by a hard tennis shot, a golf club that whacks into the ground, or just soreness after hitting an extra bucket of balls [2]. At first, it is often ignored. But at some point — when reaching out to shake hands, or lifting a brief case — the pain recurs and does not go away. What happened?

The collagen that makes up tendons has the ability to stretch, retract, compress and expand, permitting our joints to move through a wide range of motion [3]. This collagen is formed into bands. The bands have crosslinks, or bridges, that connect them, and specialized macromolecules that lubricate the gliding fibers surrounding them [4].

When forces are applied that exceed the limits of the stretch, a tear occurs [5]. The tear may be a minor one; a Grade 1 strain where little collagen is torn and the body’s repair process rebuilds the damage without scarring. Or it could be a more major tear, where the healing process requires laying down new collagen fibers, building new bridges and forming new matrix molecules.

Sometimes this reconstruction process loses its ‘general contractor,’ so to speak. Repair cells arrive on the scene, but they are misdirected. Instead of orderly collagen fibers with beautiful crosslinks, scar tissue forms. This scarring is simply disorganized collagen — sometimes with dead areas of abnormal collagen, and sometimes with chronically inflamed tissue in between the injured fibers [6]. No amount of anti-inflammatory medications or cortisone will help this ugly mess.

Tennis elbow can be the kind of tearing that heals naturally, or the ugly kind that leaves weakened scar and chronic pain [7]. Treating the injury in a way that helps increase the probability of normal tissue healing is the goal. First steps may include soft tissue massage, which stimulates the repair cells to lay down new collagen in an organized fashion [8]. Gentle exercises are designed to just barely stretch the injured tissue, helping the newly formed fibers to align along the lines of stress. (Rested or immobilized injured tissue, it turns out, has a higher chance of scarring.)

Bracing the wrist, so as to decrease the distance the tendons are stretched often helps — as does an elastic band wrapped around the forearm.

While ice and anti-inflammatories help in the first few hours, the problem is not one of inflammation, but of tissue injury. Therefore, various new strategies for stimulating repair are being used. All involve using growth factors from blood components called platelets or stem cells and introducing them into the damaged tissue. The growth factors have a direct stimulating effect on the cells at the site of repair, and induce the desired collagen formation [9].

Recognizing the injury as soon as it occurs, treating the tissue with love and stimulation, then adding growth factors when necessary define the 21st century approach to tennis elbow — and to most other soft tissue injuries as well.

References

1. Kraushaar, B. S., & Nirschl, R. P. (1999). Tendinosis of the elbow (tennis elbow): clinical features and findings of histological, immunohistochemical, and electron microscopy studies. Journal of Bone and Joint Surgery, 81(2), 259.
2. De Smedt, T., de Jong, A., Van Leemput, W., Lieven, D., & Van Glabbeek, F. (2007). Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. British journal of sports medicine, 41(11), 816-819.
3. Fratzl, P., Misof, K., Zizak, I., Rapp, G., Amenitsch, H., & Bernstorff, S. (1998). Fibrillar structure and mechanical properties of collagen. Journal of structural biology, 122(1), 119-122.
4. Charulatha, V., & Rajaram, A. (2003). Influence of different crosslinking treatments on the physical properties of collagen membranes. Biomaterials, 24(5), 759-767.
5. Hess, G. W. (2009). Achilles tendon rupture: a review of etiology, population, anatomy, risk factors, and injury prevention. Foot & ankle specialist.
6. Norton, J., Bollinger, R. R., Chang, A. E., & Lowry, S. F. (Eds.). (2012). Surgery: basic science and clinical evidence. Springer.
7. Ollivierre, C. O., & Nirschl, R. P. (1996). Tennis Elbow. Sports Medicine, 22(2), 133-139.
8. Davidson, C. J., Ganion, L. R., Gehlsen, G. M., Verhoestra, B. E. T. H., Roepke, J. E., & Sevier, T. L. (1997). Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Medicine and Science in Sports and Exercise, 29(3), 313-319.
9. Connell, D. A., Ali, K. E., Ahmad, M., Lambert, S., Corbett, S., & Curtis, M. (2006). Ultrasound-guided autologous blood injection for tennis elbow. Skeletal radiology, 35(6), 371-377.

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