Oh, My Aching Body - 3 - Tennis Elbow

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!

Oh, My Aching Body - 2 - Dem Bones, Dem Bones

 ‘Dem Bones, ‘Dem Bones

This month’s “Oh, My Aching Body” submission will address our amazing bones and the problems we cause them on occasion. 

This might seem off topic, but I’m going to start with a look at the honeycombs that bees are so good at constructing. Not a single bee ever attended engineering school, and none of them have ever been taught that the hexagon is one of the strongest strength-to-weight shapes that can be constructed. But there they are, constructing those honeycombs like engineering masterminds.

The reason I bring this up is because our bones have a very similar structure. If our bones were solid, they’d be REALLY heavy, and it would be much harder for us to move. But the honeycomb-like construction allows them to be ounce-for-ounce stronger than concrete, yet light enough for us to move and function the way we do. 

I know I’ve said it before, but I’ll say it again. …. Miraculous.

In addition to giving our bodies form and structure, our skeletons are home to the bone marrow that produces our blood cells. Some of those blood cells carry oxygen to all of our tissues (the red ones), some of them fight infection and give us immunity to ailments (the white ones), and other blood cells cause the blood to clot so we don’t bleed to death with every little cut or bruise (platelets). So while we may look at a classroom skeleton and see an inanimate structure, or a Halloween decoration, the bones inside our bodies are really quite active and full of life.

Bones adapt wonderfully to activity. Several years ago, scientists measured the bone density of a bunch of third graders’ tibias (shin bones) at the beginning of the school year. Half of the third grade classrooms were led by their teachers to stand up next to their desks and stomp their feet 20 times each, 5 times per day. The other half of classrooms didn’t do anything different than usual. At the end of the experiment, those little third grade bones that stomped 100 times per day showed REMARKABLE differences in bone density. It’s not like their non-stomping control group counterparts weren’t also jumping and running and playing as much as they possibly could during the experiment. They’re all third graders, so they’re non-stop motion, jumping off playground equipment, running wildly for no good reason, hopping onto benches to avoid imaginary lava, jumping over rocks to avoid imaginary alligators…. But the experimental group stomped an additional 100 times per day, and their bones adapted noticeably to the added stress.

Ballet dancers who spend a lot of time en pointe have remarkably thicker first metatarsal (instep foot bone) than non-dancers, because that bone becomes a weight-bearing bone, and must adapt to support the entire body weight of a ballerina (like, 85 pounds, right?). But it’s not all good news for bones under stress. Sometimes we ask more of our bones than they can deliver. Those dancers with the super thick first foot bones are at a fairly high risk of experiencing something that’s actually called “Dancer’s Fracture” when the fifth foot bone just snaps while they’re dancing.

 

Last month I wrote an article about muscle strains and joint sprains, and I was able to give a pretty standard recommendation for approaching any and all strains/sprains. For virtually every strain/sprain you’ll ice, rest, and elevate for 48 hours, then add heat and return to play slowly. But when we’re talking about bones we can’t make such sweeping statements. For example, one time I had two football players with broken lower legs. One broke his tibia (shin bone), which is the weight bearing bone of the lower leg. The other broke his fibula, which is the non-weight bearing bone on the outside of the lower leg, and its main function is to serve as an attachment point for the tendons and muscles that operate our toes and ankle. One player was in a cast, on crutches, not allowed to put any weight on his foot for several weeks. The other player was walking around in a walking boot three days after breaking his leg. Both of those are fractured lower-leg bones, but the protocols varied significantly. If you break your wrist, you’ll have a different protocol than if you break your skull. If you break your nose, you’ll have a different protocol than if you break every. single. rib. in your rib cage.

I don’t know which readers need to know this, but after menopause we lose estrogen, and that leads to lack of bone density.

After that sentence I have two things to say. 

First, it’s wise to stomp your feet and stress your bones after menopause, to counteract the effects of a natural decrease in bone density. 

Second, shout out to the guy who discovered the correlation between estrogen levels and bone density! World War II was underway at the time of this discovery, so while one group of scientists was figuring out how to turn atoms into weapons of mass destruction, Fuller Albright was connecting the dots of a mystery that had plagued women for millennia, about three decades before the emergence of “Women’s Health” as a medical discipline. So, hooray for his pioneering work on estrogen replacement therapy! He discovered that women who received estrogen replacement didn’t shrink as much as women who didn’t, and they didn’t experience osteoporosis and bone fractures the way their control group counterparts did. It was really a remarkable finding, it didn’t happen until my mother’s lifetime, and today we take that knowledge for granted.

More recent scientific advances have figured out that in osteoporosis, the cells that build new bones aren’t working as quickly as the cells that cart away decaying bone. Scientists figured out how to slow the function of the cells that cart away old bone. (WHAT?!?! That’s incredible!) People with brittle bone disease and osteoporosis have a new lease on life with medications like Fosamax. But whenever humans get involved in modifying how the body works, we always solve one problem but create others (as you’ll always learn when you listen to the side effects portions of pharmaceutical commercials). Fosamax might increase bone density, but the density isn’t being preserved in a hexagonal/lattice pattern discussed at the outset of this article, so there’s a higher incidence of people’s femurs (thigh bones) just fracturing horribly under normal activity when they take Fosamax. A woman will just be walking down the sidewalk with the dog, and her thigh bone breaks! Her wrists and spine and other bones are fine, but then she experiences what everyone says is the most painful fracture possible. I encountered one woman with a fracture like the one you’re seeing in this x-ray image when I  was working at a physical therapy clinic in Phoenix. She went on a ski vacation and managed to break her femur when she wrapped her thigh around a tree trunk while downhill skiing. It’s not an easy bone to break, usually requiring a car accident or motorcycle accident, and setting it right takes a lot of anesthesia, traction splinting, rods, plates, screws, and pins. To fracture a femur while walking a dog illustrates the necessity and brilliance of that honeycomb design that makes our bones function more like steel, and less like a stick of chalk.

One of the newest interventions for osteoporosis is vibration plate therapy. Instead of stomping on the floor next to an elementary school desk, similar benefits can be gained by standing on a vibrating plate for just a few minutes each day. Vibration plates deliver stomp-like stresses to the bones and muscles, forcing them to adapt by getting more dense. Whole Body Vibration (WBV) on a vibration plate also increases the abundance of those cells that build bone, which is an effect also noted with regular exercise (like pickleball).

In summary, if you think you have a broken bone, you’ll need a doctor to evaluate it. For it to heal - I hate to say it - you’ll have to rest it. Bones that are broken are very busy at the cellular level, and must be allowed to knit together for about six to eight weeks, without the added pressure of holding a pickleball paddle with a broken hand, or getting around without crutches on a broken ankle, or protecting your panting lungs with broken ribs. Just sit down and let the bone heal. If this is relevant to you, ask your doctor about hormone replacement therapy, consume calcium, take some Vitamin D to help absorb the calcium, and stomp or vibration plate your way to some better bone density. The best thing for your bones is weight-bearing activity, so do some planks for stronger arm bones, walk or stomp for stronger leg bones, and keep getting your bones out onto the pickleball court!

Any other topics of interest? Let me know!

Oh My Aching Body - 1 - Introduction

 

Hi, all! This is the first installment of “OH, MY ACHING BODY”. Today’s focus is foundational. We’ll start with some basic definitions, which will apply to virtually every installment from here on. 

The vast majority of what causes our bodies to ache after physical activity can be narrowed down to problems with ligaments, tendons, and muscles. Someday I’ll branch out to address problems with bones, bursae, cartilage, intervertebral discs, and maybe even cataracts, but for now I’m just addressing the majority of sports injuries. 

• Muscles: move the skeleton and give it support. 

• Tendons: attach muscles to bones.

• Ligaments: connect one bone to another bone. 

• Strain: tearing of a muscle or tendon.

• Sprain: tearing of a ligament.

• Acute: an injury that starts suddenly and usually heals within weeks (sprained ankle)

• Chronic: an injury that takes a long time to develop, and takes a long time to heal (tennis elbow)

This article talks about muscle strains, and the best and worst things to do when you get one. But this information can be applied to muscle strains, ligament sprains, and almost every other acute injury you’ll ever have.

Let’s say you’re out on the court paying close attention to Coach Mo, and you’re trying to keep your knees bent and shuffle side-to-side like she does. The next morning you notice that your thighs are sore. Muscle soreness is a natural part of muscle development. When body builders talk about “getting ripped,” they’re referring to a phenomenon where muscles that are being trained actually go through micro-tearing, and in that process the number of muscle fibers multiplies. It’s like when Hercules pulled off the head of the hydra and seven grew back. 

That’s what the muscle does. Physical effort tears, or “rips” the muscles, and the muscle fibers multiply, which causes the muscle to get bigger. It’s one of many miracles we encounter when we study physiology. Anyway, that muscle soreness is normal after a good workout, and it isn’t injury yet. Body builders and weight lifters will wait two days before stressing that muscle group again, in order to allow those muscles to heal from the exertion. They are always chasing soreness, but never pushing to excess.

But you go out with your sore muscles the next day, instead of waiting two days before another workout, because it’s pickleball and you’re addicted. You lower your hips into an impressive squat at the kitchen line, and suddenly you feel a pain in your right thigh in a specific spot. Now the muscle is strained. You start to feel what everyone always refers to as a “knot” in the muscle. The knot you feel is the (also miraculous) process of muscle guarding. Cavemen didn’t have splints or casts. They had the body’s own internal immobilizing process, which is where the healthy muscle fibers contract in order to keep the injured caveman from running, thus allowing the muscle to get some rest and heal.

 

Back to that kitchen line. Inside your injured quadricep you’ve got a few torn fibers, out of thousands and thousands of muscle fibers. Those little torn fibers are bleeding a little, and that blood is irritating to the surrounding muscle tissue when it leaks out, and that irritation triggers the muscle guarding “knot” response. 

The initial injury - muscle fibers being torn - is what we refer to as the “primary injury.” Think of a break in a water pipe in your house. That water pipe is the primary injury. Everything else that is affected by that burst pipe is “secondary injury”. The damage to the walls, the floor, the ceiling caving in, the valuables that get ruined are all secondary to the burst pipe. If you can fix the leaky pipe quickly, you’ll have less damage to everything else. As an Athletic Trainer we do what we can to prevent the primary injuries from happening. We’ll fit football players in shoulder pads and helmets, and we’ll inspect a soccer field to make sure there’s no holes where a player might twist an ankle. But once an injury happens we are really focused on preventing secondary injury. The primary injury (broken water pipe, strained muscle fibers) might take days to overcome, but the secondary injury (caved-in ceiling, completely bruised thigh) might take weeks to remedy.

Back to your thigh again. You have a tight, irritated muscle that’s bleeding a little, you can feel a knot around the strain, and you’re limping a little. But you keep playing, because it’s pickleball, and you’re addicted. 

Playing warms the muscle. Warming up the muscle makes the blood less viscous, so it leaks out more quickly. It’s like putting syrup in the microwave so that it will flow more quickly. Warming the area also dilates the blood vessels, which also makes the blood leak out a little quicker. It’s like taking the cap off the syrup bottle, because syrup doesn’t want to flow through the tiny hole in the cap. Exercising those muscles keeps your heart pumping, and staying on your feet lets gravity take the blood to your thigh. It’s like squeezing the bottle hard to force the syrup to come out, because when you just hold the bottle upside-down, the syrup isn’t flowing.

After playing on a strained thigh for several hours, you sit down to watch your friends play for a while. When you try to get out of your camp chair, WHOA! That hurts! You think to yourself, “I’d better use a Thera-gun on this,” or “I’d better take a warm bath” or “I’d better get this into the rec center jacuzzi” or “I think I’ll put a heat pack on this” or “I’ll just massage that tight muscle,” or “I’d better stretch this out real good.” All of those ideas are horrible. Every time you add heat before the tear closes, more blood will leak into the area. The secondary injury is just getting worse.

 

Going back to that initial quadriceps strain again, what if your first decision had been to lie down with ice on your thigh right after you felt it the first time? The ice makes the blood more viscous, and if it isn’t as runny it can’t leak out of the blood vessels so quickly. (The syrup is cold.) Ice also constricts the blood vessels, making it difficult for the thicker blood to move through the skinny tubes. (The cap with the tiny hole is on the bottle.) Lying down stops the exercise, and gravity isn’t bringing blood to the muscle as. (No one is squeezing the syrup bottle.) Instead of dealing with a very bruised and knotted quadricep muscle that will take weeks to heal, in this scenario we’re dealing with a few torn muscle fibers. You can add heat and light activity to the area after 48 hours, because that’s when the cap on the syrup bottle will be closed. You might even be well enough for pickleball by next week!

I can hear you now. “A WHOLE WEEK?!?!”

I know how you feel. I’ve been that athlete. I’ve treated hundreds and hundreds of those athletes. Science tells us that it takes six weeks for soft tissues to heal. So playing next week isn’t the best idea, but you can try it if everything feels good. It would be smarter to sit in the rec center jacuzzi or take a warm bath next week, but if you do play, warm up well, stretch slowly, try not to play like Coach Mo for another week or two, and force yourself to stop after an hour even if you don’t want to. But if you feel that “twinge” in your muscle, it’s time to stop and ice. If everything feels okay during and after playing, you can come back in two days - not the next day - and do an hour with a little more knee bend - but not a lot more knee bend. Don’t hurry the healing. Think about it, if Caitlin Clark can sit there and watch other people play her favorite sport, so can you.

Gradual return to activity is the key to a successful return that won’t cause you to be sidelined constantly for weeks and weeks. This is true if you strain your quadricep, twist your ankle, or feel a pull in your back. Ice and rest for two days, then take it slow.

That’s all for the inaugural article. When it comes to our aching bodies, what do you want to know about? Is there an injury that you’d like to understand and manage better? I’d love to hear from you!