What is “Tennis Elbow” and why does it take so long to heal? Is it because it is an incurable/ poorly understood condition or do a series of unfortunate events lead to its delayed healing?
First of all, though it is called Tennis Elbow, it rarely affects those that play tennis regularly. To put this precisely, Tennis elbow is usually caused by ‘overexertion’, usually in some ‘unaccustomed’ activity.. It can be either somebody trying to perfect a weak stroke by repeatedly striking the ball in a new style, or a regular cyclist playing an extended game of tennis all of a sudden, or a recreational athlete playing a tennis tournament requiring him to play tennis everyday (something that he was unaccustomed to): a tennis player practising/ playing every day in his natural style rarely suffers a “Tennis Elbow”.
Tennis elbow can of course happen without holding a tennis racquet at all.. eg. If an upper body workout was suddenly increased in intensity, or some heavy furniture was handled during renovation, a cricketer changes his bat, chooses a slightly heavier one and does an extended practice session with it, etc. The pain usually starts after an elongated period of repetitive, strenuous, unaccustomed movement. Though the patient is not usually aware at this stage that he has tennis elbow, we will call this “Stage 1”
The pain usually starts as a minor niggle that can be easily ignored. It is usually a slight discomfort or dull ache on the outside of the elbow, the upper forearm. The pain may be transient, and not dramatic enough to seek help. Since the pain has come on due to an activity that the person has chosen to do (not really a one-time activity), the person is more often than not going to repeat that activity for a few days/ weeks: for e.g. If a cricketer has bought a new bat he is going to continue practising with it; If a tennis player is perfecting a stroke, he is going to continue practising it; If a tournament is going on, the player is going to play matches everyday; If a house is being renovated, the person may shift things around every day. The pain becomes worse because the same repetitive, strenuous, unaccustomed movement is repeated daily for days or weeks till the onset of acute pain. This is usually when the patient seeks help, and we will call this “Stage 2”
The healing response in the human body is very strong and at “Stage 1” itself, the cells surrounding the site of tendon injury are activated to mobilize repair material to reconstruct the damaged tendon. This involves excess blood, disruption of some tissue and increase in the number of new cells, all of which increase the “Swelling” or “inflammation” in that area. A few days of rest from the aggravating strenuous activity taken at this stage, will let the body heal itself. Unfortunately, we do not always listen to the small signals our body gives us, and this healing reaction is wasted by repeating the stressful activity and leading to “Stage 2”.
In “stage 2”, the body’s healing mechanism is still trying to repair the damage, but due to a larger area of damage, more disruption of tissue and larger collection of blood, now the healing process works against the tendon, and immature, dysfunctional cells are generated.
Because the patient has now asked for help, help comes from all directions. He will be asked to take rest for a week or two, also given physiotherapy, medications, massage, compressive brace, etc. More often than not, none work immediately at this stage, and the patient is not much better after 1 week. We must remember that it is very difficult to “give rest” to the wrist extensors at this stage because they are involved in all hand functions! In fact even lifting a teacup or a sheaf of papers is difficult and painful!
Two to three frustrating weeks have now passed and if the patient is a sportsman, he is not ready to wait any longer. He is probably training for a major tournament (he was perfecting a stroke when he got injured) or is insecure about his place in the team, or just does not like being away from his sport. His friends are advising him to try something different, his colleagues are practising hard, his family is worried, and he is unhappy and edgy.
He revisits his surgeon, or goes to another, and seeing that he is so impatient, they now suggest “PRP” or “Steroid injection” for pain relief.
“PRP” or platelet-rich plasma is increasingly being used for tissue healing of all kinds. Blood harvested from the same person is processed to make the PRP and is injected at the site to enhance healing. It has been proved that it releases at least 7 different growth factors that stimulate healing in bone and tissues.
“Cortisone” is a natural steroid that is made by our body in adrenal glands, and released in times of stress. The injectable cortisone is synthetically made, but has the same composition as the natural one, and is used for local injection (In to site of pain). It reduces pain by reducing inflammation (swelling) and has no role in tissue healing. In fact by its very effect (reducing inflammation), it PREVENTS tissue healing.
Let us examine the effect of either of these two choices. Though the trend is changing, the steroid shot is usually (unfortunately) tried BEFORE the PRP.
The “Steroid shot” is given so that the player can resume play. The steroid injection can bring about pain relief after 2-3 days and if it works, the effect can last for several months or years. Unfortunately, sometimes it does not work, or sometimes also increases pain tremendously due to “crystallization”. If it does work, remember it has not caused any healing, only pain relief and compromised the healing process. If pain relief occurs, the player is going to resume play within a week, and increase intensity immediately to make up for lost time. He will also probably wear a compressive brace to protect the tendon.
If the player is young and has injured his elbow for the first time without too much damage, he may not get a recurrence of symptoms. If, on the other hand he is older, and has had a worse damage, the case will be completely different.
Tendons have a lower blood supply than muscle fibres. The function and structure of muscle and tendon is different, but they are both contractile in nature, and both need energy to work (contract). Tenocytes (Tendon cells) produce their own energy by aerobic and non-aerobic processes going on inside them. “Aerobic” processes require oxygen, which is carried to the cell by blood, and obviously, when blood supply is lower, the aerobic capacity decreases. But aerobic energy generation is the most profitable and desired by the cells. In sporting activities that go on for long hours at a time, eg. Tennis, Batting, etc. aerobic energy production is very important. In older tendons, blood supply is further reduced, and is actually 7 times less than younger tendons!! Obviously then, in an older athlete, with an injured tendon, especially after the steroid shot when blood supply is suppressed, the aerobic energy generation of the tendon is compromised. This is actually made worse by the compressive “Tennis elbow support” that he is wearing. Without sufficient aerobic energy, the tendon is forced to use the less efficient anaerobic systems, which lead to a build up of toxic material causing pain and inflammation to increase.
It is now 5 weeks since the player first noticed pain, and he is again in pain and discomfort, very unsure of whether to continue playing or to take rest again. He meets his surgeon, and again the surgeon has two choices: 1. Repeat the Steroid shot, and 2. Try PRP now.
More often than not, Steroid will be given one more chance. The whole process is now repeated again, but the steroid now may have weakened the tendon and cartilage (one of the known side effects of steroids). Now when the player plays or trains, he is at risk of actually damaging/ tearing the weakened tendon more!! Once again, pain may or may not subside, but the tendon is now more at risk, and at least 8 frustrating weeks have gone by!
If, on the other hand, the surgeon chose PRP before the first Steroid shot (3-4 weeks after first pain was noticed), let us examine what might happen.
As opposite of Steroid shot, PRP is given so that the tendon might heal. The surgeon here is assisting the body’s own healing mechanism by introducing platelets that will promote healing. Unfortunately as this technique and assumption is not fully understood as yet, and not too many studies (clinical trials) have been conducted, the surgeon and the patient may have different expected outcomes. Though the surgeon is giving “healing” a chance, the player probably thinks he will get quick pain relief. Ideally after PRP, a week of rest and light stretching, followed by light activities and gentle strengthening for 2 weeks, and then a gradual (over 2-3 weeks) return to play/ normal activities is advocated. This gives time for the healing process to be completed (tendon repair by the body takes between 6-10 weeks to complete). The player’s haste to play, and the surgeon’s need to prove the efficacy of the technique may end up compromising the healing process by the decision to resume training/ play early (usually the player tries to start training in a week after the shot, and resumes play within 2-3 weeks). If luck and age is on his side, all might go well and he will be rid of the symptoms. But more often than not, this haste is detrimental, and then another shot of PRP or now of Steroid is tried.
If PRP was not tried at 4th or 5th week, and the player has taken 2 shots of steroid, PRP has almost no chance of working after 8-10 weeks. By now the tendon is weakened, damaged beyond repair, has extensive connective tissue damage, and is in a chronic inflammatory stage (here the inflammation is not curative, but more “degenerative” in nature). The principles of treatment that apply to inflammatory conditions cannot be applied here. In fact once in the degenerative stage (Tendinosis), all treatments work by “trial and error”.
When in a chronic stage, all treatment in tennis elbow is palliative. Pain relief using drugs, electrical stimulation, heat, ice, massage/ manual techniques should be achieved along with a planned “Tensile loading” using all the principles of exercise science. Gradual strengthening, eccentric training, flexibility exercises to prevent adhesions, and “activity specific” training, all help if care is taken not to damage the tendon further. Taping and bracing for short periods of time help, if used with care. It is important to understand that what works for one patient may not work for another, and a short daily assessment is required.
If all else fails, after several months, the surgeon may advise a surgery to relieve the symptoms. This is of course an invasive procedure, and during surgery, either the tendon sheath is trimmed, or the tendon itself is released from the bone. In most patients, surgery gives the required pain relief after 3-4 weeks, and return to normal activities in 4-6 weeks is expected. Return to play takes 12-16 weeks, a full 12 months after the patient first felt a twinge of pain!!
Though Tennis elbow is known as “Lateral epicondylitis”, the physiology of exact damage is not understood. Tendonitis, tendinosis, tenosynovitis, peri-tendonitis, etc. are the several names given to injuries/ conditions affecting the “muscle-tendon” unit. The exact nature and area of injury cannot be determined by an examination and even after using various diagnostic tools available (Imaging: US, MRI) we will only be slightly better informed. Though some research is available on the acute inflammatory stage of tendon damage, a major drawback to understanding the chronic tendinopathy is that there are no suitable animal models available for research on chronic tendinopathies! Obviously, animals take rest when injured and let their body heal naturally. The only animal models available for research are Race Horses, who suffer similar chronic tendinopathies as humans! They are obviously not suitable subjects for research, and now research is going on by artificially creating such injuries on rabbits.
The natural process of tendon healing after an acute onset takes about 9-10 weeks to complete and goes through the inflammatory, proliferative and remodelling/ consolidation phases. Restricting activity in the first 2-3 weeks after injury, using available treatments at that stage to help healing without causing further damage, then introducing a flexibility and light strengthening program in the second or third week, increasing the loads and adding eccentric strengthening in the fourth to sixth week and introducing sport-specific strengthening from the 7th to 9th week will ensure that the return to play is smooth and incident-free. All treatment options available do have a role to play at different stages of healing, but should be applied after evaluating their efficacy at the stage, and the goals and expectations of the player/ patient. For eg. If the player has a major international tournament of great significance to his career, suppressing the inflammatory process with a local steroid shot is warranted and acceptable. Of course explaining the expected outcome to the player is crucial. But if there is no urgent need for intervention, it is best to play a supportive role to nature and use simple modalities like therapeutic US, electrical stimulation and a wise use of exercise and taping to assist the healing process.
Understanding the physiological and pathological processes going on in the body and conveying the need to “Go slow” effectively to the patient is the duty of the advising Doctor/ professional. Players are often overwhelmed by the diversity of advice and treatment options available, are under various pressures of their own, and their team members and coaches probably have expectations which they need to fulfil.
Tennis elbow then is not poorly understood, nor incurable, but is a series of unfortunate events/ decisions/ actions/ accidents often leading to a very long period of pain and stress!