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04-27-2007, 01:09 PM
Spring's here. It's time to restring your tennis racquet or dust off the old golf clubs, but that tendon pain in your elbow, shoulder or ankle may force you to keep the clubs in the bag or the racquet in its case.

For some people, resting the affected tendon may be all they need to ease the pain, but others with chronic pain struggle to find relief. The good news is physicians now have a large array of techniques from new approaches to physical therapy and rehabilitation to new, less-invasive treatments that stimulate your body to heal the problematic tendon that can help you keep swinging your racquet or clubs without pain.

"We're altering the landscape in dealing with a lot of these tendon issues," said Robert Dimeff, M.D., medical director of Cleveland Clinic Sports Health. "These are still difficult problems to deal with, but the options are so much better now than they were 10 years ago."

What's causing the pain?

Most people attribute tendon pain to tendinitis (inflammation of a tendon), but more often the pain results from tendinosis, a breakdown of connective tissue resulting in a series of tiny tears in and around the tendon. Experts refer to the two conditions collectively as "tendinopathies," which occur most commonly in the elbow (tennis elbow or golfer's elbow), the ankle (Achilles tendon), in the shoulder (rotator cuff) and the knee.

While tennis, golf and other activities that involve repetitive use and overuse of a tendon are the usual culprits, other daily activities also can trigger pain. Generally, tendinopathies occur in middle and older age, from your 30s to your 70s.

First treatment approaches

If your tendon pain lasts more than a few weeks, see a doctor to rule out another, potentially more serious cause of the pain, such as a stress fracture. If your pain is sports-related, the doctor may have you check the size and weight of your racquet, golf clubs or other equipment and work with a pro on the mechanics of your swing.

The initial treatment for a tendinopathy usually entails warming up the muscle/tendon before exercise, resting it, applying ice and wrapping it shortly afterward, and taking pain relievers. You also may do gentle stretching exercises to prevent stiffness.

Dr. Dimeff also recommends physical therapy and rehabilitation to stretch and strengthen tendons and muscles. The therapy includes eccentric (pronounced "ee-sentric") exercises that elongate the muscle and tendon while strengthening them. The exercises require the guidance of a physical therapist.

On the treatment vanguard

Researchers have learned that with cortisone injections often prescribed for tendinopathies, the tissue damage caused by the injection may be more therapeutic than the cortisone itself. The trauma to the tendon tissue prompts the body to deliver blood and nutrients to the site as part of its healing response.

This idea of creating a healing trauma is behind newer treatments such as noninvasive shockwave therapy and autologous blood injections. In shockwave therapy, the doctor uses high-energy ultrasound waves to hammer problem areas and stimulate healing. The treatment, although somewhat painful and therefore not for everyone, is relatively safe, carries few adverse effects and can be effective for many tendinopathies.

Newer to the treatment armamentarium are autologous blood injections, in which the doctor injects your own platelet-rich blood into the region of the injured tendon to deliver nutrients that help heal it. A study in the November 2006 issue of the British Journal of Sports Medicine found that the blood injections relieved pain in patients with medial epicondylitis ("golfer's elbow"). Side effects include soreness and a minimal risk of infection.

Another newer tendinopathy treatment option under study is the topical nitroglycerin patch. Normally indicated to treat chest pain (angina), the patch is not widely used off-label to treat tendinopathies, but Dr. Dimeff has found it effective in his patients. Nitroglycerin dilates blood vessels and increases blood flow to the tendons. It also increases levels of nitric oxide, which may stimulate healing.

Dr. Dimeff typically prescribes the patch for three months. The patch is easy to use, is relatively inexpensive and carries few side effects (headache and dizziness are the most common). However, nitroglycerin can lower blood pressure, and patients on blood-pressure medications should talk to their physician or cardiologist before using it.

While these newer therapies offer promise in treating tendinopathies, they can require several weeks of treatment, and they don't eliminate the need for physical therapy and rehabilitation, Dr. Dimeff said.

"The important thing is to stick with the program and don't jump from doctor to doctor. Go to somebody who's listening to you and willing to try some of these other new things," he said. "And, I can't emphasize enough the importance of the rehab exercises. With all of these newer treatments, you still have to be doing the rehab exercises."

What You Can Do

- Use moist heat to warm up your problem tendon before exercising. Afterward, apply ice and wrap the tendon with a compression strap or sleeve.

- Use simple analgesics such as ibuprofen, naproxen or acetaminophen before activity and as needed.

- If your tendon pain is sports-related, make sure your tennis racquet, golf clubs or other equipment is sized correctly for you, and have a pro analyze your swing to make sure it's not causing your pain.

- Talk to your doctor about physical therapy, and work with your physical therapist to learn eccentric exercises that elongate and strengthen muscles and tendons.

- Ask your physician if newer tendinopathy treatments such as shockwave therapy, autologous blood injections or nitroglycerin patches are right for you.

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