Rob wrote a piece for our Alpine Physical Therapy blog a couple of months ago about Tennis Elbow (lateral epicondylitis), which is an inflammatory condition that can develop from stress on a tendon in the elbow.

True lateral epicondylitis stems from an acute tendon injury, resulting in clinic inflammatory signs (heat, swelling etc). As he mentioned in his post, the first phase of treating an acute injury such as this is to utilize the concept of R.I.C.E (rest, ice, compress, elevate).

Historically, it was thought that all lateral elbow pain was due to acute inflammation of the tendon, therefore treatment always focused initially on anti-inflammatory treatments. Over the past 15 years, however, there has been growing evidence that the majority of lateral elbow pain is actually due to a breakdown over time (or degeneration) of the tendon fibers rather that an sudden injury and resultant inflammation.

This process is now being termed as Tendinosis, or Tendinopathy.

In a normal tendon, the body is always removing damaged or old fibers and replacing them with new healthy ones. This process, when working smoothly, results in the tendon staying healthy and strong. When tendinosis occurs, the body does not remove and replace the damaged fibers like it should, leading to a damaged tendon that cannot tolerate the normal forces placed on it.

Since tendinosis is not the result of a sudden injury, but rather a slow breakdown of the tendon over time, anti-flammatory treatments (R.I.C.E, ant inflammatory medication) are not usually as effective. Furthermore, since tendinosis typically takes a long time to develop, it can often take a long time to recover from.

Physical treatment for this type of problem usually focuses on deep-tissue work, often utilizing tools to stimulate the body to break down and remove the damaged tissue. This, in turn, allows the body to regenerate new healthy fibers to heal the tendon.

Treatments such as ASTYM or IASTM (instrument assisted soft tissue mobilization) are often used, followed by exercises designed to load the new healing tissue so that the new fibers can realign to tolerate future stresses placed on them. Eccentric wrist curls (eccentric loading) have been shown to be the best exercise to stimulate the proper regeneration and remodeling of the damaged tendon seen in tendinosis.

How do we know if it is tendinitis or tendinosis?

Typically, tendinitis will come on suddenly, usually with a certain movement, and it will feel like a specific injury.  Tendinosis will usually come on slowly over a period of time.

However this general rule is not always the case, so an evaluation with a physical therapist can help determine the right course of treatment for elbow pain, or any other tendon-related pain.

Below is a good exercise to try if you believe you may be suffering from tendinosis:

Eccentric Wrist Curls

This exercise takes advantage of eccentric loading principles to help strengthen the common extensor tendon.

To perform the exercise, rest your forearm on a table with the wrist hanging over the edge. Grasp a weight with your palm facing the floor. Use your opposite hand to help raise the wrist toward the ceiling, then allow your wrist to lower back toward the floor for a count of four.

The key here is that the other arm assists the weight back up, while the painful arm does all the work for lowering the weight back down. The proper weight should be whatever weight causes slight discomfort in the location of the elbow pain.

This exercise is to be done 1 time per day, every day, for 8 to 12 weeks.