Keeping Tennis and Golfer’s Elbow at Arm’s Length

By: Dr. Barry S. Kraushaar

Tennis Elbow and Golfer’s Elbow are names for similar tendon injuries that occur at the tendon attachments on the outer (lateral) and inner (medial) sides of the elbow joint. If you have pain on or near the points of bone that serve as the origins of the muscles of the forearm, you may have this diagnosis. The forearm muscles, which give power to your grip, attach to these anchoring points called epicondyles. They can tear off of the bone or within their fibers. Tendons are injured throughout our lives, but they usually heal themselves, making it rare to need medical help. When a tendon attachment to your elbow tears and fails to heal it can be Tennis or Golfer’s Elbow.

TENNIS ELBOW is an injury at the outer (lateral) bony prominence of the elbow. You can have this diagnosis even if you do not play tennis, but the name comes from the observation that tennis players get it as part of the sport. This is because the grip of a long tennis racquet and the wrist motions of the tennis swing put strain on the muscles which originate at the lateral epicondyle. Expert tennis players rarely get tennis elbow because they have powerful forearms and good swing mechanics. If you have the wrong grip size, string tension, timing (late swing), racquet type, or stroke mechanics (wrist motion), you are at risk for Tennis Elbow. In fact, any type of forearm overuse can cause tennis elbow, and the treatment options, described below, are the same.

GOLFER’S ELBOW refers to pain on the inner, medial side of the elbow. In this sport, the problem is caused by the combined effect of the long club length being gripped by the trailing arm (the right arm in a right-handed swing) as the club-head strikes the ground, such as in the rough, the sand or when taking a divot to get under the ball. The forearm is driving forward as the hand is held back, causing strain in the muscles that control the wrist. The damage occurs at the tendinous origin on the inner side of the elbow. Ironically, golfers can also get Tennis Elbow, because the leading arm sees strain on the outer, lateral side during the same movement.

Treatment

There are many additional reasons for tendon injuries about the elbow, usually involving pulling or twisting motions during exertion. It can happen from low level stresses or big motions. From an orthopedic view, the approach is to identify the causes and help the patient adjust activities to allow the tendons to heal themselves.  This may involve a period of partial or complete rest from the aggravating activity. It may involve different equipment or technique. During a flare-up, you may benefit by using a brace. If you wear a wrist brace it may help the elbow by limiting the motions that are traumatizing the injured tendon. A tennis elbow strap is different, as it works by re-directing forces coming up the forearm and deflecting the pulling effect on the tendon origin. Pills, such as non-steroidal anti-inflammatory drugs (NSAIDS like ibuprofen) or analgesics (acetaminophen, Tylenol) may temporarily help the symptoms, but they do not cure tendon injuries. Similarly, a steroid (cortisone) injection may relieve pain for now, but the chemical may damage tendon, and after a few months the problem can come back even worse. Sometimes, a small injection is used as part of a bigger plan.

The most effective and lasting way to manage Tennis or Golfer’s Elbow is to perform exercises to strengthen the forearm. Since the elbow is injured, the exercises need to be rehabilitation type, which is different than fitness exercise. Doctors often prescribe Physical Therapy because a therapist should know the gradually increasing exercises that achieve the goal of lasting recovery without a setback. While many videos exist online, there is no substitute for personal guidance. Once you learn these exercise you can do them yourself. 

Other non-operative treatments exist but are less commonly used. One promising intervention is Stem Cell Injection Therapy. Currently, this technique involves having your blood drawn and spun in a centrifuge. The provider injects a small volume of your own special stem-cells back into you at the site of the pain, and you grow new tendon in the damage zone. Stem cells can also be harvested from your fat or marrow. The use of Stem Cells is usually not covered by insurance, and the statistics of success are still not high enough for many people to be willing to pay out of pocket (costs hundreds to thousands of dollars).  Ask your doctor if you want to know the current trends.

Ultimately, surgery may be necessary for tendon injury at the elbow. There is a minimally invasive technique that requires a brief, light period of sedation and/or local anesthetic injection. The doctor introduces a special needle through your skin over the injured area and activates a device that either causes the tip of the needle to heat up and melt the damaged tendon, or it injects a pressurized water jet into the tendon to break up the scar tissue and cause the tendon to react by developing scar tissue to replace the damaged area. During this process, the surgeon may also use stem cells, described above.

The open surgical technique for Tennis or Golfer’s Elbow is well established and has an excellent success rate. The operation is not usually very long, involves little or no risk to nerves and vessels, and recovers rather quickly, although you may need a period of protection and rehabilitation afterward to give the tendon a chance to heal and the muscle groups time to recover. Basically, the surgeon opens the tendon and removes the bad scar tissue, the tendon is given a chance to grow fresh tissue in the place of the old, painful region, which is usually right where the pain was. In my practice, fewer than ten percent of patients with Tennis or Golfer’s Elbow go to surgery, and nearly every patient reports real improvement from the intervention. Return to sports and full activities is possible in most cases.

Summary

If you think you have Tennis or Golfer’s Elbow, try to identify the causes and address them yourself. Try to gently strengthen your muscled without overdoing it. Consider a brace and careful usage of medicines, if you can do so safely. If you do need orthopedic care, you may be discussing physical therapy and the other treatments described above. Know that if you have to go to surgery, the options in most cases are likely to be effective. Hopefully, you can continue to enjoy your active lifestyle, doing what you need or want to do. The specialists at NEOSM are there to help along the way.

You’ve torn your ACL, now what?

By: Dr. Barry Kraushaar

The diagnosis of a torn ACL can be scary for any athlete. Fortunately, you can get back to your sport with proper evaluation and treatment. Here’s a better understanding of what you may be dealing with and your options.

Your knee is a hinge-type joint that is held together by ligaments. In the center of the knee are the Posterior (rear) and Anterior (front) Cruciate Ligaments (PCL and ACL). Together, these cables of collagen stabilize the knee when you pivot or perform sports. Unfortunately, the ACL is often vulnerable to tearing suddenly during a pivot/twist maneuver, making ACL tears a common sports injury. When an ACL tear occurs, a decision needs to be made about whether to live with a torn ligament, to repair it or to replace the ligament. It depends on patient function and future needs.

  • Living with a torn ACL: Some patients choose to live with a torn ACL. For younger people, it may not be advisable to live a lifetime with this ligament torn. Although in some cases the ACL ligament can scar onto the PCL and act stable, more often instability occurs and it should not be ignored. An unstable knee can develop secondary damage, such as meniscus cartilage tears, and over time this can result in early-onset arthritis.  For those who do not sense instability, an ACL-deficient knee may be treated with rehabilitation and a brace. A custom designed brace will fit more closely. When a knee already has arthritis, an ACL reconstruction may not only be unnecessary, but the surgery may actually “Capture” the knee and hasten the worsening of arthritis.
  • Repairing the ACL: Because the ACL ligament tends to spread into separate strands like a torn rope when it ruptures, a simple repair of this ligament is rarely possible. The torn remnant is usually rolled up or shortened and it is hard to make it attach to the place on the femur bone from where it usually detaches. On rare occasions, it may be possible to perform a micro-surgical repair of your own ligament and keep your own structure.
  • Reconstruction of the ACL:  The most common treatment for a torn ACL in an adult who has no arthritis is to replace the ligament. A replacement can be strong and long enough to bridge the area of ACL detachment. The ligament is routed through the center of the knee and fixed to the bones above and below so that it acts similar to the original. The success rate of this procedure is high, but not 100%.  
    • For older and less active patients, cadaver ligament graft can be used. It is less painful and has a quicker recovery, but there are reports that the failure rate is higher than using your own graft material.
    • For younger, active patients, the best success rates are achieved if you use your own Patellar tendon (in front of the knee), Hamstring or Quadricep tendons on the inner part of the knee. The outcomes of these graft types are similar, so your surgeon may have preferences based upon their experience.
  • Rehabilitation from ACL surgery is individual for every patient but most cases finish doctor-supervised acre after three months. Return to sports occurs as late as nine months, depending on the type of activity.

ACL reconstruction techniques and methods are still evolving. The fellowship-trained Sports Medicine specialists at Northeast Orthopedics and Sports Medicine keep up with current trends and bring the latest treatment to you. If you’ve experienced a ligament tear, contact us to meet with our physicians and discuss treatment options available for you. 

If you do encounter an ACL or other orthopedic injuries, contact us today to find out what’s wrong and how we can help.