The View from Sports Center

Put the Squeeze on Tennis Elbow

What is the name of the condition for pain on the outside of your elbow when you shake hands, pick up a six pack of soda, or swing a tennis racket? If you're thinking Tennis Elbow, you're right.

Tennis Elbow is also known as Lateral Epicondylitis (EPEE-CONDALL-LIE-TIS) which means "inflammation of the epicondyle". The epicondyle is the end of the upper arm bone that forms part of the elbow joint and "itis" means inflammation. Your bone is inflamed.

But, there is some confusion about Tennis Elbow. While the term means "bone inflammation", the actual tissue injury in most cases is tendon. Tennis Elbow is an example of labeling gone awry just like another condition: Plantar Fasciitis. The main causes of Tennis Elbow, or perhaps more aptly named, Lateral Elbow Pain, are:

• Inflammation of the epicondyle.
• Inflammation of the common extensor tendon (that connects to the elbow).
• Weakness of the common extensor tendon (also known as tendonosis - (TEN-DIN-OH-SIS).
• Osteoarthritis of the elbow joint.
• Entrapment of the radial nerve.

In most cases, the cause of lateral elbow pain in an active, athletic population is tendonosis of the common extensor tendon. Tendonosis is a focal weakness of the tendon similar to the worn spots on the knees of an old pair of blue jeans. The fabric is thin and weak. The pain from tendonosis is more from the stress applied to the tissue than from an active inflammatory process. But, since the most common term used to describe the symptoms has an "itis" in it, the conventional approach is to use non-steroidal anti-inflammatory drugs (Advil, Motrin, Aleve), ice, stretching and then...hope.

The symptoms of common extensor tendonosis (and the technical term would be extensor carpi radialis brevis and longus tendonosis,   - see why I use the term "common extensor"?) include pain on the outside of the elbow area especially with gripping, squeezing or lifting. Your grip may seem weak. You will typically not hurt until you perform some type of activity and then may hurt for 24-48 hours. The pain seems to come and go but never goes completely away.

To beat tennis elbow due to tendonosis, you need at least the following:

1. An accurate assessment of your grip strength and wrist extension strength. You need to know how much force you can produce and NOT hurt while gripping and then extending your wrist. Remember, pain is all or none and shows up when you greatly exceed your physical capability. If you do not know what your physical ability is (in this case, grip and wrist extension force), how will you know if you are any better or if you are doing the right things?
2. An exercise regimen designed to purposely fatigue and stress the common extensor tendon. The exercises should produce some mild discomfort and should take place under the supervision of a physical therapist or athletic trainer familiar with tendonosis. And, since the hand serves at the pleasure of the shoulder, the exercises must include movement of the shoulder girdle not just the wrist. The shoulder sets the platform upon which the rest of the arm functions. If your shoulder is weak, you may overload the wrist and hand.

How long will it take to rebuild the strength of your tendon? Months not weeks. Tendonitis resolves in weeks, but remodeling a tissue like tendon is much slower. Persistence is a must.

The take home point is that most cases of Tennis Elbow are:

1. Due to tendonosis.
2. Treated like tendonitis.
3. A source of great frustration.

To put the squeeze on your Tennis Elbow, think tendonosis, establish your baseline strength levels, stress the common extensor tendon and avoid tendonitis treatments.

Make today count.

Doug Kelsey
Author. Speaker. Therapist.

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What is a Stress Fracture?

Ever had  shin splints or know someone who did? What exactly is a shin splint?

A "shin splint" is a term often used to describe pain on the front of the lower leg. Shin splints are small tears in the interface between the tendon and bone (the fibers are called Sharpey fibers). The tendon weaves its way into the bone forming a very strong connection. When you run or jump too long or too much, you can tear this connection.

But, pain on the front of the lower leg can also be something more ominous: a stress fracture. A stress fracture is a tiny bone break so small you cannot see it on xray until the bone begins to heal. Stress fractures happen when the physical demand placed on the bone exceeds the bone's ability to repair itself.

Bone is one of several tissues in the body which transform themselves from physical load. Two types of cells in bone are responsible for this remarkable makeover:

1. Osteoblasts
2. Osteoclasts (I call them blasters and clasters)

Blasters produce new bone and clasters tear down existing bone. When bone is exposed to a physical load, as in jogging, clasters go to work carving out new tunnels for more bone while the blasters start churning out new bone cells. As long as the blasters stay ahead of the clasters, all is well. When the clasters win, you lose.

From the athletes we have seen with this problem, I think a better name for a stress fracture might be a distress fracture. Imagine having pain in your lower leg, it hurts when you run or sometimes even walk, hurts at night, you're tender to touch over your lower leg but your Xray is negative. You take 4-6 weeks off from doing the things you love only to find, upon resuming activity, your leg still hurts perhaps even more than prior to taking the time off. You try non-steriodal medications, ice, heat, massage, rest, more rest, magnets, orthotics, but you still cannot run.

The answer to healing a stress fracture and restoring your running ability is to jump start the blasters. You need more bone formation than destruction.  But resting does not boost blaster activity. Remember, bone is dynamic and responds to a consistently applied stimulus (as do all other tissues of the body). Put a person in bed for six weeks, and you will see a dramatic drop in bone density. If you have a stress fracture, the last thing to do is rest for long periods of time. In most cases, the advice to rest is well intended. The thinking is that if you stop the offending activity, running, then your bone will heal. But, how does the bone ever regain the strength it needs to withstand the pounding of running if you are sitting on the sidelines?

The are two keys to helping bone heal:

1. One is to match the bone's capacity with its need. You must reduce, not completely eliminate, what is referred to as ground reaction force (GRF). GRF is the load produced when your foot hits the ground while walking or jogging. This force can exceed 6 times your body weight for running and up to 11 times body weight for jumping.
2. The second key is maintaining adequate protein in your diet and body fat levels. One the most common problems, more so in female runners, is a low protein and fat diet which can manifest itself in more severe cases as an eating disorder (Visit Dr. Ed Tyson for expert advice and information). The low body fat levels interfere with the production of key hormones that help maintain bone density. A female runner should have at least 12% body fat while males need slightly less at about 6%. If your body fat goes below these levels, you will be at risk for other medical problems. While training to come back from an injury, you will need approximatley .5 - 1 gram of protein / lb. of body weight. So, for a 150 lb. athlete, protein intake would be 75 grams per day. For a reference point, a chicken breast the size of a deck of cards is about 20 grams of protein (a great resource for nutritional advice is Real Life Nutrition).

So what do you do if you have been diagnosed with a stress fracture? Do you have to stop running? It all depends on how badly your bone has been injured and whether you can reduce the GRF enough to stimulate bone formation. Some people can use an insert or shock absorbing shoes (Nike Shox, Z-Coil) and find that they can continue to run while others need to train in a gravity controlled device (Newton Speed Trainer).  This technology allows you to regulate, in small increments, the amount of ground reaction force while you run. Your training then becomes a blaster booster. But, while this sounds simple, the process can be difficult. You rarely have a smooth, unfettered run back to full body weight. Since bone responds to load, if the training load is a little too great, your bone may hurt. The good news is, in nearly every case, you can adjust the load and keep training. Week by week you will know exactly how close you are to full body weight and, more importantly, you will feel positive and hopeful.

So, the next time you hear the term "shin splints" remember, shin splints can be a stress fracture. Stress fractures need proper nutritional support (protein and fat) and the application of controlled physical load. Do these things, and you have a great chance of beating a stress fracture.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.

When Can I Run Again

Harry opened his front door and felt the cool morning air on his face. The sun was just coming up creating a soft glow in the distance. He was anxious to get started. Harry loved to run and it had been a very long time since he injured his heel cord. He stopped running altogether for several months. It seemed as if the pain and stiffness would be a permanent fixture in his life but finally he felt ready. He waited not only until the pain had gone away but an extra two months just to be sure. Today he would run. Run for his health, to lose weight and run for fun.

He did not know he was smiling as he walked down the street and began a slow jog. He was surprised. His muscles felt tight. He moved as if he needed oil in his joints. He could hear the air rush in and out of his lungs. But he was running. Then he noticed a faint but familiar sensation. The heel cord was talking again. He ignored it. "Nah, I'm just not warmed up. It'll go away," he thought.

But it did not go away. The message grew in intensity as if the heel cord was shouting "Hey, are you listening to me? I do not like this at all! And if you keep it up, I am going to just shut down the whole system!"

Harry was listening though. He slowed his jog to a walk and turned around to go home. What had started out as such a gloriously bright day turned gloomy and hazy. "When will I ever be able to run?" thought Harry.

Tendinosis lurked silently in Harry's heel cord only to come out to wreak havoc when he tried to run. Tendinosis is the body's attempt at repairing weakened and damaged collagen. The result for Harry is a weak, flimsy tendon incapable of withstanding the physical demand of running. It operates in stealth mode only revealing its true nature with physical exertion.

What can be done about tendinosis? From recent scientific studies, it appears the repair is influenced by mechanical load.

A group from the University of North Carolina has demonstrated a relationship between tendon healing and eccentric exercise. The mechanical load produced by eccentric exercise appears to promote DNA and collagen production (Banes AJ, Hu P, Xiao H, et al. Tendon cells of the epitenon and internal tendon compartment communicate mechanical signals through gap junctions and respond differentially to mechanical load and growth factors. In: Gordon SL, Blair SJ, Fine LJ, ed. Repetitive motion disorders of the upper extremity. Rosemount: American Academy of Orthopedic Surgeons, 1995: 231-245.). Harry thought by resting his ailing heel cord he was healing it. Instead, the prolonged inactivity left him pain free but weak.

What should Harry have done? At SportsCenter, the first step in our rebuilding program for Achilles Tendinosis is to find Harry's pain free threshold to rise up onto his toes. This motion will load the Achilles Tendon. We use a Variable Incline Plane (VIP) such as a Total Gym for the test. Each angle of the VIP is a specific percentage of body weight. By raising or lowering the VIP, we increase or decrease the physical force applied to the tendon. Harry rises onto his toes then lowers the heel slowly down. We adjust the load until we find the amount of force which produces pain. We then lower the force a few pounds to locate his pain free threshold. We now know exactly how much physical load Harry can withstand.

Harry's training requires both eccentric loads to stimulate collagen production and high volume repetitions to stimulate the sluggish tendon metabolism. For eccentric loads, we generally use 20-30 repetitions, 2-3 sets per drill. Higher volume training includes lower physical loads with 100-200 repetitions per set, 2-3 sets per drill. By the end of the session, Harry should have a low level of pain. The pain indicates the training has stressed the tendon (no transformation without perturbation). The pain will subside within 24-36 hours. He trains 2-3 sessions per week.

Every two weeks, we test Harry's pain free threshold and adjust his training accordingly. After 2-3 months, Harry should be close to a full body weight force but in some cases the time frame can be as long as a year (dependent upon severity, chronicity and initial pain free threshold). But, to run he needs above body weight force capability. The forces created while running are 4-6 times body weight. To help Harry shorten the rebuilding time, maintain and improve his cardiovascular fitness and give him a glimpse of what is possible, we use a Newton Speed Trainer.

Healing tendon requires physical loading. While stretching, massage, ice and other measures relieve the discomfort, only one thing changes the physical capacity of tendon: controlled loading. Now that you know how to heal the chronic Achilles Tendinosis, can you think of how to apply the same idea to perhaps a rotator cuff tendinosis? Or how about patellar tendinosis? Just remember, tendon is tendon regardless of where it is in the body. Once you know the fundamentals of the healing stimulus, you will be well prepared.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.

The Heart of the Issue

Sara's mother stood tensely concerned as her daughter came off the tennis court. "Honey, are you hurt? You're limping?" "I'm fine, Mom. Really. I ran too hard is all."

The ten year old was determined to play at Tennis Nationals in six weeks. "It will go away. I'll be fine," she told herself as she subconsciously rubbed her left heel cord. She vividly remembered the moment it happened. Two days ago rushing from one side of the court to the other, Sara tripped and felt her left foot stick suddenly on the court causing her body to lunge forward. After rapidly stretching her heel cord beyond capacity, she had a nagging feeling something was wrong and it was getting worse.

Even after another week she couldn't run, walking hurt, and her left heel cord was very sore, swollen and even warm to the touch. Sara and her mother both wondered what was wrong and what to do. The tournament was just over a month away.

After another week of unresolved symptoms, Sara ended up in my office. She seemed older than her ten years. She explained to me what happened and then asked:

1. What's wrong with my leg?
2. Why does it hurt?
3. What do I do?
4. Will I be able to play in the tournament?

The simplicity of her questions was penetrating. She went to the heart of the issue in a matter of seconds. Unlike adults who might feel the need to be careful with their questions or hesitate, children just say it. And, they know when you don't know. I discovered from Sara that answering her four questions is what every client wants. Simple but not easy.

Sara had achilles tendinitis which is caused by too much physical load. Exposure to too much force too quickly or for too long causes damage to the tendon sheath. The ensuing pain, swelling, warmth and dysfunction are all hallmarks of inflammation. The warmth comes from an increase in blood as small blood vessels dilate. The exudation of plasma and leukocytes from the leaky microvessels into the small space between the cells causes the swelling. The pain is from excitation of sensory nerve endings caused by mechanical compression from swelling and by chemical irritants released from the cells such as prostaglandin and bradykinin.

Many people think of tendon strength in physical terms as if an injured tendon is "torn" much the same way you tear a piece of paper. While this makes the injury easy to visualize, it is not exactly correct. A tendon is held together by a chemical bond referred to as a "cross link". The number and strength of these bonds determines the tensile force capacity of your tendon. As the oxygen levels within the tendon drop, the number and strength of the cross links drops as well resulting in a weakened tendon. Think of the cross links as a twisted rope. Twisting a rope increases its tensile strength. Collagen creates its strength as the cross links twist in much the same way. A weakened rope is often frayed and an injured, weakened tendon looks very similar.

If you follow certain rules, tendinitis is a short term condition lasting no more than three to four weeks in most cases. Stop the offending activity, start low load intermittent motion and protect the area from excessive force. Gradually increase load and motion week by week. The problem is most people fail to follow these rules. The result is a prolonged inflammatory cycle, weakening of the tendon and chronic symptoms.

For every client, think about Sara's four questions. When you answer each one clearly and concisely, your client list will grow, problems will be few and your days will be fun.

Make today count.

Doug Kelsey
Author. Teacher. Therapist.