Tendonitis
Sports related tendon injuries often involve high repetitive loading of
tendons with microscopic areas of rupture, surrounding inflammation and scar
formation. In the tennis player, golfer or swimmer, this may be seen with a
painful elbow or shoulder.
In basketball this may be seen as patellar tendonitis
of the knee, and in the runner it may be seen as Achilles tendonitis. Causes of
tendonitis include repetitive or acute tendon overload, constriction of a tendon
sheath with associated tendon friction, direct blow to a tendon attachment site,
or systemic diseases which cause generalized soft tissue inflammation. The site
of injury may be at the anchor site of tendon to bone, the midsubstance of the
tendon , or at the muscle tendon junction. In tennis, lateral epicondylitis
occurs at the bone-tendon origin of the wrist extensor muscles in the forearm.
In golf, the medial epicondylitis is more commonly affected.
Symptoms
Pain is the primary symptom and is activity related. In early stages of
tendonitis, pain resolves within 24 hours of exercise. In the most severe cases,
tendonitis may progress to constant rest pain which may disturb sleep or
ultimately lead to tendon rupture and attendant mechanical dysfunction. Although
local warmth may accompany local inflammation, this is not associated with fever
or generalized symptoms.
Diagnosis
Diagnosis is usually based on history and physical exam. Rarely are scans
necessary to make a diagnosis, except in instances where occult rupture is
suspected, or other more serious problems are felt to be likely. Tendonitis must
be differentiated from nerve entrapment syndromes, especially with elbow tendonitis, synovial sheath stenosis in the wrist or ankle, or generalized
inflammatory conditions such as rheumatoid arthritis.
Prevention
Prevention of tendonitis is accomplished by stretching the areas prone to
injury and maintaining strength without tendon
overload. "Warm-up"
should occur before sports. It should include motion through the full range of
the joint involved.
Overuse injuries are to be avoided. This means easy play
after periods away from sport. Equipment of light weight with
correct grip size
is essential to avoid injury. In the case of tennis, string tension should be
even and properly adjusted in the racquet. In tennis new light materials and
larger grip diameters may reduce tendon loads. Improved flexibility of racquet
and club handles also reduces the risk of tendon injury. Muscle strengthening
will decrease the likelihood of tendon injury. Playing technique is important in
avoiding injury. Excessive force, or poor stroke mechanics in contacting the
ball in golf and tennis may cause injury.
Treatment
Treatment for tendonitis centers on rest, oral anti-inflammatory
medication, activity
modification and local modalities for pain. Splinting the affected part rests
the muscle origins which are injured. This is the reasoning for the use of wrist
splinting in tendonitis at the elbow. Steroid injection around major
load-bearing tendons is contraindicated. These medications slow healing through powerful local anti-inflammatory affects. In this way they may predispose an
already compromised tendon to fail catastrophically, thereby necessitating
surgery. Stretching the affected muscle tendon unit daily helps avoid stiffness
and improves healing with minimal pain. Formal physical therapy is sometimes
helpful in difficult cases. The most important aspect of treatment is avoidance
of aggravating activities. Modification of tennis racquet handles to larger
diameters and more flexible shafts may allow earlier return to sports without
pain. Splints may also allow earlier return to sports, and should be worn
initially at all times except at bed. Stroke modification may decrease
irritation. Consult your golf or tennis pro for advice, and remember that
avoidance of pain is critical to rapid healing. As you return to sports play
carefully at first to avoid repeat tendon injury.
Rehabilitation
Weak muscles are a common cause of elbow tendonitis in tennis players. Gentle
stretching of the wrist and elbow should be through a full range of motion
including rotation daily. As pain and inflammation subside, strengthening
exercises are added on a daily basis. Light wrist curls in flexion and extension
with the forearm supported on a table, and rotation and squeezing a soft small
rubber ball are also helpful. Strengthening exercises should always be performed
without pain. As strength improves, sports participation may be slowly resumed.
Tendonitis may be slow and difficult to cure, and prone to recurrence, but in
general surgical intervention is only occasionally indicated.
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