Cause of Elbow Tendinopathies Remains a Mystery

If you have ever had tennis or golf elbow, you may know the frustration of not being able to use that arm without pain. And you have probably experienced the poor results of any treatment tried -- whether that was steroid injections, antiinflammatories, stretching, or strengthening exercises. In many cases, patients feel they get better on their own regardless of the treatment applied.

What's the answer to this problem? In this article, Dr. J.E. Kazanjian from the Philadelphia College of Osteopathic Medicine reviews all aspects of elbow tendinopathy from anatomy to pathology including diagnosis and treatment. Tendinopathy refers to the fact that tissue samples taken of tendons on the affected side of the elbow show no inflammation at all. Scarring and fibrosis can be seen on microscopic exam but there are no signs of acute tendon damage or healing.

Surgeons aren't sure what the true pathology is that causes tendinopathies. There is some evidence that cell death is going on. The tenocytes (tendon cells) almost seem to commit suicide. But what turns that mechanism on and why it gets started in the first place remain a mystery. Without a clear understanding of the underlying problem, it's difficult to find a specific treatment that is effective.

That's one reason nonoperative care is the first line of treatment for elbow tendinopathies. Even though the "best" plan of conservative care is also unknown, until studies reveal the true pathoanatomy, treatment may remain a virtual hit-and-miss proposition.

Physical therapists have joined the search for some answers. From the clinical side, they are trying different approaches to see what might work best. Using bracing, proprioceptive (joint sense of position) techniques, and heat treatments such as ultrasound and laser therapy, they give the treatment and then measure results and observe who gets better. Examining characteristics of patients who improve and those who don't might shed some light on the problem.

Other nonoperative approaches used with some success have included manual therapy and extracorporeal shock wave therapy (ESWT). Manual therapy is a hands on technique of moving soft tissue and bone to restore normal alignment and tissue tension. Shock wave therapy is thought to work by causing microtrauma to the tissue that is affected. The body responds to the microtrauma with a healing response. The result is blood vessel formation and increased delivery of nutrients to the affected area. The final outcome is pain relief from the tendinopathy.

When conservative measures fail to provide relief from painful symptoms or to improve function, then the surgeon starts to consider a surgical solution. As with nonoperative care, there are many choices available to the surgeon. Deciding on the approach (arthroscopic, percutaneous, open incision) is one consideration. Studies done to date have been unable to show that one of these three techniques is better than the others. In fact, no one (single) surgical technique has been shown to be superior to the others either.

Surgeons have tried muscle resection, debridement (shaving away frayed edges), reattachment of torn tendons to the bone, repair with tendon grafts, release of tendons, and combinations of these treatments. The author reports there isn't enough good scientific evidence to support one treatment over another. All methods have worked to some extent but many patients still have painful symptoms. Return to daily activities and work remain an unfulfilled goal for many people.

As you might expect, the conclusion to this review of elbow tendinopathies and summary of treatment is that more high-quality studies are needed. Surgeons need to compare the results of the various treatment approaches (operative and nonoperative) to this condition. Until a definitive pathology is discovered, it looks like treatment will remain palliative (treat the symptoms) rather than curative.

References: Jack E. Kazanjian, DO. Tendinopathies of the Elbow. In Current Orthopaedic Practice. September/October 2010. Vol. 21. No. 5. Pp. 485-488.