When I was in grade school the kids in my neighborhood used to grab some gear and head to the baseball diamond at our neighborhood park. Home plate was always there, so we’d use a frisbee for first base, a sweatshirt for second base, and maybe a pizza box from the trash for third base. We’d play whatever games we could invent with a bat, a ball, and a few baseball gloves.
From those experiences I learned that the crack of a wooden bat on a baseball is an incredibly gratifying sound and feeling. But every now and then I might connect with the ball, only to feel the vibrations of a cracked bat. That “BZZZZZZ” feeling traveled through my hands all the way to my elbows. Or sometimes to my shoulders. And sometimes it even felt like it rattled my molars.
I’m wondering if this is a generational experience that has been lost, whether to aluminum bats, a generational shift towards soccer, a generational shift towards Pokemon Go, a reduction in outside play, or kids just avoiding neighborhood parks. But if you’re reading this and you ever struck a baseball with a cracked wooden bat, you cringed when I described what it’s like to feel those noxious vibrations up your arms. For those who can relate to that experience, it won’t surprise you to learn that those vibrations, if repeated over time, can cause long-term damage to your body.
TENNIS ELBOW
Tennis Elbow is the nickname given to a condition that is formally known as lateral epicondylitis. The reason it’s called “Tennis Elbow” is two-fold. First, “lateral epicondylitis” is hard to say without spitting food on people when you’re eating nachos. Second, it’s very common in tennis players. Recently it has been nicknamed “pickleball elbow,” to give you an idea of how things are going for the pickleball community. Tennis and pickleball players who spend hours on the court hitting a ball with a racket or paddle have micro-vibrations traveling through the racket/paddle to the elbow. The tendons that connect to the outside (lateral) prominence of the elbow (epicondyle) get inflamed (-itis).
In the first installment of “Oh, My Aching Body” I addressed acute injuries – those injuries that happen with a quick onset, and heal over a period of weeks. Unlike those conditions, Tennis (Pickleball) Elbow is a chronic condition – a condition that takes months to develop, and usually takes months to resolve. The experience and resolution of these injuries is super frustrating.
As athletic trainers we had three acute injury seasons, and the Spring was chronic injury season. Summer, Fall, and Winter gave us football players with dislocated shoulders and broken legs, or soccer players with ruptured ACL’s. Winter gave us basketball players with sprained ankles, and wrestlers with every imaginable sprain, strain, and dislocation. The injuries happened at a specific, memorable moment. I would spend a few weeks getting the injured athlete back to activity and wouldn’t see him or her anymore. But with chronic injuries we ask, “When did this start?” and we get a vague, “Uh… I’m not sure.” Every Spring I could count on baseball and softball players suffering from rotator cuff tendinitis, track athletes suffering from shin splints, and tennis players struggling with tennis elbow.
Chronic injuries develop slowly, and they get persistently worse until the athlete comes to the training room. When they finally come to see me they’re still not sure they should be coming in, because “it doesn’t ALWAYS hurt.” But the reality is that they should have come in weeks earlier, because we could have limited the severity if they had addressed things sooner. I’ll explain this later, when talking about the three stages of tendinitis.
TENDINITIS
Tendons are the tissues that attach muscles to bones. If you’ve ever pulled the meat off a chicken bone, it’s the white, cord-like tissue at the joints. Muscles are commonly injured with a sudden movement, but tendons get inflamed through constant, irritating activity. The suffix -itis indicates inflammation. Tonsilitis = inflamed tonsils, appendicitis = inflamed appendix, gingivitis = inflamed Gingers. 😉 If you hit a ball with a cracked bat you know how irritating those vibrations can be in an instant. Connecting with a pickleball while holding a pickleball paddle might not create the BZZZZZ vibrations that are experienced with a cracked bat on a baseball, but over time those bzzz vibrations yield chronic inflammation to the tendons in the elbow.
Incidentally, tendonitis happens in several areas of the body. Golfers experience the same issue on the inside (medial) of the elbow. They call it “Golfer’s Elbow.” Basketball players and volleyball players experience this issue just under the knee cap in the patellar tendon. They call that “Jumper’s Knee.” The common thread is the long-term vibratory forces on a tendon, which eventually results in chronic inflammation, pain, and functional limitation.
There are three stages of tendinitis. If you have tendon pain, maybe you can identify which stage you’re in.
Stage 1 - The tendon hurts after activity.
Stage 2 - The tendon hurts during and after activity.
Stage 3 - The tendon hurts all the time.
I’d usually see athletes when they were in late Stage 2, or even Stage 3. By then things are very difficult to reverse.
INFLAMMATION
Inflammation is an important and beneficial immune response to injury. With an acute injury you get redness, swelling, and an injury that feels warm to the touch, and the pain it causes forces the injured person to limit activity. Within a few weeks everything is back to normal. It’s as if you had a burst pipe in your house, so you call a plumber, he comes out to fix it, you have to see the top of his butt crack for an hour or two, but then he leaves and everything is back to normal.
But with a chronic injury the inflammation response never goes away. Tissues are being constantly irritated through vibrations up the paddle, and the body’s response is to send inflammation to the injured tendon to heal it. For the first few weeks we aren’t really feeling much pain, so we keep playing. Over time the tendon is getting more irritated, and the inflammation response itself becomes the cause of trouble. It’s as if you have a slow leak in a pipe, so you call a plumber. He doesn’t have the replacement part, so instead of fixing the problem he just mops up the mess every few hours. He stays in your house. He yells, “Beer me!” He drinks your beer and eats your food. He hangs out in your kitchen with the top of his butt crack showing. He burps when you’re trying to watch your favorite show. He’s so annoying! You wish he’d go away, but as long as that pipe is leaking, he’s not going anywhere.
TREATMENT
So how do you get that plumber to go away?
You turn off the water. There won’t be anything to mop up and the plumber will leave.
You know what that means in this analogy, right? That word I keep repeating in every article:
REST.
The vibrations through your paddle are causing the problem, so you need to stop doing the activity that’s causing those vibrations.
But there are a few less-drastic answers to this problem, because there are other methods to stopping those vibrations getting to your lateral epicondyle. Tennis players have vibration-reducing devices that are inserted between the strings near the handle of the racket. If you can dampen the vibrations at the strings of the racket, you’ll reduce the vibrations getting to your elbow.
ProKennex introduced pickleball paddles with tungsten beads that ProKennex calls “kinetic mass microspheres” in the paddle body and handle. These beads absorb vibrations to prevent inflammation in the hands, elbows, and shoulders. If you’d like to try one, I’ve got two.
Sometimes you’ll see tennis or pickleball players wearing straps around their forearms near the elbow. These dampen the transmission of vibrations at the strap, to keep them from getting all the way to the elbow.
REAL LIFE EXAMPLES
The worst case of “tennis elbow” I ever saw in my years working at a physical therapy clinic was in 1991. It was suffered by a guy who never played tennis in his life. His job was to stock grocery store shelves with bottles of wine. The top shelves were where they stocked the large glass bottles with the little finger loop on the neck of the bottle. He’d bend to the floor to the box of bottles, and with his thumb pointing toward the floor he’d loop a finger through that finger loop and lift the bottle to the top shelf an an upward backhand motion. Over and over, bottle after bottle, box after box, store after store, day after day. We couldn’t solve the problem. We’d treat him with ice and ultrasound, stretching and targeted strengthing. He’d come in during his lunch break between hours of stocking shelves. One step forward, two steps back.
That was the worst case I saw in the physical therapy clinic. The worst case I’ve ever seen ever was my own. I started developing sore forearms and elbows when I was doing deep tissue massage. After five years of doing massage I couldn’t lift the remote control, let alone do a deep tissue massage, without severe pain.
It was time for physical therapy, which was very familiar to me, as I had spent so many years treating others, including the wine-shelf stocker previously mentioned. At first physical therapy consists of modalities to reduce inflammation. This includes ice, ultrasound, electric stimulation, and massage.
(Not my elbow.)
Once pain is reduced we can start eccentric strengthening exercises. To explain this term let’s take the knee as an example. When you’re seated, the quadriceps, on the front of the thigh, contract to straighten the knee. This shortening of a muscle is a concentric contraction. But to bend the knee you don’t have to contract the hamstrings on the back of the thigh. You need to slowly release the quadriceps in a controlled lengthening, as gravity lowers the foot to the floor. The controlled lengthening of a muscle is known as eccentric contraction.
If your tennis elbow is in your right elbow, you support your right forearm on a counter or table while holding a weight in your right hand, which hangs off the table. You don’t lift the weight with your right hand with a concentric contraction. Instead, you lift the weight with your left hand, then slowly lower the weight with the right hand. The eccentric phase of contraction puts more load on the muscle, and less on the tendon, so it is ideal for tendinitis rehabilitation.
Irrelevant pro tip: Because the eccentric phase puts more load on a muscle than the concentric phase, it yields greater strength gains in weight training. If you’ve ever done a bench press, the concentric move is when you push the weight up. The eccentric move is the lowering of the weight to your chest, and science tells us that this is the phase where more strength is gained. Push the weight up with a 2-count, and lower it with a 4-count.
If all of these interventions don’t improve your tendinitis, it might be time for a cortisone injection. Cortisone is an anti-inflammatory steroid which reduces pain and inflammation within a day or two. The relief lasts for months if you do nothing else, but it allows you to engage in rehabilitation activity that could prevent the pain from ever returning, so it’s a great treatment for chronic pain and limitation due to tendinitis. Regrettably, it can’t be repeated very often, because over time the cortisone will deteriorate the tendon fibers.
If steroid injections don’t last, and mine didn’t, it’s time to see an orthopedist. The orthopedist I saw ordered an MRI to see what was happening. He hoped we could avoid surgery. When he reviewed my MRI he said, “We’re going to have to do surgery, and I know exactly what I’m going to see when I get in there.”
(Not my MRI.)
TENDINOSIS
When inflammation hangs out long enough, the condition that started as tendinitis – an inflammation of the tendon – turns into tendinosis – a the deterioration of the tendon.
When surgery was over my surgeon said, “It’s exactly what I expected. It wasn’t a white cord, like you normally see in a tendon. It was like gray gristle.” During surgery he spliced the tendon open, took out the gristle, stitched the tendon back up, and then scraped the surrounding bone to cause bleeding and facilitate healing. I wouldn’t recommend it. Rehabilitation was horrible.
(These photos are my elbow, twelve days after surgery.)
I went home in a splint and wasn’t allowed to bend my elbow for a few weeks. I was grateful that it was my non-dominant arm, because not being able to bend my right elbow would have been a severe limitation.
SUMMARY
Don’t keep pushing through pain until tendinitis turns into tendinosis. When you start to feel your elbow acting up, reduce time spent on the court, get a vibration-reducing paddle, use a strap on your forearm, ice after you play, and do eccentric strengthening exercises. If things don’t improve, reduce play further and see your doctor about next steps.
Are there other aches and pains you’re dealing with that you’d like to know more about?
This is the only source of medical information where you’ll read the words “butt crack” in the synopsis. Send me a message!
