Summer is approaching here in Connecticut, and with it comes the usual outdoor recreational activities like tennis and golf. Some injuries to be aware of when playing these sports are “tennis elbow” and “golfers’ elbow”, which are types of Tendon Overuse Injuries, and in the case of just the elbows, Elbow Tendinopathy.
Tendon Overuse Injuries have all been termed “tendinitis”. But really, several distinct pathologies exist—tendinitis, paratendinitis and tendinosis. To further complicate matters, these injuries may co-exist in the same tendon!
Tendinitis is inflammation of a tendon, usually due to injury at the tenoperiosteal or musculotendinous junction.
Paratendinitis is inflammation of the paratendon of the tendon sheath where these structures are associated with a tendon, either of which may be irritated by the tendon as it rubs over a bony prominence. Paratendinitis is associated with tendon injuries. It is also called “tenosynovitis” or “tenovaginitis”. In the past, a distinction was made between the latter two. Tenosynovitis is irritation of the inner surface of the tendon sheath by the roughened surface of the tendon. Tenovaginitis is irritation and thickening of the sheath itself.
Tendinosis describes degenerative changes occurring with Chronic Overuse Tendon Injuries, such as “Tennis Elbow” and “Golfers’ Elbow”. Aging and avascularity, lack of blood supply, may be contributing factors to tissue degeneration. With tendinosis, while there are no signs of inflammation in the tendon itself, biopsies have shown angiofibroblastic degenerative changes occurring. This is an invasion of organized vascular tissue and a disorganization of collagen tissue in the tendon. The granulation tissue is richly supplied with nerve endings, which may explain the painfulness of the lesion. The injury may progress from degeneration to microtearing to a partial or complete tendon rupture.
Tendinitis? Tendinosis? Is there a Difference?
Inflammation is not the only cause of tendon pain and weakness. Tendinosis, has been labled to describe tendons that have sustained significant damage but are no longer inflamed. Tendons with tendinosis may have significant accumulations of scar tissue and a reduction of weight-bearing strength, but the inflammatory process is no longer at work—that is until the structure is re-injured.
Massage is frequently suggested for athletes and other patients with tendinosis to stimulate circulation and improve nutrition in the avascular connective tissue structures, as well as to help stretch and mobilize the muscles involved with the damaged tissues.
With “tennis elbow” and “golfer’s elbow” the tendons to be treated by your massage therapist would be the Common Extensor Tendon and the Common Flexor Tendon.
To palpate the common extensor tendon, the elbow of the seated client is placed in slight flexion, the tendon is distal to the lateral epicondyle. It may extend over top of the radial head. This can be located by the client pronating and supinating the hand while the therapist palpates of the moving head.
With extensor tendinosis, microtearing occurs in the extensor carpi radialis brevis (ECRB) origin. Extensor carpi radialis longus and extensor digitorum may also become involved.
Repetitive forceful extension, supination and radial deviation are the movements most likely to provoke extensor tendinosis. Racquet sports players, especially novice players with poor backhand technique, are prone to injury. Wheelchair athletes are also susceptible, as are people with occupations such as plumbing and meat cutting. Pain is local to the lateral epicondyle, specifically at the origin of extensor carpi radialis brevis.
Sources differ as to whether this is a tendinosis or a true tendonitis. Lateral epicondylitis and “tennis elbow” are other terms for this condition.
To palpate the common flexor tendon, the elbow of the seated client is placed in flexion and the wrist is supinated. The tendon is located distal to the medial epicondyle.
With flexor tendinosis, microtearing occurs in the flexor tendon and in the pronator teres tendon. Repetitive activity such as hammering or using a screwdriver may cause the injury. Sports activites involving wrist flexion and pronation as golfing and overhead serving in tennis are other causes. Pain is at the medial epicondyle. A weak grip is also a complaint. An ulnar neuropathy may co-exist with flexor tendinosis, as the ulnar nerve passes through a hiatus in the flexor carpi ulnaris muscle. There is also disagreement as to whether the pathology is a tendinosis or a tendonitis. Medial epicondylitis and “golfer’s elbow” are other terms for this condtion.
In Conclusion, if you experience any Tendon Overuse Injuries such as, “tennis elbow” or “golfer’s elbow”, see your massage therapist to help relieve you of your pain.