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Suezee
01-07-2010, 07:47 AM
I'm a physical therapist (and tennis player) with 20 years of clinical experience in the sports medicine setting, and have recently started to participate in some research on tendinopathy. At my age, I also have plenty of first-hand experience dealing with some of the aches and pains associated with our game. In my own profession, there is still some confusion on what is going on with tendon injuries, and I have seen similar questions posted in this forum. I would like to take this opportunity to share what I have learned so that you all will better understand your own injuries and can take an informed stance when you are trying to help yourself.

Inflammation of a tendon (tendinitis) can occur following an acute injury, which might even involve localized micro-tearing. In these cases, rest, bracing, ice, and medication helps, then you slowly get back to your prior training levels. Sometimes, that's the end of the story. Sometimes, however, it goes away for awhile, then the pain comes back. It is in these cases where we think a degenerative process is going on. (tendinosis) Following the original injury, the body tries to heal itself, but it does so in an inferior manner. The resulting repair or scar is not as strong as a normal, healthy tendon would be. This makes future injuries more likely. Imaging shows that you can get pockets of "fresh" inflammation, but the primary problem is degenerative. That's why anti-inflammatory treatments can help, but not always permanently.

There's another change that occurs with degenerative tendinopathies: the blood vessels are different. They are weaker, disorganized, and really don't do a good job bringing blood products to the interior portions of the tendons. That's another reason why degenerative tendons don't heal so well. If you want to embrace your inner nerd and see pictures of this, you can go to googlescholar.com. Type "Kraushaar and Nirschl" in the search bar. The third one down should be "Current Concepts Review: Tendinosis of the Elbow..."

One more thing is that you can have this degenerative process going on and not know it, until one day the tendon becomes symptomatic or even ruptures. One study looked at over 800 spontaneous Achilles tendon ruptures...none of these people had any history of pain: the tendon just popped one day. They biopsied the tissue and found no signs of inflammation. The tendon was degenerating, but the person didn't feel it. This might explain why a person suddenly has a painful area, even though they cannot recall a specific episode which caused it. The tissue might be degenerating, and it just "blows" one day...(Kannus P, Histopathologic changes preceding spontaneous rupture of a tendon. J of Bone and Joint Surg 1991;73-A(10): 1507-1525).

So basically, with most tendon problems, to get it better, one needs to manage the dysfunctional scar tissue, get healing blood products to the deep portions of the tendon, appropriately re-model the newly healed structures into something that is strong and functional, and deal with any racket, form, or strength issues. The Flex-Bar seems good and I like hearing the suggestions about changing your form or how you string your racket. Some doctors are trying to accomplish the first two goals with techniques like PRP injections. The shock-wave treatment for plantar fasciitis is also thought to accomplish this through a controlled application of micro-trauma. In my practice, I perform a technique called ASTYM, which is designed to stimulate a healing response in these degenerated tendons, and has a documented success rate of 89.8% with tennis elbow.

For those of you who are still awake, I hope this information sheds some light on some of these stubborn problems like tennis elbow, infrapatellar or Achilles tendinosis; why they come and go for no known reason, and why they can be so difficult to get over.

scotus
01-07-2010, 07:58 AM
Welcome to the forum.

Yes, tennis elbow is usually a combination of tendinitis and tendinosis. Decades ago, some researchers used the term tendinyosis to refer to this combination, but I am not sure if the term stuck.

At any rate, tell me more about ASTYM.

charliefedererer
01-07-2010, 08:44 AM
Thank you for the information.

Would you not conclude that "an ounce of prevention is worth a pound of cure?"

Would you agree that exercise routines should include preventative exercises to help prevent the common overuse injuries that bother so many players?

Do you have recommendations for such a regimen?

ninjatennis
01-07-2010, 09:29 AM
suezee - thanks for the informative post. do you think applying heat would be enough to bring blood and nutrients to the damaged tendons? i was looking up ASTYM and it seems to be a form of cross friction massaging. is ASTYM successful in healing patellar tendinitis/tendonisis? thats what i'm dealing with right now. thanks for the all the help!

Suezee
01-07-2010, 03:52 PM
Thank you for your very nice responses. I wasn't sure how such a long post would be received, and I am happy to answer your questions as best as I can.

ASTYM is a treatment program designed to stimulate healing in degenerated tendons, as well as stimulate the resorption and remodeling of scar tissue. In the early phases of treatment design, the technique was indeed based on a cross-fiber, friction-massage theory: i.e. a way to break down scar tissue. During the research process, however, it was discovered that too much pressure slowed the healing, and in some (animal) cases, caused damage in the treated tendons. (laying down of calcium deposits). As a result, the treatment was modified to be performed along the direction of muscles, tendons, or ligaments. In addition, through rat hamstring studies, it was determined just how much pressure it took to get the stimulatory effect without causing damage in the process. ASTYM certified therapists use specially designed instruments to identify dysfunctional areas. Then, the instruments are run firmly along the skin over the injured area. The certification process insures that the therapist is performing the technique in a proper manner so that they achieve a stimulatory, not damaging effect. ASTYM is only performed in rehabilitative settings: the patient is assessed for biomechanical dysfunction, and is given a customized stretching and strengthening program, thus insuring that proper re-modeling of the tissue occurs.

ASTYM has a documented success rate of 90.1% with patellar tendinopathy. I have treated alot of people with that diagnosis and have gotten great results.

Regarding the application of heat: Remember, the capillary beds are different in degenerated tendons vs. healthy ones. They have weak walls, and sometimes don't have a good connection to the body's blood supply. That's why it can be so difficult to heal these structures because bringing in blood products is what stimulates the healing process. It would appear that a more intense stimulus is needed to get blood flowing to the interior portions of these tendons.

Yes, I would agree that we all need to train outside of our sport if we want to play without pain. (Especially those of us over 35). There's been alot of attention on "core" training, which is a good thing, but I like to combine trunk stability when training the shoulder/scapular muscles, and bring in the hip as well. In my field, hip work is "the new thing"...I have a saying: "the butt is the new 'core' ". Here's two of my favorites for tennis players: (please check with your physician before starting any exercise program, and discontinue immediately if you feel pain).

Diagonal pulleys: Pulley handle starts high. Your fist starts in front of your face and you pull down and back at a 45 degree angle, keeping your palm forward. You will have to put your body on an oblique angle. Make sure your elbow is straight and your body does not rotate. Keep your body weight even between both feet. You want all of the force through the shoulder and the scapula. You can eventually incorporate eccentric work into the exercise by assisting the down (concentric) motion with the left arm, and then returning the weight with your right only. That deceleration is great training for ground strokes. You can challenge your trunk more by standing on just the left foot. I always work both sides for body balance, since tennis is such a one-sided sport already.

Dynamic forward lunges: Classic long-stride split lunges, but you alternate stepping one foot forward, then feet together, then the other one steps forward. Use a marker on the floor to insure that you maintain your long stride length as you fatigue. In addition, the front knee should not go ahead of the ankle. Make it more dynamic by punching forward with both hands as you lunge. Can even be progressed to using a medicine ball.

I hope that answered your questions, and thank you again for your positive response.

mike53
01-08-2010, 06:35 AM
Inflammation of a tendon (tendinitis) can occur ... Sometimes, however, it goes away for awhile, then the pain comes back. It is in these cases where we think a degenerative process is going on. (tendinosis) ... Imaging shows that you can get pockets of "fresh" inflammation ...


Hi Suezee, Thank you very much for your authoritative explanation of some very confusing problems. Maybe you can help me answer some questions I have been wondering about for a while.

If one had what they though was tendinitis, or maybe even had it diagnosed, and it goes away eventually, if pain returns to the area does one then have a degenerative process? If not, how can someone tell?

Is pain itself enough to establish that one have inflammation? If not, can one determine if they have inflammation without the effort of imaging?

How does one determine the presence or absence of scar tissue? Should someone be able to feel it with their fingers in the affected area? Does tendon injury/inflammation always result in the formation of scar tissue?

Any thought you might have would be greatly appreciated. Thanks, Mike

mikeler
01-08-2010, 06:48 AM
Suezee,

Thank you so much for this information. For all of us who suffer or have suffered with these problems, it is nice to know all the options out there.

charliefedererer
01-08-2010, 07:44 AM
Hi Suezee, Thank you very much for your authoritative explanation of some very confusing problems. Maybe you can help me answer some questions I have been wondering about for a while.

If one had what they though was tendinitis, or maybe even had it diagnosed, and it goes away eventually, if pain returns to the area does one then have a degenerative process? If not, how can someone tell?

Is pain itself enough to establish that one have inflammation? If not, can one determine if they have inflammation without the effort of imaging?

How does one determine the presence or absence of scar tissue? Should someone be able to feel it with their fingers in the affected area? Does tendon injury/inflammation always result in the formation of scar tissue?

Any thought you might have would be greatly appreciated. Thanks, Mike

Mike,
I too am interested in what Suezee will have to say on this, but I thought I might interject the following:

Imaging studies, even MRI, only show the signs of acute or chronic inflammation when they are relatively advanced.
In the "earlier: stages of inflammation, if we could cut out someon's tendons and look at them under the microscope, there would be evidence of micro tears, white blood cell infiltration at the site, layering of some fibrin, and small amounts of fluid containing mutliple mediators of inflammation. But this would be "invisible" on an MRI. And of course, no one is going to cut out a tendon to look at it under the microscope. So the evidence that this is going on is "clinical"; that is pain and tenderness at the site.
If we stopped playing at this early stage, the inflammation would resolve over a week or two. But of course, we are all taught from an early age "No pain, no gain". And usually this is right.
But sometimes the low grade acute inflammation persits and worsens so that even if activity is stopped it takes a long time for the inflammation to subside. And by this time, some of the tendon stucture may be destroyed by the inflammation, with the fibrin and collagen cross linked into "normal" needed scar tissue to fill in the injured areas. But unfortunately "abnormal" scar is also forming adjacent to the tendon, fusing it to bone, tendon and muscle that would limit movement if left intact, but which will initiate a new round of inflammation if disrupted with physical therapy so the normal tendon movement can occur.

In the beginning, the hard part for patients is waiting out the period of inflammation to subside.
The area is used in activities of daily living, so stretching and breakdown of some of the scar tissue causes futher inflammation, and the process continues.

Once the scarring is more extensive, it is very hard to know how much stretching/platelet therapy/heat/ultrasound therapy is beneficial, and how much is continuing the inflammatory process. It is hard to know because the only guides are pain,tenderness and inflammation at the site in any one patient. An experienced practitioner, and the patient, can tell if if improvement or worsening is occurring, but there is no good instrument/imaging device to monitor progress/regression. All that can be said is that it will take a long time for the inflammation to resolve, and difficult to thread the needle by doing enough physical therapy to prevent new abnormal scar tissue from forming and limiting tendon movement, and yet letting "good" scar tissue progress in the line of tendon to replace the damaged tendon fibers that will never regenerate with their normal anatomical architechture.

charliefedererer
01-08-2010, 07:55 AM
Hi Suezee, Thank you very much for your authoritative explanation of some very confusing problems. Maybe you can help me answer some questions I have been wondering about for a while.

If one had what they though was tendinitis, or maybe even had it diagnosed, and it goes away eventually, if pain returns to the area does one then have a degenerative process? If not, how can someone tell?

Is pain itself enough to establish that one have inflammation? If not, can one determine if they have inflammation without the effort of imaging?

How does one determine the presence or absence of scar tissue? Should someone be able to feel it with their fingers in the affected area? Does tendon injury/inflammation always result in the formation of scar tissue?

Any thought you might have would be greatly appreciated. Thanks, Mike

Mike,
I too am interested in what Suezee will have to say on this, but I thought I might interject the following:

Imaging studies, even MRI, only show the signs of acute or chronic inflammation when they are relatively advanced.
In the "earlier: stages of inflammation, if we could cut out someon's tendons and look at them under the microscope, there would be evidence of micro tears, white blood cell infiltration at the site, layering of some fibrin, and small amounts of fluid containing mutliple mediators of inflammation. But this would be "invisible" on an MRI. And of course, no one is going to cut out a tendon to look at it under the microscope. So the evidence that this is going on is "clinical"; that is pain and tenderness at the site.
If we stopped playing at this early stage, the inflammation would resolve over a week or two. But of course, we are all taught from an early age "No pain, no gain". And usually this is right.
But sometimes the low grade acute inflammation persits and worsens so that even if activity is stopped it takes a long time for the inflammation to subside. And by this time, some of the tendon stucture may be destroyed by the inflammation, with the fibrin and collagen cross linked into "normal" needed scar tissue to fill in the injured areas. But unfortunately "abnormal" scar is also forming adjacent to the tendon, fusing it to bone, tendon and muscle that would limit movement if left intact, but which will initiate a new round of inflammation if disrupted with physical therapy so the normal tendon movement can occur.

In the beginning, the hard part for patients is waiting out the period of inflammation to subside.
The area is used in activities of daily living, so stretching and breakdown of some of the scar tissue causes futher inflammation, and the process continues.

Once the scarring is more extensive, it is very hard to know how much stretching/platelet therapy/heat/ultrasound therapy is beneficial, and how much is continuing the inflammatory process. It is hard to know because the only guides are pain,tenderness and inflammation at the site in any one patient. An experienced practitioner, and the patient, can tell if if improvement or worsening is occurring, but there is no good instrument/imaging device to monitor progress/regression. All that can be said is that it will take a long time for the inflammation to resolve, and difficult to thread the needle by doing enough physical therapy to prevent new abnormal scar tissue from forming and limiting tendon movement, and yet letting "good" scar tissue progress in the line of tendon to replace the damaged tendon fibers that will never regenerate with their normal anatomical architechture.

mike53
01-08-2010, 08:19 AM
Thanks Charlie. There is a lot for me to learn here. An older person may have had tendon inflammation over years past that naturally went away in multiple areas (hopefully not all at the same time). When pain (re)appears in one of these areas, do we have an inflammatory process, a degenerative process or neither? I am wondering whether pain and weakness which might be diagnosed as tendinitis, an inflammatory process, may actually be referred to the tendon from a spasm or contraction in another area. For example, I have had serious achilles tendinitis in the past. When I experience pain in the achilles area, how can I know if I have scar tissue that needs treatment, whether or not I have tendon inflammation or whether this is just overexertion of the calf muscles?

hifi heretic
01-08-2010, 09:52 AM
It's a shame that most doctors - including orthopedic docs specializing in sports injuries - are not as well informed as you are. ..In dealing with my tennis elbow a few years back I saw four different docs and only one was aware of the important distinction b/w tendonitis and tendonosis as it relates to TE. ..The three who presumed it to be tendonitis prescribed the same old time-honored - though largely ineffective - treatments of ice and NSAIDS and it continued to worsen. ..The last doc told me that these were probably making it worse by reducing blood flow to the damaged tendons. Alas, by that point it had progressed too far. ...In the end I needed surgery to repair.

86golf
01-08-2010, 11:25 AM
It is a complicated injury and I read much of the article on googlescholar, yes I must have too much time on my hands, and I'm still confused on the issue. It would be good to get clarity on what 90.1 % success rate means. Does that mean the patient went from Phase IV to phase III or does than mean the patient went from phase IV to no pain ever the rest of their playing life?
I've gone from stage IV/V to stage I/II from doing the typical physical therapy sessions, Aleve and exercises.
It really puzzles me why you can message the pain out of a tendon. Seems contrary to the scar tissue explaination. I'm not talking about any professional therapy, just a temporary relief from self massage. Also, why does the nerve glide temporarily relieve the pain? When I was stage III, I could do 3 sets of tricep pull-downs and play 2 sets without pain. I paid for it the next day, but I was able to trick my injury for a few hours. BTW, I have the medial version of this aka GE. Finally starting to see the light, after 5 mos.

charliefedererer
01-08-2010, 11:59 AM
Thanks Charlie. There is a lot for me to learn here. An older person may have had tendon inflammation over years past that naturally went away in multiple areas (hopefully not all at the same time). When pain (re)appears in one of these areas, do we have an inflammatory process, a degenerative process or neither? I am wondering whether pain and weakness which might be diagnosed as tendinitis, an inflammatory process, may actually be referred to the tendon from a spasm or contraction in another area. For example, I have had serious achilles tendinitis in the past. When I experience pain in the achilles area, how can I know if I have scar tissue that needs treatment, whether or not I have tendon inflammation or whether this is just overexertion of the calf muscles?

Your questions go to the core of why treatment of inflammatory and fibrotic problems, especially in athletes, is so hard to define and treat. In most instances no one knows precisely what is going on in YOU at the tissue level. It's an "educated guess" in which YOU are lumped in with other patients with similar symptoms and given therapy which on average is beneficial. But a spectrum of differing problems is actually being treated, and YOU may not specifically benefit (although you very well may). Very frustrating for all involved.

On the other hand injuries like fractures and tendon disruptions, can be firmly diagnosed, treated specifically, and a specific rehab program all planned from the time of the initial injury. These injuries usually are thought of as "worse" or "more serious" but there is a lot less frustration from not knowing what is exactly going on, and what to do.

mikeler
01-08-2010, 01:23 PM
Darn, I looked at the ASTYM finder and there are not any near me.

ab70
01-08-2010, 01:55 PM
you might want to look for Graston practioner... same idea, slight different instruments

mikeler
01-08-2010, 02:06 PM
you might want to look for Graston practioner... same idea, slight different instruments


Thanks for the info. Has anybody tried seeing an Osteopathic Doctor?

mikeler
01-08-2010, 02:27 PM
Looks like Graston is much more effective at TE than GE.

http://www.grastontechnique.com/Outcome_Data.html

I'm ambidextrous, maybe time to become a lefty...

kslick
01-08-2010, 02:32 PM
Look a little closer at the data. Fewer treatments, fewer 100% completion...you get the idea. I wouldn't worry about numbers instead what works for you. I've had 1 treatment and can tell a slight difference. Nevermind the bruising. :)

Just keep at it until you find what works best for your body.

mikeler
01-08-2010, 03:42 PM
Look a little closer at the data. Fewer treatments, fewer 100% completion...you get the idea. I wouldn't worry about numbers instead what works for you. I've had 1 treatment and can tell a slight difference. Nevermind the bruising. :)

Just keep at it until you find what works best for your body.


I don't bruise easily, not that I even care about that if it works. Anything is worth a shot at this point, so I may give it a try.

Suezee
01-09-2010, 10:13 AM
This is in response to Mike53's questions.
If one had what they though was tendinitis, or maybe even had it diagnosed, and it goes away eventually, if pain returns to the area does one then have a degenerative process? If not, how can someone tell?

Based on what I have read, I think most of the literature would say that it is probably tendinosis. When I think of "tendonosis", I think of 35-55 year olds, who able to live and play through their injuries, maybe with the straps, braces, or Advil. That's not to say that I haven't seen more dramatic cases who end up having tendinosis as well. When I think of "tendonitis", I think of someone who had a clearly-defined injury...not just pain that comes on after a typical game, but someone who really did something to hurt themself. These folks are in alot of pain, need to rest the area, and clearly respond to anti-inflammatory treatments. Of course, the exceptions apply here as well. Remember the study on spontaneous Achilles rupture...perhaps the degeneration was ongoing and asymptomatic, then an accident occurs, but the body can't handle it because of the prior degeneration.


"Charliefedererer" wondered how one would know how much treatment is needed. For me, when the tissue smooths out, the pain is gone, and the person is playing pretty much how they were playing before, we stop.

Mike53 wondered if a spasm in the muscle can lead to tendon pain? Yes definitely. Anything that causes abnormal or excessive forces going through a tendon can lead to problems. In many cases, the area of pain is separate from the area of dysfunction. Recently, there's alot of interest in how hip tightness or weakness can result in knee or ankle problems.

86golf: What parameters define the 90.1% success rate? The patient rates their own improvement and improved to much improved. You also had a question on how you can temporarily massage the pain away? Could be increasing the blood flow removes some of the chemical irritants. We know with ASTYM, there's some sort of a neurologic response that occurs. Pain relief is immediate, but we don't know why because the reparative effect that is stimulated should take some time to occur. There's a study that showed a transitory increase in strength that occurs after ASTYM that lasts about 3 hours. We don't know why.


Is pain itself enough to establish that one have inflammation? If not, can one determine if they have inflammation without the effort of imaging?

No. I have had patients who have pain with palpation, pain with contraction, and/or night pain who end up with MRI's showing tendonosis.

How does one determine the presence or absence of scar tissue? Should someone be able to feel it with their fingers in the affected area? Does tendon injury/inflammation always result in the formation of scar tissue?

There's things my patients and I can feel with the ASTYM instruments and different things I can feel with my hands. With training, you could probably feel it yourself as well. I do know that with ASTYM treatment, the fibrotic tissue definitely smooths out, and my patients feel it as well. I would have to say the changes I feel with my hands are less clearly defined.
I'm not sure how to answer the second question. People often have one-time injuries that never recur...Younger people have better cellular turnover than older people. I don't have any references on those cases to guide me.

Suezee
01-09-2010, 11:02 AM
Sorry, that last post got a little out of order. Had to get up and down from the computer....teenager needing to eat...the nerve!

mikeler
01-09-2010, 11:24 AM
Again, many thanks for taking the time to type all that useful information Suezee.

mikeler
01-11-2010, 06:32 AM
I just made an appointment with a certified Graston guy for tomorrow. I'll report back afterwards. Also ordered my flexbars from Amazon and started doing forward and reverse wrist curls last night. Did some triceps extensions behind my head too.

kslick
01-13-2010, 10:18 AM
I just made an appointment with a certified Graston guy for tomorrow. I'll report back afterwards. Also ordered my flexbars from Amazon and started doing forward and reverse wrist curls last night. Did some triceps extensions behind my head too.

So....how did it go?

mikeler
01-13-2010, 10:41 AM
So....how did it go?


I had to cancel the appointment. My in-laws, my son, my wife and I all came down with a nasty intestinal virus over the last several days. I'm hesitant to reschedule until I know I'm over this.

kslick
01-13-2010, 10:43 AM
Wow, hope everyone makes a quick recovery.

mikeler
01-14-2010, 08:50 AM
Wow, hope everyone makes a quick recovery.


This one is kicking our butt; however I'm seeing the light at the end of the tunnel. I'll probably schedule something at the middle to end of next week.

Suezee
01-14-2010, 08:58 AM
I just made an appointment with a certified Graston guy for tomorrow. I'll report back afterwards. Also ordered my flexbars from Amazon and started doing forward and reverse wrist curls last night. Did some triceps extensions behind my head too.

I really hope that you get some good results, because I know there is not an ASTYM therapist in your area.

I just wanted to mention that ASTYM is a different approach from the tool-assisted friction massage of Graston or Sastm techniques, the use of Starr and GSO tools, or even using the edge of a spoon. To my understanding, the tool-assisted techniques are designed to mechanically break down dysfunctional soft tissue, and both healthy and un-healthy tissue can be affected. I am sure that these techniques probably help some people. It can be diffucult, however, to make generalizations regarding their success because the treatment can differ greatly between practitioners. To my knowledge, there is little real scientific evidence that this approach consistently works. The only article that I know of that specifically studied instrumented cross friction massage showed that it had no long term benefits on healing. (Lonhmani TM. Instrument-assisted cross-fiber massage accelerates knee ligament healing. J Orthop Sports Phys Ther;2009;39(7):506-514).

In stark contrast, the goals of ASTYM treatment are to activate the body's healing mechanisms and stimulate the regeneration of tissue, and there is evidence to confirm ASTYM's effectiveness in the medical literature. There are too many articles to list here. If you are interested, you can check out: http://www.astym.com/professionals/evidence.asp. ASTYM accomplishes regeneration by delivering measured doses of pressure and sheer forces in patterns particular for each diagnosis. The certification process insures consistent delivery of the technique and consistent results among practitioners. In addition, because ASTYM is performed in rehabilitation settings, therapists can addresses compensatory and contributory issues throughout the entire kinetic chain. (Biomechanical issues, tightness/weakness patterns, etc.)

I can understand that if you watched a video on You-Tube, the methods might look similar. In my practice, I have treated several patients who previously underwent Graston technique, and they all have stated that the methods, their response, and the subsequent results are different. It bums me out that there are no ASTYM therapists in your area, because my bias is quite evident. If you know any therapists, ask them to get certified. It has been such a great adjuct to my practice and I would be happy to talk to them about the technique. Good luck. I hope you find some relief.

kslick
01-14-2010, 09:12 AM
I really hope that you get some good results, because I know there is not an ASTYM therapist in your area.

I just wanted to mention that ASTYM is a different approach from the tool-assisted friction massage of Graston or Sastm techniques, the use of Starr and GSO tools, or even using the edge of a spoon. To my understanding, the tool-assisted techniques are designed to mechanically break down dysfunctional soft tissue, and both healthy and un-healthy tissue can be affected. I am sure that these techniques probably help some people. It can be diffucult, however, to make generalizations regarding their success because the treatment can differ greatly between practitioners. To my knowledge, there is little real scientific evidence that this approach consistently works. The only article that I know of that specifically studied instrumented cross friction massage showed that it had no long term benefits on healing. (Lonhmani TM. Instrument-assisted cross-fiber massage accelerates knee ligament healing. J Orthop Sports Phys Ther;2009;39(7):506-514).

In stark contrast, the goals of ASTYM treatment are to activate the body's healing mechanisms and stimulate the regeneration of tissue, and there is evidence to confirm ASTYM's effectiveness in the medical literature. There are too many articles to list here. If you are interested, you can check out: http://www.astym.com/professionals/evidence.asp. ASTYM accomplishes regeneration by delivering measured doses of pressure and sheer forces in patterns particular for each diagnosis. The certification process insures consistent delivery of the technique and consistent results among practitioners. In addition, because ASTYM is performed in rehabilitation settings, therapists can addresses compensatory and contributory issues throughout the entire kinetic chain. (Biomechanical issues, tightness/weakness patterns, etc.)

I can understand that if you watched a video on You-Tube, the methods might look similar. In my practice, I have treated several patients who previously underwent Graston technique, and they all have stated that the methods, their response, and the subsequent results are different. It bums me out that there are no ASTYM therapists in your area, because my bias is quite evident. If you know any therapists, ask them to get certified. It has been such a great adjuct to my practice and I would be happy to talk to them about the technique. Good luck. I hope you find some relief.

Isn't one of the differences is that ASTYM goes along with fibers as the other will also go against (cross-friction)? Along with pressure or technique.

charliefedererer
01-14-2010, 10:41 AM
In stark contrast, the goals of ASTYM treatment are to activate the body's healing mechanisms and stimulate the regeneration of tissue, and there is evidence to confirm ASTYM's effectiveness in the medical literature. There are too many articles to list here. If you are interested, you can check out: http://www.astym.com/professionals/evidence.asp. ASTYM accomplishes regeneration by delivering measured doses of pressure and sheer forces in patterns particular for each diagnosis. The certification process insures consistent delivery of the technique and consistent results among practitioners. In addition, because ASTYM is performed in rehabilitation settings, therapists can addresses compensatory and contributory issues throughout the entire kinetic chain. (Biomechanical issues, tightness/weakness patterns, etc.)


You sound knowledgable and well intentioned.

But it certainly is going too far to say that ASTYM has been PROVEN
to be of benefit for ANY condition.

The vast majority of the "literature" are case reports in which it is unknown whether the ASTYM sped up, or in fact delayed, recovery.

Some animal literature SUGGESTS that there may be some benefit to the theory.

The vast majority of the cited articles are not in well respected scientific journals.

It could turn out the specific manipulations in ASTYM turn out to provide some benefit. I would think that the vast majority of the "benefit" would turn out to be maintaining a gentle range of motion while abnormal scar tissue is being broken down by the range of motion exercises, and the abnormal scar tissue is prevented from attatching to adjacent tissue by the range of motion exercises.


Interestingly, Robert (chess9) posted a thread "Effectiveness of PRP questioned by study." http://tt.tennis-warehouse.com/showthread.php?t=306416
It would take such a study of ASTYM to really prove or disprove its benefits.


But perhaps my comments posted in that threat on PRP are worthwhile being posted here:

"Tendonitis, be it tennis or golfer's elbow, patellar tendonitis or any other area, is a poorly classified area that includes multiple causes, different degrees of severity, different lengths of severity, differing degrees of fitness in those afflicted, differing degrees of compliance in recommendations for rest, and often incorporating multiple treatments over time including physical therapy, steroid injections and other manupulations including PRP injections.

In other words "tendonitis" is a mess of diagnoses and treatments.

As a mess, it attracts all sorts of theoretical treatments, with varying degrees of soundness of the theories for treatment.

Tendonitis also invites quackery, with its quicksilver definition and hard to assess outcomes.

Tendonits invites the well intentioned, but biased practitioners to try out new attempts at treating the frustrating inflammatory process of tendonitis.

Tendonitis is avoided by most sensible researchers because of all the impossible to quantify variables.

The body is amazing, and often will heal tendonitis on its own over weeks and months, DESPITE some of the attempted treatments, and poor compliance of patients.

Good luck to all those suffering from tendonits.

Smart is the tennis player who works hard to stay in shape, and doesn't keep playing when tendonitis symptoms appear.

It is hard to stop playing tennis and let tendonitis heal if you enjoy the game so much."

Suezee
01-14-2010, 05:40 PM
CharlieF: Great post! If you play tennis as well as you assess clinical research, you must be quite a formidable opponent! Let me see if I can provide some further information.

Point 1: Regarding case reports: I agree, that the findings from controlled studies are much more believable than case studies. As a therapist, I like reading them because it gives me ideas on how to treat that I may not have thought of myself.

Speaking of controlled studies: I have some findings that are "hot off the press". The following are results from a large randomized clinical trial on lateral epicondylosis that was completed and awarded a platform presentation at the American Society for Surgery of the Hand's national meeting. This study is now being prepared for submission to a peer reviewed journal. (I don't know which one, at this time). Basically, 121 subjects who met criteria for "tennis elbow" were randomized into two treatment groups. One group received instruction in stretching and eccentric-emphasis strengthening exercises, which were performed for 4 weeks. The second group received ASTYM combined with the same exercises as the control group. Outcome measures included grip strength, visual pain analog scale, and a standardized functional questionnaire for the upper extremity (the DASH).

Here are the findings:
Phase 1: After 4 weeks of treatment, 78.3% of ASTYM subjects had symptom resolution (vs. 41.6% of the controls).

Phase 2: After an additional 4 weeks, the ASTYM group showed superior outcomes to the control group in all objective parameters.

At this point, the control group underwent treatment with ASTYM and 95.6% of them then met the resolution criteria.

All subjects who received ASTYM were followed, and improvements were maintained at 12 months for all variables.

Regarding the reputation of the journals: To my knowledge, Med Sci in Sports and Exercise is reputable across a variety of professions. Perhaps the rest of them pertain just to my profession, and may not be recognized by those outside of my field.

Regarding your point about exercise being critical. I absolutely agree with that. For that reason, only professionals who are in the rehabilitation profession can be certified in ASTYM, because exercise is critical to a strong and functional re-modeling process.

What do you think....are we now at 15/15???

charliefedererer
01-14-2010, 08:19 PM
CharlieF: Great post! If you play tennis as well as you assess clinical research, you must be quite a formidable opponent! Let me see if I can provide some further information.

Point 1: Regarding case reports: I agree, that the findings from controlled studies are much more believable than case studies. As a therapist, I like reading them because it gives me ideas on how to treat that I may not have thought of myself.

Speaking of controlled studies: I have some findings that are "hot off the press". The following are results from a large randomized clinical trial on lateral epicondylosis that was completed and awarded a platform presentation at the American Society for Surgery of the Hand's national meeting. This study is now being prepared for submission to a peer reviewed journal. (I don't know which one, at this time). Basically, 121 subjects who met criteria for "tennis elbow" were randomized into two treatment groups. One group received instruction in stretching and eccentric-emphasis strengthening exercises, which were performed for 4 weeks. The second group received ASTYM combined with the same exercises as the control group. Outcome measures included grip strength, visual pain analog scale, and a standardized functional questionnaire for the upper extremity (the DASH).

Here are the findings:
Phase 1: After 4 weeks of treatment, 78.3% of ASTYM subjects had symptom resolution (vs. 41.6% of the controls).

Phase 2: After an additional 4 weeks, the ASTYM group showed superior outcomes to the control group in all objective parameters.

At this point, the control group underwent treatment with ASTYM and 95.6% of them then met the resolution criteria.

All subjects who received ASTYM were followed, and improvements were maintained at 12 months for all variables.

Regarding the reputation of the journals: To my knowledge, Med Sci in Sports and Exercise is reputable across a variety of professions. Perhaps the rest of them pertain just to my profession, and may not be recognized by those outside of my field.

Regarding your point about exercise being critical. I absolutely agree with that. For that reason, only professionals who are in the rehabilitation profession can be certified in ASTYM, because exercise is critical to a strong and functional re-modeling process.

What do you think....are we now at 15/15???

I always hope that there will be better treatments for a condition, so I certainly hope that ASTYM will help more patients than "standard" therapy.

At a minimum, including physical therapy would seem to insure that patients get active exercise that would help to break down abnormal scar tissue and prevent firm fixation of new scar tissue to surrounding muscle/ligaments/tendons, and increasing the strengh of muscles that have atrophied from disuse due to pain.

It will be interesting to see when/if this study you mention on tennis elbow makes it into print. Of course, most cases of "tennis elbow" do not happen in tennis players, so at a minimum it will be interesting to see for the purposes of this forum, how many people had tennis elbow from playing tennis.

Most importantly, did the non-ASTYM patients receive the specialized and individualized physical therapy minus the instrumentation, or did they just receive generic instruction for stretching and exercise? That is, did this study seek to answer the question whether the instrumentation aspect of ASTYM is important, or is it a study comparing individualized physical therapy by expert physical therapists versus nonindividualized therapy by less expert physical therapists?

While "randomised" did both treatment groups receive treatment by the same therapists, or were the non-ASTYM patients treated by different therapy groups in the the community? Did both treatment groups have similar degrees of tendonitis as defined by severity, length of illness and etiology?
Did both treatment groups receive the same amount of physical therapy sessions? Were there higher drop out rates in one group?
Were the evaluators of the outcomes the therapists administering the care?
Is it not unusual that after only 4 weeks of treatment 78% of ASTYM patients had "resolution of symtpoms", therefore calling into question how serious the cases of tennis elbow were to start with? Or were the symptoms actually "improved" after 4 weeks, and not "resolved"?

All these questions sound a bit negative, but I'm really just asking for more information. I would like to thank you for bringing the above study to our attention, and also providing all of the other information you have brought.

mikeler
01-15-2010, 05:55 AM
Suezee,

What kind of effort is involved for a PT to achieve the certification?

Suezee
01-16-2010, 07:17 AM
Suezee,

What kind of effort is involved for a PT to achieve the certification?

It's a 3 day continuining education course. Some pre-reading ahead of time and some testing during the course. At the end of the course, you need to demonstrate all of the techniques on the instructors to be certified.

Suezee
01-16-2010, 07:34 AM
Isn't one of the differences is that ASTYM goes along with fibers as the other will also go against (cross-friction)? Along with pressure or technique.

Yes, that's right. The pressure and technique aspect of the treatment came from the early rat tendon studies that showed the treatment did indeed stimulate increased cellular activity in the treated tendons, and that this response was pressure-dependent. Some of the early studies on rabbit tendons showed that too much pressure caused some damage, specifically, calcium deposits in the tendons. For that reason, the developers moved away from the early methods and refined the technique into what is being performed today. There is another differences that, as a physical therapist, I appreciate. The developers of ASTYM are physicians, researchers, and physical therapists, and they are still actively involved in the technique. That means that experts are continuing to refine the treatment as research and outcome measures emerge. In addition, if I have a question; for example, if a patient does not respond as expected, or perhaps they have a medical condition and I wonder if the treatment is appropriate, there's someone I can immediately contact and get answers. As a therapist, I want to know that my treatments are safe for my patients and up to date, and this group has helped me with that.

Suezee
01-16-2010, 08:30 AM
One more on this Saturday morning! I wanted to get back to the original subject of this post and why I felt it pertained to tennis players. I imagine that many of you, like myself, continue to play with our little aches and pains. Most of the time, they go away, but sometimes, they persist.

Some very good issues have been posted regarding my question, "Is it tendinitis or tendinosis?". The questions and controversy exists among medical professionals, as well.

Based on my professional experience and the reading I have done, I am convinced that those of us with our elbow and knee straps, who occasionally take Advil before a match, are suffering from tendinosis. I believe that to recover from this, one needs to manage the dysfunctional tissue that was improperly laid down, get blood products delivered to the interior portions of the tendons, and re-model the new, healthy tissue into something strong, flexible, and functional.

If you ask a surgeon about how to accomplish this, he might tell you that you need to cut out the scar tissue and the resulting bleed will deliver blood products to the dysfunctional area.

If you ask another doctor, he might say that poking a tendon with a needle will get blood into the tendon and start the healing process.

If you ask a PT, they might have a variety of ways to manage the dysfunctional tissue, and we ALL believe that exercise is the best way to re-model the newly healed structures.

If you ask a medical researcher, they might say that eccentric loading is the best way to accomplish this. Incidently, from what I have read, it takes a pretty substantial load to get the desired results. As a therapist who treats "live" patients, I'm somewhat fearful of that concept, as it can make people really sore.

My intention with this post is that I want you to be informed consumers so that you can ask the question before someone just does something to you. The information on tendinosis has been around for almost 20 years. Evidence-based, innovative treatments are relatively new. Medical professionals may understand the concept, but until now, there have not been alot of appropriate and successful treatments for them to recommend. Those of us in the medical profession are beholden to recommend or perform treatments that have gone through extensive research, so that their safety and efficacy is insured, and that the results will be consistent when performed by different practitioners. That's why it has taken so long for the practical applications to catch up with the original research findings.

That's not to say that un-proven techniques may not be helpful. You may find one massage therapist that really helps you, but those of us in this field strive to find successful methods that trained practitioners can perform across the country.

So, back to you, who is sitting there in your tennis clothes, with a strap on your arm. What are you supposed to do? Keep your core muscles strong, so that your arms and legs don't have to absorb so much force. Stay flexible, because one of the hallmarks of tendinosis is adaptive shortening. Try massage or eccentric training of the injured areas and see if that helps. It just might. Then, if things don't get better, try to find someone who knows about this stuff so that they can help your pain and keep you playing.

athiker
01-16-2010, 09:43 AM
Suezee, thanks for posting this information to consider and referring me to this thread from the cortisone shot survey thread. I'm glad there are some studies going on about outcomes, b/c with my experience in general medical treatment I often wonder how a doc has a clue if something worked or not. Thanks also to the other contributers.

When I received my cortisone shot in my shoulder I was undergoing PT and considering surgery. The effects of the shot wore off quickly but the therapy eventually did moderate my pain to the point I decided against surgery. As far as I know, since I never spoke to the doc/surgeon again, he probably thinks the cortisone cure me. :) The fact is whenever I get lax about strengthening the muscles around my shoulder the pain returns so the PT is what was/is effective for me. It never really goes away, but moderates as long as I am vigilant.

I have dealt with tennis elbow recently as well, rear heel pain and now outside hip pain so this thread is very interesting to me. In addition my wife is a PT (mostly deals with stroke patients) so I hear quite a bit about various treatments and become her "patient" after various continuing ed courses. She took a Myofascial release course once, a couple actually over the years,...those are very interesting and probably the ones I enjoyed being her "patient" on the most.

I would be interested in anymore information you can give about the hip joint re: strength and flexibility.

Thanks again.

charliefedererer
01-16-2010, 07:07 PM
Suezee, thanks for posting this information to consider and referring me to this thread from the cortisone shot survey thread. I'm glad there are some studies going on about outcomes, b/c with my experience in general medical treatment I often wonder how a doc has a clue if something worked or not. Thanks also to the other contributers.

When I received my cortisone shot in my shoulder I was undergoing PT and considering surgery. The effects of the shot wore off quickly but the therapy eventually did moderate my pain to the point I decided against surgery. As far as I know, since I never spoke to the doc/surgeon again, he probably thinks the cortisone cure me. :) The fact is whenever I get lax about strengthening the muscles around my shoulder the pain returns so the PT is what was/is effective for me. It never really goes away, but moderates as long as I am vigilant.

I have dealt with tennis elbow recently as well, rear heel pain and now outside hip pain so this thread is very interesting to me. In addition my wife is a PT (mostly deals with stroke patients) so I hear quite a bit about various treatments and become her "patient" after various continuing ed courses. She took a Myofascial release course once, a couple actually over the years,...those are very interesting and probably the ones I enjoyed being her "patient" on the most.

I would be interested in anymore information you can give about the hip joint re: strength and flexibility.

Thanks again.

Interestingly your results with early relief with a cortisone shot, but subsequent best management with PT exactly matches a just pusblished study that reached the same conclusions:

"Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review.

CONCLUSION: Overall, the findings indicated that corticosteroid injections are effective at short-term follow-up, and physiotherapeutic interventions are effective at intermediate- and long-term follow-up. However, due to the limited number of high-quality RCTs and differences in the interventions and outcomes utilised within each of the included studies, any conclusions drawn must be interpreted with caution."
- http://www.ncbi.nlm.nih.gov/pubmed/19892089?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVDocSum&ordinalpos=10

charliefedererer
01-16-2010, 07:11 PM
It's a 3 day continuining education course. Some pre-reading ahead of time and some testing during the course. At the end of the course, you need to demonstrate all of the techniques on the instructors to be certified.

3 days!!!

I can see how you can pick up the instumentation basics in three days, but how can you get any feel for the procedure in that limited time? If you just start practicing without feedback from someone with more experience, isn't that on the job training?

kslick
01-16-2010, 08:41 PM
Yes, that's right. The pressure and technique aspect of the treatment came from the early rat tendon studies that showed the treatment did indeed stimulate increased cellular activity in the treated tendons, and that this response was pressure-dependent. Some of the early studies on rabbit tendons showed that too much pressure caused some damage, specifically, calcium deposits in the tendons. For that reason, the developers moved away from the early methods and refined the technique into what is being performed today. There is another differences that, as a physical therapist, I appreciate. The developers of ASTYM are physicians, researchers, and physical therapists, and they are still actively involved in the technique. That means that experts are continuing to refine the treatment as research and outcome measures emerge. In addition, if I have a question; for example, if a patient does not respond as expected, or perhaps they have a medical condition and I wonder if the treatment is appropriate, there's someone I can immediately contact and get answers. As a therapist, I want to know that my treatments are safe for my patients and up to date, and this group has helped me with that.

Thanks for posting. I'm really enjoying what you have to say. From someone who suffers from Golfers Elbow I try and learn about treatments and absorb all the info I can......knowledge is king. I've been to the ASTYM website but its hard finding a lot of info. I find a lot about Graston. Anyway thanks again,

mikeler
01-18-2010, 12:59 PM
I don't think I'll be scheduling a Graston appointment. It seems that the nasty Rotavirus I had fixed my elbow! I hit for about an hour Saturday with no problem. Then I played 2 sets of doubles yesterday and 3 today. The bony protrusion on the inside of my elbow gets slightly sore but that could be due to the air cast cushion. I'm finding that if I toss all my serves like a twist serve, this feels best on my arm.

Suezee
01-19-2010, 06:24 AM
I don't think I'll be scheduling a Graston appointment. It seems that the nasty Rotavirus I had fixed my elbow! I hit for about an hour Saturday with no problem. Then I played 2 sets of doubles yesterday and 3 today. The bony protrusion on the inside of my elbow gets slightly sore but that could be due to the air cast cushion. I'm finding that if I toss all my serves like a twist serve, this feels best on my arm.

What a crack-up. That's great you are feeling better all-over. Maybe you just needed some rest. My shoulder has been hurting...perhaps I should volunteer at the local elementary school cafeteria...

Suezee
01-19-2010, 07:07 AM
3 days!!!

I can see how you can pick up the instumentation basics in three days, but how can you get any feel for the procedure in that limited time? If you just start practicing without feedback from someone with more experience, isn't that on the job training?

If you were training someone who did not have the academic background and clinical experience, I agree that 3 days of training would be inadequate. However, the ASTYM people only train and certify licensed rehabilitation professionals, so students enter the course with that knowledge behind them. The training is a practical expansion on what they already know. In addition, the courses do not occur in some big lecture hall. There is a maximum ratio of 6 students to one instructor. This allows plenty of time for one-on-one instruction, so that participants leave the course with excellent manual training. Prior to certification, participants perform all techniques on the instructors, which insures consistency and efficacy of their methods.

Suezee
01-19-2010, 07:12 AM
Suezee, thanks for posting this information to consider and referring me to this thread from the cortisone shot survey thread. I'm glad there are some studies going on about outcomes, b/c with my experience in general medical treatment I often wonder how a doc has a clue if something worked or not. Thanks also to the other contributers.

When I received my cortisone shot in my shoulder I was undergoing PT and considering surgery. The effects of the shot wore off quickly but the therapy eventually did moderate my pain to the point I decided against surgery. As far as I know, since I never spoke to the doc/surgeon again, he probably thinks the cortisone cure me. :) The fact is whenever I get lax about strengthening the muscles around my shoulder the pain returns so the PT is what was/is effective for me. It never really goes away, but moderates as long as I am vigilant.

I have dealt with tennis elbow recently as well, rear heel pain and now outside hip pain so this thread is very interesting to me. In addition my wife is a PT (mostly deals with stroke patients) so I hear quite a bit about various treatments and become her "patient" after various continuing ed courses. She took a Myofascial release course once, a couple actually over the years,...those are very interesting and probably the ones I enjoyed being her "patient" on the most.

I would be interested in anymore information you can give about the hip joint re: strength and flexibility.

Thanks again.

That's alot to answer here...have your wife MMT your glut medius and max, and do the Thomas test on you. That will give you a good start. Squats and lunges are great hip strengtheners. She can look up Chris Powers for the latest on hip work. With squats and lunges, just make sure you keep your knee tracking over your second toe (vs. crossing midline). Improper form can lead to problems down the line.

panta77
02-07-2010, 10:37 AM
That's alot to answer here...have your wife MMT your glut medius and max, and do the Thomas test on you. That will give you a good start. Squats and lunges are great hip strengtheners. She can look up Chris Powers for the latest on hip work. With squats and lunges, just make sure you keep your knee tracking over your second toe (vs. crossing midline). Improper form can lead to problems down the line.

Hi Suzee, first thanks for all your posts here, they are very interesting. You say you are a tennis player and a MT, which is awesomme for us that play tennis and we have any issue with our body. Where in the US are you?

rumbey
02-08-2010, 07:52 AM
Hi,

I haven't played Tennis for over 3 months now. :(

I have just seen a chiropractor and I was told to ice and rest, not even stretching. Up until this recent appointment I have been using a Blue flex bar for about 4 weeks and stretching and I only seem to get pain when my arm is either fully flexed or straight. My grip is also OK.

Now I thought that at this stage of my injury which came about over slowly last season, I'd need heat treatment. I guess I'm confused and don't want to wait 3/4 weeks resting and still have no improvement. Icing doesn't seem to do anything?

Suezee is there a definite time span when Ice or heat should be used?

Regards
Dave

kslick
02-08-2010, 08:11 AM
If you are still in pain. The blue Flex Bar is to much. Start with the red or maybe the green one first. This isn't something you can push.

mikeler
02-08-2010, 08:58 AM
If you are still in pain. The blue Flex Bar is to much. Start with the red or maybe the green one first. This isn't something you can push.


The only time I feel even a twinge of pain is when my arm is fully extended or completely in the back scratch position. It does not hurt at all when I do the blue flexbar.

kslick
02-08-2010, 09:03 AM
Oh...Mikeler I know you have a pretty good handle on things. i was referring to Rumby. Seems like he is maybe pushing it a bit.

Suezee
02-09-2010, 08:06 AM
Hi Suzee, first thanks for all your posts here, they are very interesting. You say you are a tennis player and a MT, which is awesomme for us that play tennis and we have any issue with our body. Where in the US are you?

Thank you for the compliment! I'm in Southern California.

Suezee
02-09-2010, 08:08 AM
Hi,

I haven't played Tennis for over 3 months now. :(

I have just seen a chiropractor and I was told to ice and rest, not even stretching. Up until this recent appointment I have been using a Blue flex bar for about 4 weeks and stretching and I only seem to get pain when my arm is either fully flexed or straight. My grip is also OK.

Now I thought that at this stage of my injury which came about over slowly last season, I'd need heat treatment. I guess I'm confused and don't want to wait 3/4 weeks resting and still have no improvement. Icing doesn't seem to do anything?

Suezee is there a definite time span when Ice or heat should be used?

Regards
Dave

Ice is used for acute injury or inflammation. I use heat to loosen-up tight muscles.

mikeler
02-09-2010, 09:01 AM
Oh...Mikeler I know you have a pretty good handle on things. i was referring to Rumby. Seems like he is maybe pushing it a bit.


My bad, I quoted the wrong post!

rumbey
02-09-2010, 01:10 PM
Ice is used for acute injury or inflammation. I use heat to loosen-up tight muscles.

Tight tendons or tight muscles for heat. My forearm is strong really.

Still none the wiser or is is case of trying both. There doesn't, to me anyway, appear to be any swelling?

Dave

panta77
02-09-2010, 07:52 PM
I am in the SF bay area. What a pity you are not around here.

spacediver
02-10-2010, 12:23 PM
Suezee, thank you for sharing these valuable and thoughtful insights.

ProgressoR
05-15-2010, 08:34 AM
Suezee, thanks for sharing your expertise. Apologise by asking you to diagnose off the hoof, but my elbow pain seems a bit unusual. I had the traditional TE pain 2-3 months back, reduced playing, massaged the forearm muscle which was spasmed, and some pain went, but not completely. Then it seemed to settle down over 1 month of no play. Now I play most days, and pain is still there, but not that bad, nowhere as bad as before. But here is the interesting thing. Immediately after play my elbow is a bit sore, but within a few hours it settles down to pre-playing very little soreness. Then it repeats every time I play, even if i play 4-5 days consecutively, it doesnt seem to get worse.

btw the pain is behind the elbow, not between the elbow and wrist, but between elbow and triceps area, at the back of the joint. It used to be in the more traditional area for TE 2 months back but that particular pain resolved itself.

Do you think I could be doing continuous harm this way? I know what the cause of the pain was (technique and string and racket) and have fixed all those so they are no longer causes. But the residual pain (which is actually very low) still hovers as described above. It may be some part of my elbow still needs to completely heal, and I guess playing every day is probably not helping, but it certainly not getting worse, and pain is mild as I say, not painful at all, like it was before.

Thanks if you have the time and inclination to reply.

decades
05-15-2010, 08:39 AM
unless there are a bunch of color snaps of Shakira in it, most of us won't even pick it up let alone read it.

jimanuel12
06-04-2010, 04:47 AM
I'm a physical therapist (and tennis player) with 20 years of clinical experience in the sports medicine setting, and have recently started to participate in some research on tendinopathy. At my age, I also have plenty of first-hand experience dealing with some of the aches and pains associated with our game. In my own profession, there is still some confusion on what is going on with tendon injuries, and I have seen similar questions posted in this forum. I would like to take this opportunity to share what I have learned so that you all will better understand your own injuries and can take an informed stance when you are trying to help yourself.

Inflammation of a tendon (tendinitis) can occur following an acute injury, which might even involve localized micro-tearing. In these cases, rest, bracing, ice, and medication helps, then you slowly get back to your prior training levels. Sometimes, that's the end of the story. Sometimes, however, it goes away for awhile, then the pain comes back. It is in these cases where we think a degenerative process is going on. (tendinosis) Following the original injury, the body tries to heal itself, but it does so in an inferior manner. The resulting repair or scar is not as strong as a normal, healthy tendon would be. This makes future injuries more likely. Imaging shows that you can get pockets of "fresh" inflammation, but the primary problem is degenerative. That's why anti-inflammatory treatments can help, but not always permanently.

There's another change that occurs with degenerative tendinopathies: the blood vessels are different. They are weaker, disorganized, and really don't do a good job bringing blood products to the interior portions of the tendons. That's another reason why degenerative tendons don't heal so well. If you want to embrace your inner nerd and see pictures of this, you can go to googlescholar.com. Type "Kraushaar and Nirschl" in the search bar. The third one down should be "Current Concepts Review: Tendinosis of the Elbow..."

One more thing is that you can have this degenerative process going on and not know it, until one day the tendon becomes symptomatic or even ruptures. One study looked at over 800 spontaneous Achilles tendon ruptures...none of these people had any history of pain: the tendon just popped one day. They biopsied the tissue and found no signs of inflammation. The tendon was degenerating, but the person didn't feel it. This might explain why a person suddenly has a painful area, even though they cannot recall a specific episode which caused it. The tissue might be degenerating, and it just "blows" one day...(Kannus P, Histopathologic changes preceding spontaneous rupture of a tendon. J of Bone and Joint Surg 1991;73-A(10): 1507-1525).

So basically, with most tendon problems, to get it better, one needs to manage the dysfunctional scar tissue, get healing blood products to the deep portions of the tendon, appropriately re-model the newly healed structures into something that is strong and functional, and deal with any racket, form, or strength issues. The Flex-Bar seems good and I like hearing the suggestions about changing your form or how you string your racket. Some doctors are trying to accomplish the first two goals with techniques like PRP injections. The shock-wave treatment for plantar fasciitis is also thought to accomplish this through a controlled application of micro-trauma. In my practice, I perform a technique called ASTYM, which is designed to stimulate a healing response in these degenerated tendons, and has a documented success rate of 89.8% with tennis elbow.

For those of you who are still awake, I hope this information sheds some light on some of these stubborn problems like tennis elbow, infrapatellar or Achilles tendinosis; why they come and go for no known reason, and why they can be so difficult to get over.

this is a very good post. i have tried everything to get rid of the this mean case of tennis elbow. have had it over a year now.
i have tried: ice, cortozone shots (2), the flexbar exercises, creams of all kinds, nothing has really done a good job. although i must say that the penetrex cream i am now using does to seem to help some but i think the injury is so bad that i am considering the ASTYM technique you mentioned above.
i got a referal from my doctor yesterday and it just so happens that i have a licensed therapist in my home town.
i am going to talk to her next week and see what my options are.
i have had it with the TE, i just want the damn thing to heal so i can play again without all the pain and braces and so on.
will let you know how it turns out.
if this works, how long does it normally take to heal and can i play while in theraphy?

sidzej
06-04-2010, 05:43 AM
Jimanuel, it seems that you are still playing tennis while having serious TE problem. You should simply take a rest, no tennis at all...at least for a few weeks or months if needed.

mikeler
06-04-2010, 05:53 AM
^ I think Jimanuel pretty much took the entire winter off. Hopefully this will finally fix his problem. I'd still recommend the ultrasound/electrostimulation treatment. A number of people at my club with TE and GE have used it with success and been out on the courts after 4-6 weeks. I did it 2-3 times per week for a month and it made a huge difference.

jimanuel12
06-04-2010, 08:04 AM
^ I think Jimanuel pretty much took the entire winter off. Hopefully this will finally fix his problem. I'd still recommend the ultrasound/electrostimulation treatment. A number of people at my club with TE and GE have used it with success and been out on the courts after 4-6 weeks. I did it 2-3 times per week for a month and it made a huge difference.

yes, you are correct, i took the entire fall and winter off, about 6-7 months with NO tennis at all!!!
i have had the ultrasound/electrostimulation also, forgot to mention that in the last post.
nothing has really worked. the arm is better but no way healed.
i can play with the elbow brace without too much pain but the arm has never been the same since i hurt it last year.
i am going to seriously look at the theraphy and go from there.

pug
06-04-2010, 08:47 AM
yes, you are correct, i took the entire fall and winter off, about 6-7 months with NO tennis at all!!!
i have had the ultrasound/electrostimulation also, forgot to mention that in the last post.
nothing has really worked. the arm is better but no way healed.
i can play with the elbow brace without too much pain but the arm has never been the same since i hurt it last year.
i am going to seriously look at the theraphy and go from there.

Hello,

I wanted to add my experience. I developed pretty severe TE back in January of this year. Bad enough that I could not pick up a coffee cup if it was full. I immediately started to look for answers, and came accross this post by Suzee speaking about ASTYM. I found a PT in my area that does ASTYM and went right away to them. They of course do additional therapies and traditional methods along with the ASTYM.

I did not quit playing tennis, but I played with my opposite hand (left) for the first month or so(no serving due to the ball toss). After about a month or so and 6-8 sessions at the PT, I started playing with 2 hands on both sides for ground strokes, but I did not serve at all. After another month or so and 6-8 more sessions, I started hitting soft forehands and serves. And now, 5 months later I am able to play with 1 hand backhand, forehand, and regular serve. My TE is about 98 % healed.

I do believe the ASTYM was beneficial, along with traditional methods, and that the ASTYM accelerated my healing. I would advise someone to:

Go immediately to a therapist at the first sign of discomfort.
Seek out ASTYM if it is available to you.
Rest your arm(s) from repetative movements like tennis as much as possible to aid in healing and recovery.
Do the perscribed exercises religeously.
When you return to the court, do so slowly and don't push it.

Also be adaptable, play with your off hand or with 2 hands for example. It sure beats sitting on the sideline, and keeps the depression of TE at bay!

Jeff

Suezee
06-08-2010, 03:10 PM
I could be doing continuous harm this way? I know what the cause of the pain was (technique and string and racket) and have fixed all those so they are no longer causes. But the residual pain (which is actually very low) still hovers as described above. It may be some part of my elbow still needs to completely heal, and I guess playing every day is probably not helping, but it certainly not getting worse, and pain is mild as I say, not painful at all, like it was before.

Thanks if you have the time and inclination to reply.[/QUOTE]

It sounds like you started with an external problem (technique, strings, raquet), that might have over-loaded your arm, which caused a temporary inflammatory problem, but then has settled in to a degenerative tendinopathy. Sadly, our tendons start to show age changes at age 35, so if you are near that point in life, you probably have tendinosis going on. (Younger people can have this problem too, but because they heal so much better, they sometimes, but not always, bounce back better. That being said, I have treated alot of high school kids for these problems, but they usually respond in half the time that it takes for the adults to recover).

When we play with pain (and you know we all do!), we might unknowingly change our strokes or use our arms a bit differently...perhaps less optimally. As a result, we can develop over-use patterns in some of the surrounding muscles. Triceps insertion problems are classically seen in conjunction with tennis elbow, and one can even find problems in an obscure muscle called anconeous. That's why it is so important that you seek help from someone who assesses and treats the whole arm, because these secondary problems can lead to chronic symptoms as well.

There are alot of individuals out there who are effective at fixing these injuries, but I think what the ASTYM people have tried to do is standardize a very effective method so that when you see a therapist who has that certification, you have a pretty good idea that you will get these same results, no matter where you receive treatment.

I hope that answered you question. Sorry it took me so long to respond...I just recovered from a shoulder injury myself and have been playing more tennis, which means less time on the computer.

ProgressoR
06-09-2010, 03:13 AM
Thanks Suezee. I am 39 so no young buck. I am very sure there are no ASTYM people anywhere near where I live. The only treatment i did have that seemed to help a bit was reflexology which seemed like massage and manipulation of the fingers, hand, elbow, shoulder and upper back and that did releive the pain a lot, and it hasnt gotten worse since then. I might try that again. Also, over the summer, I will have some weeks where I cannot play at all so that should help, rather than my body having to play 6 times a week currently.

Thanks Again.

mikeler
06-09-2010, 04:10 AM
My problems started 2 months before I turned 36. I play ping pong left handed and that elbow has some very minor pain in it now too. Getting old sucks...

jimanuel12
06-09-2010, 04:37 AM
for over a year now i have suffered from TE.
i have tried everything i could think of, as posted here and in another post.
so, yesterday i went to see an ASTYM therpist and she said that she thougth the therapy will help my particular case.
she said they have a 90% sucess rate.
so i am thinking of trying this and see what happens.
i will post my results once i begin the treatment.
nothing else has worked, so i am willing to try something different.

mikeler
06-09-2010, 04:44 AM
^ Hopefully this is the end of the road for you and it works. Maybe start a new thread for that treatment so we can follow along.