North Texas Musculoskeletal Medicine

Enhancing the body's innate ability to heal

Regenerative Orthopedics Osteopathic Manipulation



Tendinopathies: “Tennis Elbow” & “Golfer’s Elbow”

Tendinopathies: “Tennis Elbow” & “Golfer’s Elbow”

What are these conditions?

The elbow is a relatively simple hinge joint which only allows flexion and extension.  However, the elbow is actually composed of three joints.

The first is the simple hinge joint formed between the humerus and the ulna called the humeroulnar joint, which allows us to bend and straighten our elbows.  The second is the humeroradial joint between the radius and humerus also allowing flexion and extension, but this joint is also involved in the more complex motion of turning the hand over so the palm faces up or down.  The third is a pivot joint formed by the radius and ulna.

The most common injuries to the elbow are from repetitive motion. When the tendon that attaches the muscle to the bone becomes irritated from overuse, it can become tender and often develop micro-tears. Because tendons have poor blood supply, healing can take a long time and injuries to tendons often never completely heal.

The two most frequent injuries to tendons are “tennis elbow” or “golfer’s elbow.” Both sports require the use of the forearm to grip, flex and swing. The motions are somewhat different, however, causing tennis elbow to hurt on the outside & golfer’s elbow to hurt on the inside.

In either case, the pain may radiate down to the wrist and make it hard to lift a coffee cup, twist a doorknob or turn on a water spigot.  There may also be swelling around the elbow and difficulty in straightening the arm completely. Rest to the injured area has previously been the only treatment method.  Regenerative orthopedic procedures, such as Platelet Rich Plasma (PRP), Stem Cell Therapy, and Prolotherapy, have presented far more positive outlooks for these conditions.

Why is this important?

Professor Maffulli of The London Independent Hospital has had more than 300 articles published in peer reviewed journals on various aspects of trauma and orthopaedic surgery, sports medicine and sports traumatology.  One of his clinical specialties is the treatment of overuse tendon conditions.

A single molecule of the main protein that constitutes tendons, collagen, takes about 100 days to fully mature. Therefore, things do not happen fast. Also, tendons have a slow rate of metabolism, and they take a long time to adapt to new stimuli. A muscle, for example, hypertrophies (gets bigger) or atrophies (wastes) within days, while the tendon retains its characteristics for a much longer period, and requires prolonged stimuli to change its biomechanical behaviour. Also, very often by the time the patients are referred to me, they have had the condition for a long while. In these instances, the biological potential of the tendons is close to being exhausted, and they need to be stimulated for longer to effect appropriate healing.

Why is does this work?

Tendinopathies blog imageLigaments and tendons often heal poorly because of weak blood supply, as is apparent in their white color.  Medical enhancement of the blood supply to the injured area, Platelet Rich Plasma Therapy (PRP), helps to accelerate the healing process by supplying a condensed dose of what the body naturally uses to heal itself.  Macrophages remove damaged cells to prepare the injured area for healing. The concentration of platelet cells then supply growth factors called alpha granules that stimulate healing.  Localized stem cells are then released to regenerate tissue that would otherwise take a long time to heal.

Treatment of Tendinopathies

Platelets were once thought to only functon in the clotting of blood.  Science now shows that these cells contain packets of healing and growth factors.  In Platelet Rich Plasma Injections, PRP, the patient’s own blood is drawn and spun in a centrifuge to isolate the platelets and their associated growth factors. The level of platelets is now elevated from a concentration of 6% to approximately 94%.  This preparation is then injected into the damaged area to stimulate blood flow, promote matrix formation of all soft tissue, and restore tendon and ligamentous proteins that may have been previously compromised. Cartilage, ligaments, and tendons heal to become more firm and resilient.

The controlled inflammation of Prolotherapy (a general term for use of injection substances that cause the body to generate tissue at an accelerated rate),  causes increased blood flow, stimulating the tissue to heal and regrow while removing damaged cells.  “Prolo,” from the term proliferation,  causes proliferation or regeneration cells.  This procedure can also be utilized through the injection of dextrose and lidocaine where the dextrose acts as an irritant, deliberately inducing inflammation, the body’s natural process in healing.

During the controlled inflammation, the body also deposits increased collagen to the injured area, the natural substance of ligaments and tendons.  As the tissue heals, the collagen hardens, often causing the tissue to be stronger than before the injury.

Dr. Maffulli further discusses the negative impact of corticosteroids and NSAIDS, a common procedure for tendon, cartilage or ligament injury:

…corticosteroids and NSAIDs (anti-inflammatory drugs) do not play a role: again, well controlled studies have shown that they do not have a lasting effect. Indeed, they should not have any such effect, as the condition that we are facing is not an inflammatory condition! Corticosteroids are catabolic (i.e. do not favour protein synthesis, while we want new protein based material to be produced by these tendons), inhibits cell growth, and may interfere with local immunity…

http://www.physioroom.com/experts/expertupdate/interview_nmaffulli_20060424.php

So, although rest of the injured area may or may not be helpful eventually, it is not your only or best option.  Modern science, combined with the body’s natural healing process, gives faster and more effective options.  

PRP and Tendinopathies in the News