Dissecting tennis elbow

OK, tennis elbow is driving me crazy. Three months now of periodic pain and swelling. Three weeks without a match and I’m losing it – playing air guitar with the vacuum cleaner and testing the limits of milk chocolate raisin consumption. While there is some relief in having a condition that my friends and relatives can pronounce, tennis elbow is complicated, painful, and usually long-term. The condition usually afflicts tennis players or people who use similar muscles repetitively. There is no “gold standard” for a doctor’s diagnosis, though ultrasound and MRI are becoming more available and useful for analysis. I was mortified that 80% of persons who suffered from tennis elbow for over a month required a year-long recovery! Needless to say, all of my other research projects are now on hold.

A few days of digging revealed yet another mystery in medicine. The underlying cause of tennis elbow (lateral epicondylitis) is under debate. New research explains that the condition should be called tendinosis, as the problem involves trauma and degeneration of the tendon rather than inflammation of nerve or bone. Exploration of the possible causes may help us better treat and avoid this condition, but I will first outline and compare the documented effectiveness of treatments available. Please consult a health professional before starting any program for treatment.

Treatments

• Cervical traction is important where cervical radiculopathy may be involved. Cervical radiculopathy describes the compression of nerves in the neck area of the spine that affects the shoulder, elbow, wrist, and fingers. A high incidence of cervical radiculopathy occurs in cases of tennis elbow. Overuse injury can also occur more frequently when the C6 and C7 vertebrae are weakened, limiting success of treatments until the spinal condition is corrected.
• Low-level laser therapy (LLLT) offers more promise than a pyrotechnic’s crate full of M-80s. But before you plunk down $1500+ for the latest home device, beware that the smoke has not cleared. I spent the last week pouring through dozens of objective studies, model descriptions, manufacturer web sites, and detailed newsletters to sort out fact from fiction. Scientists are oh-so-close to figuring out optimal cold laser wavelengths, power, dosages, and time for tendonitis and many other conditions, but you will need to travel from here on your own. Find a local doc, therapist or chiropractor who has some positive experience with using lasers for your condition, and proceed with caution. While LLLT appears to have longer beneficial effects than ultrasound or brace, you may want to combine it with some of the treatments below.
• Exercises that strengthen the surrounding muscles help speed recovery. Wrist extensor eccentric exercise is a promising new technique using a simple rubber bar called Thera-band Flexbar.
• Brace therapy uses a lateral counterforce elbow band to offer relief, especially during activity and exercise. A study showed that the forearm/hand splint was not more effective than the elbow band as a treatment.
• Creating platelet-rich plasma appears to be effective in recent studies. There are discussions about extracting blood, treating it, and reinjecting it in the affected tendon as a future therapy.
• Nitric oxide (NO) delivered through transdermal (skin) patches helped speed recovery in studies. Nitric oxide is not the same as nitrous oxide, laughing gas. Nitric oxide is vitally important to healing, as it fights bacteria, kills inflammatory cells, and causes vasodilation to increase blood flow to the area. Tendons consume less oxygen than muscles, so they heal more slowly. Increased age and low metabolism reduces nitric oxide activity and speed of healing, though physical exercise can combat this. Women may experience increased nitric oxide activity in the luteal phase of the menstrual cycle. Treatments like low-level laser therapy appear to increase nitric oxide levels, perhaps explaining its effectiveness. As with too much of a good thing, excessive nitric oxide can cause excess inflammation and damage, and more research is necessary to establish related treatments for injured tendons and other conditions.
• Prolotherapy is a new and relatively safe, alternative treatment that involves injecting a substance like dextrose or glucose in the tendon, stimulating healing and thickening the weakened tendon. Dr. Rabago is just now finishing a study that should confirm the effects of prolotherapy on tennis elbow.
• Icing the tendon may provide some relief and reduce inflammation, though one study did not see a difference in pain when icing was added to exercise therapy. The Nicholas Institute of Sports Medicine has information on exercises and icing.
• Ultrasound treatment has been helpful in some studies and not others. Home ultrasonic devices are available, but professional guidance is recommended.
• Acupuncture is effective for short-term pain relief, though there is no standard in treatment among doctors. Acupuncture enhances nitric oxide production which may improve pain relief.Tui na treatment is one approach within Chinese medicinethat may soothe and increase blood flow in tendons. This approach, like most in Chinese medicine, does not apply icewhich may cause stagnation within tissues. Another reported success is with needling and cupping of acupoints around the shoulder. Chinese medicine considers the invasion of wind, cold, and dampness as external triggers for tennis elbow.
• Botulinum toxin type A injection seems to improve pain by increasing circulation and aerobic metabolism, though its side effects may include weakness of fingers in the affected arm. Botulinum toxin is a protein produced by a very toxic bacteria, commercialized as Botox. Long-term safety has not been established.

Support

• Vitamin support for healing and regrowing tissue includes plenty of vitamin C and vitamin B6 and B12. Avoid taking vitamin C with fat, as cancer-causing nitrosamines are created when the nitric oxide from vitamin C and acid diffuses into fat.
• Hydration with plenty of water is important for healing tissues which are primarily composed of water.
• Light massage across the tendon can increase circulation and help regenerate damaged tissue after inflammation has subsided.
• Strengthen the adrenals. Aldosterone is made by the adrenal glands and enhances nitric oxide production.
• Improve sleep and treat sleep disorders. Inflammation is elevated in obstructive sleep apnea and likely to affect overall health and healing.
• Nutritionally raising nitric oxidemay improve the health of blood vessels and  affect the healing of tendons. The supplement L-arginine can increase nitric oxide activity, though in studies L-arginine only improved NO activity in patients with chronic heart failure. New studies are examining how Chinese herbal formulas are raising nitric oxide levels as well. Foods or supplements containing quercetin (highest in black and green tea), epicatechin (rich in cocoa), and resveratrol (in purple grapes and red wine) enhance nitric oxide production and function of blood vessels. Dietary nitrates found in spinach, beets, radishes, celery and cabbages are also vasoprotective and appear to lower blood pressure through the nitric oxide process. So how about those hot dogs? Believe it or not, the infamous sodium nitrate has proven to reduce fat accumulation, triglycerides, and prediabetic traits in mice. Sodium, however, appears to reduce nitric oxide formation, so limiting dietary salt may theoretically be helpful to boost NO levels.
• Sunlight on the skin appears to mobilize nitric oxide processes, so a little exposure might improve healing. Vitamin D also regulates substances that prevent inflammation and enhance immunity.

Related disorders

• Tennis elbow is often mistaken for radial tunnel syndrome or resistant tennis elbow. While the pain in tennis elbow starts where the tendon attaches to the lateral epicondyle, the pain in radial tunnel syndrome is a bit further down the arm. Radial tunnel syndrome involves entrapment of the radial nerve and is similar to carpal tunnel syndrome.
• Medial epicondylitis or golfer’s elbow is similar, but the pain is located on the inside of the elbow.
• Elbow bursitis or olecranon bursitis involves swelling and inflammation around the sac-like tissue behind the elbow. This may occur after a blow to the area or prolonged pressure. Patients prone to gout or arthritis may be at risk for infection from this condition.
• Viruses, parasites, and fungi can cause pain around joints. Arthritis Center of Riverside lists many associated microorganisms that can cause arthritic pain that be confused with tendonitis. One study describes elbow tuberculosis, a rare bacterial disease that is frequently mistaken for arthritis. Bacteria and other pathogens can trigger pain and inflammation and may not always be detectible by microscopic examination. In one case, DNA was extracted to identify tuberculous tenosynovotis. Even streptococcal infections have caused pain in the tendons and joints and diagnosed as poststreptococcal reactive arthritis.

Underlying clues

• Real-time sonoelastography revealed abnormalities in tendons around tennis elbow, including hard tendon structures, lesions and softening of tissue.
• Ultrasonic readings showed increased calcification and tendon thickening.
• One study mentioned tiny loose fragments of cartilage in the elbow area that were visible during surgery.
• Decreased circulation in the extensor carpi radialis brevis muscle may result from anaerobic metabolism and produce symptoms.
• Tendonitis can occur with other conditions like arthritis, gout, fibromyalgia, thyroid disorders, and other autoimmune diseases.
• If there are calcium deposits in the tissues and excess calcium in the bloodstream, there may be an underlying metabolic problem that promotes inflammation and requires additional specialized treatment.
• There may be underlying conditions where pain is heightened by elevated nitric oxide levels. These challenges include chronic fatigue, multiple chemical sensitivity, fibromyalgia, and posttraumatic stress disorder. In these circumstances, review Dr. Martin Pall’s protocol for down-regulating nitric oxide cycle through nutrition. This puzzling process might provide clues to why some cases do not respond to so many therapies for tennis elbow.

It is up to each of us to discover the unique formula that best relieves our pain and inflammation. Most promising treatments appear to aggressively stimulate the immune system without regard for underlying imbalances or body chemistry. For best results, each person’s immune personality would shape their protocol, including intensity and frequency. To prevent future suffering, we also need to understand why our inflammation happened. Health journals and detailed recollections might reveal bacterial infections, spinal misalignments, allergy exposure, or overuse injury that may be overlooked as triggers of tendonosis and pose future threats to health. As in every good game of tennis…know your opponent!

Update June 1: My tennis elbow is 90% improved after these efforts:

1) My thumb joint pain increased with my elbow pain, and my tennis racket handle was almost unbearable. After unwrapping the grip, I noticed the handle edges were sharp, and my husband sanded them down before rewrapping with a heavy cushion grip. This helped my thumb sprain heal which corresponded to improvements in my elbow!

2) I lowered the amount of oxalates consumed in my diet that affected my pain levels. Nuts, spinach, chocolate, tea, and herbal supplements were high sources of oxalate in my diet. Calcium oxalate crystals can settle in susceptible bones, tissues and joints and increase inflammation. This metabolic problem is starting to reveal clues to chronic conditions, including my intestinal permeability that contributed to celiac disease. I suffered for 2-3 years with heart tissue pain and valve disruption that I linked to dietary oxalates. Daily vitamin K-2 was also critical in preventing the problem. I have not been careful about my oxalate consumption in the past year, enjoying homemade granola for the past 6 months!

4) With a nudge from Dr. Wooley, I started antifungal herbs that have improved my immune system by clearing my sinuses, reducing food cravings, and allowing for better sleep. The a-ha moment came when I found research that explained how oxalates are produced by fungus. I hope that the antifungals have reduced the amount of circulating oxalates as well!

5) Taking probiotics is just as important as antifungals. With chronic candida, there is an imbalance of good bacteria in the gut and risk of increased permeability that can prevent healing throughout the body.

Update January 2012: My tennis elbow is 100% improved after some final key steps:

1) In September I discovered a photo of me holding an ice pack on my elbow during Christmas vacation last year – two weeks before my chronic pain started. I had bumped my elbow on a chair and forgotten about the injury! Obviously I had aggravated it with tennis before it was able to heal. 

2) Though my elbow pain had not disappeared, I had new pain after badly spraining my left ankle in September. By November my ankle was still very sore, and I explored a wide variety of treatments including hot/cold baths, exercises, and nutrition. I had both good and bad results with laser therapy on my elbow, so I purchased my own unit to control the settings and treatment time. The more affordable TQ solo unit from MultiRadiance Medical began working on my ankle and mobility.

3) The TQ Solo from MultiRadiance Medical has super pulsed delivery of photons, including 905 nm laser wavelength, 875 nm infrared wavelength, and 660 nm red wavelength. This major investment started paying off with reduced ankle pain. However, my elbow was much slower to heal, especially when I was limiting my treatments to the high frequency settings meant for range of motion and acute injury. Once I treated my elbow with the lower frequency at 50 Hz and 5 Hz, the pain erased immediately. These laser frequencies work best for inflammation and tissue repair. I also used the laser along the cervical spine where my elbow nerves originate. By January 2012, the pain was 100% gone!

4) Lowering oxalates while increasing calcium foods appears to have improved my elbow pain as well as other vague body aches. I am certain that oxalate crystals deposited in the injured tissues and irritated the nerves. Increasing calcium and probiotics while lowering oxalate-rich foods can help the body eliminate oxalates. High-oxalate foods such as baked potatoes continue cause a slight pang of pain within 24 hours. Herbs such as tumeric and cayenne and foods such as kale and spinach also associate with vague aches and pains in my body. Many autoimmune conditions such as celiac, fibromyalgia, and cystic fibrosis are associated with oxalate sensitivity, possibly due to an enzyme and probiotic deficiency.

This journey has illuminated the connection between oxalate metabolism and chronic pain in my body. Low-level laser therapy probably increased the nitric oxide levels and circulation in challenged tendons surrounding my elbow, obviously improving healing in painful areas afflicted by oxalate crystal deposits. Considering this success, I recommend cold laser therapy and a low-oxalate diet to others with autoimmune conditions experiencing acute injury and chronic pain.

Good luck!