By Michael Dakkak DO
Dr. Dakkak
is a fellowship-trained sports medicine physician practicing at Cleveland Clinic Weston Hospital in Florida. He specializes in non-surgical treatment options for treating orthopedic injuries or chronic pain.
Epicondylitis is a commonly used term to describe tendon pain in the elbow.
Often, when a patient is told they are experiencing pain from “epicondylitis,” “tennis elbow,” or “golfer’s elbow,” the real diagnosis may still not be fully clear. Is the cause of pain due to an acute injury or is it chronic? Is it due to inflammation in the tendon, or is there tissue degeneration and other changes to the tendon structure? In other words, is it truly tendinitis, or is it tendinosis?
If you are suffering from chronic tendon pain, it’s important to understand how tendinosis differs from tendinitis—and why treatments like TenJet, designed specifically for tendinosis, merit attention from both patients and their physicians.
What is epicondylitis?
Epicondylitis is a commonly used term to describe tendon pain in the elbow. It is also commonly referred to as tennis elbow or golfer’s elbow.
The word epicondylitis is a combination of a medical term “epicondyle” and the suffix “-itis”. An epicondyle is the prominence on the bone. In an elbow, the epicondyle is on the humerus bone and may be on the medial or the lateral side. In Latin medical terminology, “-itis” indicates the presence of inflammation. When the tendon attached to the lateral epicondyle develops tendinitis, it is called lateral epicondylitis or tennis elbow, and when the tendon attached to the medial epicondyle is affected, it is called medial epicondylitis or golfer’s elbow.
What is the cause of tendon pain?
Tendon pain could be a result of inflammation after an injury, due to repeated overuse of the forearm doing specific motions during sports or work-related activities, or degeneration of the tendon due to age or other factors. When the tendon is inflamed or weakened, the tendon is unable to transmit the forces generated by muscle contraction to the bone, ultimately affecting the patient’s ability to perform simple tasks like picking up a coffee cup, rotating a door knob, or lifting a bag of groceries.
What is the difference between elbow tendinosis and tendinitis?
Tendinitis refers to an inflamed tendon in the acute stages of an injury. If this inflammation is in the common extensor tendon of the elbow, it is known as lateral epicondylitis or tennis elbow, and if it is in the common flexor tendon, it is known as medial epicondylitis or golfer’s elbow.
A majority of patients with tendon pain suffer from tendinitis.
However, in patients suffering from chronic tendon pain, a breakdown or degeneration of the tendon structure results from overuse or failed healing after an injury. This condition is scientifically referred to as tendinosis.
Tendinosis refers to the breakdown of collagen fibers within the tendon structure, leading to fluid buildup, formation of atypical vascular granulation-like tissue, calcifications, or fatty infiltration within the tendon. Left untreated, tendinosis can lead to partial tears or even full-thickness tears of the tendon, with a possible risk of rupture depending on their characteristics and severity.
To summarize, “tendinosis” and “tendinitis” are not the same—and, although the two have historically been treated similarly, the ideal treatment for one is not always the ideal treatment for the other.
Who is at risk of tennis or golfer’s elbow?
Tennis or golfer’s elbow is not limited to athletes. It can affect anyone with a job or participating in activities that require heavy strain on the arms and elbow.
Individuals who work in jobs, participate in sports, or engage in activities that require much forearm use with repetitive elbow movements may be more at risk for elbow tendinitis or tendinosis. These can include:
- Athletes in sports such as tennis, rowing, or strength training
- People who work in construction, painting, carpentry, plumbing, auto repair, or other manual labor professions
- Those who lift heavy objects
- Musicians who play musical instruments, such as the piano
- Workers who prepare food, type on computers, or handle a cash register
- Gardeners or those working in outdoor landscaping
Elbow tendinitis or tendinosis may also be more prevalent in patients 60 years of age or older, largely due to higher risk factors for overuse over the course of their lifetimes, underuse due to lack of activity, or to medications such as statins, which have been shown to affect tendon strength.
What causes elbow tendinosis?
Generally, overuse of the tendon or muscle without sufficient rest can lead to a repetitive strain injury. If left untreated, this can lead to damage and degeneration (or breakdown) of tendon tissue, which can result in buildup of fluid or calcific deposits and cause discomfort.
When the elbow tendon has experienced tendon fiber breakdown and buildup of diseased tissue, the typical treatments for tendinitis (inflammation of the tendon tissue) may not be effective. At this stage, resection of diseased tissue combined with physical therapy may be the best treatment for allowing tendons to truly heal and recover.
What are the signs and symptoms of elbow tendinosis?
For patients with elbow tendinosis, basic tasks such as turning a doorknob, unscrewing a cap, holding a cup, or even keeping a strong grip can become painful and difficult.
Elbow tendinosis is usually characterized by a few key symptoms, each of which may present in varying degrees of severity:
- Pain in the elbow when moved or touched, and this pain may spread outward to the upper forearm, forearm, or hand.
- Stiffness, which makes moving the elbow or making a fist difficult and painful.
- Weakness, especially when making a fist or attempting a strong grip.
- Numbness or tingling, which may radiate from the elbow down the forearm and even into the fingers.
For patients with “tennis elbow” (lateral elbow tendinopathy), pain will typically be centered on the outside of the elbow. Similarly, “golfer’s elbow” (medial elbow tendinopathy) tends to produce pain inside the elbow.
How is elbow tendinosis diagnosed?
Many patients living with pain from elbow tendinosis may not be receiving the proper treatment—and this may be because their tendinosis is actually (incorrectly) being diagnosed or treated as tendinitis.
Tendinosis of the elbow can be a tricky condition to diagnose. Doctors might suspect tendinitis based on symptoms and medical history, often confirmed through a clinical examination. With modern advancements in imaging technologies, such as ultrasound and MRI, orthopedic physicians are now able to further evaluate a tendon’s structure in greater detail. Evaluating the tendon pathology is crucial for distinguishing between tendinitis and tendinosis.
Being able to make a distinction between tendinitis and tendinosis with confidence is vital for pinpointing the exact cause of elbow pain and choosing the best treatment strategy. Patients may start by consulting a non-operative sports medicine physician trained in the use of ultrasound imaging for diagnosis or an orthopedic surgeon specializing in hand or shoulder issues.
How has elbow tendinosis traditionally been treated?
As with many other tendon issues, elbow tendinosis has largely been treated the same way as tendinitis—even though the two are not the same ailment.
Conservative treatments tend to focus on rest and rehabilitation of the affected tendon—a treatment plan that may be effective at reducing inflammation in patients with tendinitis but may not fully address the root cause (degenerative tissue) causing pain in patients with tendinosis. These treatments include:
- RICE, physical therapy, wrist splints. This is the most basic form of treatment, involving rest of the affected tendon, combined with regular loading of the tendon to improve its structure and strength.
- Steroid injections, which may help to reduce inflammation, swelling, and pain in the affected tendon for a short amount of time, typically a month.
- Needle fenestrations, performed by a physician who usually makes 2-3 attempts to stimulate a healing response by reinjuring the tissue. This may not always provide lasting relief to patients with tendinosis.
- Platelet rich plasma (PRP) or stem cell injections. This technique may help to encourage tissue healing by injecting growth factors into the tendon.
While many of the conservative or non-surgical treatments may be effective at easing the pain from tendinitis, they are not very effective at providing lasting relief for patients with tendinosis—and that distinction is critical.
Open or arthroscopic surgery has been an option for patients experiencing tendinosis, although this may involve a fairly intensive recovery period for patients, along with potential surgical complications.
Many physicians recognize that it’s time to start treating tendinosis with its own approach, which is now possible thanks to advanced technology paired with ultrasound imaging.
How does TenJet treat elbow tendinosis?
Instead of simply treating tendinitis and tendinosis with the same treatments, TenJet is specifically designed to treat tendinosis with a minimally invasive technique. Using a 12-gauge, 2-lumen needle, TenJet allows a physician to perform precise and selective resection of degenerative tendinopathic tissue without harming healthy tendon.
The procedure may be performed using only a local anesthetic or light conscious sedation, depending on the preference of the patient.
TenJet has been used to effectively treat elbow tendinosis in a variety of patients. Two publications with more information include:
What do recovery and rehab from elbow tendinosis look like?
Rehabilitation and recovery after treatment with TenJet follow three phases: protective phase, restorative phase, and reloading phase. Physicians may recommend wearing a wrist splint to protect accidental overuse during the day or accidental overstretching of the tendon while sleeping.
All patients should follow the recovery plan provided by their physician, and each patient’s experience may vary depending on their unique circumstances.
A Better Treatment for Elbow Tendinosis is Possible
Patients living with elbow tendinosis in the form of “tennis elbow” or “golfer’s elbow” often go far too long without the right treatment, some living with pain and discomfort for months or even years.
Not only does this mean a lower quality of life for those patients, but it could lead to even more degeneration and more pain the longer the tendinosis is left untreated.
Thanks to TenJet, patients no longer have to suffer from tendon pain or be consigned to treatments designed more for tendinitis than for tendinosis. TenJet offers a minimally invasive treatment for chronic tennis elbow or chronic golfer’s elbow.
For any patient interested in seeing how TenJet can provide better treatment for tendinosis, the first step is to find a TenJet doctor nearby. They can help identify the right course of treatment, and ultimately, get patients back to enjoying the things they love.