Best Doctor for Tennis Elbow?

Discussion in 'Health & Fitness' started by JPW, Jan 14, 2013.

  1. JPW

    JPW Rookie

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    I'm 43 (male), live in Houston, TX, and have been playing tennis off and on for about 20 years. About 15 years ago I developed some very bad tennis elbow and probably some myocitis (sp?) and tendonitis in my forearm. It was so bad I could lift a glass and I basically quit the game for a few years. The bug hit me about 6 years ago and I got back in to it. Everything was fine until the early part of this past summer. After playing for about five minutes I noticed some tenderness in my forearm and elbow. I quit immediately for fear I would do any significant damage. Unfortunately, even though I wasn't playing the pain just got worse. I knew I shouldn't play until I had zero pain and after laying off for over 6 months it feels like I might be getting close. It is still there, but improved quite a bit.

    My goal is to return to tennis pain-free and NEVER run the risk of having this problem again. The rest I'm sure did me good, but I should probably seek the advice of the best doctor possible who might specialize in treatment and recovery for tennis elbow. Does anyone happen to know anyone in Houston they could recommend? If not, is there a specific doctor that I should look for that would know how to properly treat something like this and offer steps to ensure it does not return?
     
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  2. sureshs

    sureshs Bionic Poster

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    Falls under sports orthopedics I suppose. You could go to any orthopedist, but some people insist on going to sports specialists. There must be many sports medicine clinics in Houston.
     
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  3. ian2

    ian2 Semi-Pro

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    I can't recommend a doctor but I can (highly!) recommend this: http://info.thera-bandacademy.com/flexbarelbow. It really works... at least it did for me.

    You might also want to take a look at your equipment as it could be attributing to the problem. What racket(s)/strings/tension are you using? How often do you restring?

    And of course technique... which could be the main contributing factor (note that pros have all kinds of injuries but hardly ever suffer from tennis elbow). Of course addressing possible technique issues is complicated, and depending on personal circumstances may or may not be feasible.

    Good luck!
     
    Last edited: Jan 14, 2013
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  4. Larrysümmers

    Larrysümmers Hall of Fame

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    a doctor is just going to load you up on some anti infalmitoriys and if it still hurts come back in a month, or suggest surgery which is a temporary fix. the best thing to do is rest it a lot, know your playing limits, make sure to stretch, and do triceps workouts.
     
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  5. ollinger

    ollinger Legend

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    A laudable goal, but completely unrealistic. Whatever you might do to improve the symptoms, nothing you can do can eliminate the risk of the problem recurring. There simply is nothing that "immunizes" you against it, particularly as you want to continue with tennis. Being over 40 in particular means greater risk of recurrence, so consider carefully how much you want to play tennis, and how often.
     
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  6. JPW

    JPW Rookie

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    Yea, I have a theraband. I hope to start using it more once I get completely pain-free if the doctor thinks it is best. I hit with a ProKennex Ki5 (very arm friendly) with all natural gut strung at 59#. I've got to believe the issue is not the racquet or strings, it must be my technique. I sure wish I could figure out with the culprit is in my swing (probably plenty of problems).
     
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  7. JPW

    JPW Rookie

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    I know what you are saying, zero risk of injury just isn't possible. I guess what I'm looking for is a path to get me as close to zero as possible.

    The reason I have it in my mind that it might be attainable is from doing P90X a couple years ago. P90X was no joke and it involved a great deal of weight training. Once I completed the 90 days (took everything I had) my arm and elbow felt as strong as it could be. Where it feels like I may have gotten myself in trouble was abandoning weight training and simply playing tennis often. My guess is that at my age I might need to be doing the strength training to allow me to play tennis pain-free. Hopefully, a doctor will be able to give me specifics.
     
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  8. Chas Tennis

    Chas Tennis Hall of Fame

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    The issue of Tendinitis (with inflammation) or tendinosis (defective healing)?
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122566/
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445129/

    TW thread including these two publications.
    http://tt.tennis-warehouse.com/showthread.php?t=442912&highlight=tendon+injury+nuthouse

    I do not know this Dr in Houston – Dr John Cianca. He wrote a short description of how tennis elbow or other tendon injuries might become chronic after an acute injury and inadequate time off for healing. The time discussed was very brief. I believe that his description is very reasonable and applies to some or most acute tendon injuries.
     
    Last edited: Jan 30, 2013
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  9. Chas Tennis

    Chas Tennis Hall of Fame

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    One of the most plausible causes for tennis elbow for a one hand backhand is described by biomechanical researcher D. Knudson in his very interesting & informative book, Biomechanical Principles of Tennis Technique (2006). He discusses why the wrist should be extended and not flexed for the 1hbh. He says that the pro's use extended wrists and many average players use flexed wrists. When I look at videos I see the pros using extended wrists on the 1hbh. In addition, the flexed wrist stretches the elbow muscles that are injured in TE making stress from wrist flexion seem plausible as a cause of TE injury.

    Knudson description of wrist issues on the 1hbh. (1997)
    http://assets.usta.com/assets/1/UST..._The One Handed Backhand and Tennis Elbow.pdf

    Knudson book. (2006)
    http://www.tennis-warehouse.com/Biomechanical_Principles__Technique/descpage-BIOMECH.html

    Pros using extended wrists on the 1hbh-
    http://www.youtube.com/watch?v=gqBEErW0vTA

    See if you can find any videos of pros impacting the ball with flexed wrists on the 1hbh. ? % ?

    Search terms & get illustrations: wrist extension, wrist flexion

    https://www.google.com/search?q=wri...IzcEbOQ0QGaloBQ&ved=0CDAQsAQ&biw=1334&bih=722
     
    Last edited: Apr 23, 2013
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  10. LuckyR

    LuckyR Legend

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    Some ideas:

    This is something you can manage yourself if you are willing to do the effort.

    True, a doctor can play a role in this issue but think about it: what does a doctor have that you don't? He can do surgery-- very rarely used for this problem and nothing you want any part of at this point. He can write Rx meds-- the only one that that is not available OTC would be steroid injections, and again they are rarely used and I wouldn't jump to it, at this point yet. Lastly, they can have experience in the problem. Trouble is, if the individual doc does not have a particular interest in this area, their experience could be less than the posters on this thread.
     
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  11. JPW

    JPW Rookie

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    Thanks everyone for the input, but I think this thread might help explain more of how confusing all this might be. There certainly doesn't seem to be any one right way to attack an injury like this. People simply have varying opinions, which makes sense. Ultimately, all the dicussion here has helped me and I think I might elect to go to a Sports Rehab Clinic somewhere. My hope is they have doctors that can diagnose exactly what my issues are, how they can be repaired, and maintained long-term.

    I only wish I could find more information around those here in Houston. I've got to believe there are plenty of high-level competitive players here and I wonder who they might recommend for injuries like this. I'll continue to hunt around and if I ever find more information I'll post it back here.
     
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  12. Chas Tennis

    Chas Tennis Hall of Fame

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    Talk to some of the older players to see if any can recommend doctors who have been effective for them and/or specialize in physical therapy approaches.

    The Dr I mentioned above, John Cianca, wrote an article that led me to believe that he has a sound understanding of tendon injuries and treatment. I had golfer's elbow and believe that what he wrote stopped me from playing more tennis and likely helped me avoid a chronic GE injury (tendinosis). I can't know for sure but that is what I believe. After reading the review articles above I believe that many tendon injuries have mostly become tendinosis perhaps mixed with tendinitis. Effective treatment is difficult. I would seek the opinion of a Dr who would discuss both tendinitis and tendinosis with me. Get more than one opinion.
     
    Last edited: Jan 15, 2013
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  13. charliefedererer

    charliefedererer Legend

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    You have the right idea - find a good Sports Rehab doctor and follow their advice.

    Working with a therapist can also help guide therapy.


    Still, understanding the basics in return to play should help.

    As you have already done, rest is the first step until almost all the pain is gone.

    A common first step is to do very gentle "range of motion" exercises.
    These are not to truly "strengthen" the muscles, but rather to get the muscles and tendons smoothly gliding past one another again.
    [Some internal "scar" tissue may have "glued" adjacent tendons/muscles together. Loosening up some of this internal scar tissue may cause some minor soreness, but should not cause real "pain".]
    One of the most common range of motion exercises is to use the red Theraband Flexbar, doing the Tyler twist and reverse twist.
    [The red Flexbar seems "too easy" to many, but again the objective is just to get the muscles and tendons moving past one another again.]

    If there is no pain with the red Flexbar, it is then time to progress to the green Flexbar.
    Slowly increasing the number of reps can let you begin to increase some strength without overdoing it.
    Any return or increase in pain means you need to drop back a step and start over after the pain is better.


    Next, strengthening the forearm even more with other adjuncts, including dumbell wrist curls, reverse curls and pronation/supination exercises can build more strength.

    Return to tennis should be gradual - start with short hitting sessions without serving.


    Good luck!
     
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  14. comeback

    comeback Professional

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    I am an instructor and tournament player. i had the worst case of tennis elbow. I couldn't lift my arm to brush my teeth, wash my hair, hold a coffee cup etc but waas finally able to heal myself with this great rehab glove..it's also reimbursed by insurance http://www.flextend.com/
     
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  15. superdave3

    superdave3 Rookie

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    I read what the sites said, and it appears the eccentric exercise is highly recommended, but they did not describe what exercises these are-could you please explain? Thanks!
     
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  16. superdave3

    superdave3 Rookie

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    I clicked on the website, but it does not seem to show how this works (like the theraband does). Could you please explain?
     
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  17. charliefedererer

    charliefedererer Legend

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    [​IMG]

    Here's a video with do's and dont's:
    Top Five Mistakes to Avoid When Using Flextend http://www.youtube.com/watch?v=06dE_-oa0wQ

    I don't have experience with the Flextend. It seems it was made largely to treat carpal tunnel syndrome of the wrist.

    Just based on how it works, I would think the twisting motion of the Theraband Flexband http://www.youtube.com/watch?v=zB3TVb8a5mk would be a better exercise for the muscles/tendons involved in tennis elbow, but it certainly does seem that comeback had great results using the Flextend.

    I hope comeback sees this and can explain further the specific exercises he used - how much flexion and extention and how much twisting exercises. Also I would love to know if he first used the Theraband Flexbar without results.
     
    Last edited: Jan 30, 2013
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  18. rufus_smith

    rufus_smith Professional

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    Your TE is severe and was quick to develop. This suggests either that you may have a congenital flaw in your elbow or that you are hitting the ball with some unusually damaging technique. In other words after it heals it will come back again. Have a sports doc make and evaluate a diagnostic image (ultrasound or other) of your elbow and have tennis expert observe you on your technique. Just my opinion from having severe TE in the past.
     
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  19. Chas Tennis

    Chas Tennis Hall of Fame

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  20. Chas Tennis

    Chas Tennis Hall of Fame

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    Last edited: Jan 30, 2013
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  21. dhnels

    dhnels New User

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    Best article link EVER posted on TT. Very technical but lots of good explanations of things I've personally experienced in the 6 months since I've resumed playing after a 6 month rest for TE. Like why TE pain from overuse takes 24-48 hours to be felt and why 1 or more rest days are necessary for healing between workouts/playing. Great advice on starting back gradually with soft training balls, alternate rest days, etc.

    Interesting that 51% of patients getting a cortisone shot see a return of primary symptoms, vs 5% in those that don't get a shot.
     
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  22. Chas Tennis

    Chas Tennis Hall of Fame

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    See also the links in Reply #8 on tendinitis & tendinosis.

    One thing about the review is that they are summarizing existing research, such as it is. Some of that research might be preliminary and involve small samples. There is not enough research as research expenditures are a very small fraction of the medical cost of these injuries.

    I have decided for myself that stopping tennis immediately when possible tendon injuries occur is probably the most effective approach and it reduces risk of chronic injury. I am now able to identify a few tendon injuries such as GE from how it feels because I have had it.

    Maybe soon some responsible organization will produce some research on what the initial response of an athlete with a possible tendon injury should be and the consequences otherwise. To have Drs inform patients to stop playing after they have had tennis elbow for 2-3 months is a very, very poor way to handle it.......

    For myself if I had chronic tennis elbow I would investigate eccentric exercises and see if I could find a knowledgeable Dr in that treatment. I would be be very conservative and not stress the tendons with any exercises or otherwise.
     
    Last edited: Jan 30, 2013
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  23. BeHappy

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    Has anyone here actually had a positive experience with eccentric excercises/prp or any of the currently in vogue treatments?
     
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  24. maleyoyo

    maleyoyo Rookie

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    From my own journey with both golfer and tennis elbows, I learn that you are your best doctor when it comes to this type of injury. There are many issues involved: knowledge, your own physiology + generic makeup, physical condition, technique, your game, equipments, nutrition, X factors…

    Unless your name is Fed or Nadal, no doctor(s) will spend the time and energy to sort out all these details for you, and all you’ll ever get are partial truths and bandage solutions which may or may not work for you.
    This is a breakdown of how I beat TE and GE:
    Technique (60%)
    Conditioning(20%)
    My game (10%)
    Others (10%)
    It takes time, money, dedication, and patience…lots of it.
     
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  25. mikeler

    mikeler G.O.A.T.

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    I've had good luck with ultrasound for GE and TE.
     
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  26. charliefedererer

    charliefedererer Legend

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    Using the Theraband Flexbar is a form of eccentric therapy - a very much less expensive form than the fancy machines that also result in eccentric therapy.

    If you go back through past threads on this forum, I think you will see a fair number who have reported success - although clearly it is not a cure all.

    Here is what the very respected Tod Ellenbecker wrote in his 2012 review article earlier referenced by Chas:

    "Elastic flexible bar (Thera-Band FlexBar, Hygenic Corp, Akron, Ohio) produces an eccentric overload to wrist and forearm musculature in patients with lateral humeral epicondylitis. A twisting exercise to eccentrically load the elbow extensor musculature showed superior results to traditional rehabilitation (Figure 2).75 Adaptation to medial humeral epicondylitis is also possible (Figure 3). The FlexBar preloads the wrist and finger musculature, followed by a slow eccentric contraction. Multiple sets of 15 repetitions are recommended75 with discomfort (visual analog scale levels 3-4).71

    Eighty-one patients with a 3-month history or greater (mean duration, 107 weeks) of chronic lateral elbow pain were randomly allocated to a concentric and eccentric exercise or control group for a 3-month period.58 Starting with a water container (1 kg for women; 2 kg for men), wrist flexion and extension were increased by one-tenth when subjects performed 45 repetitions (3 sets of 15 repetitions). After 3 months of training, 72% of the exercise group had a 30% reduction of pain with the maximal voluntary muscle provocation test, as compared with 44% in the control group."
    - http://sph.sagepub.com/content/early/2012/10/29/1941738112464761.full




    One of the problems with most of the other treatments is that when large numbers of patients are treated, there doesn't seem to be any advantage in the treatment compared to not doing the treatment.

    But "tennis elbow" has different degrees of severity and different stages from early inflammation to end stage burnt out scar tissue.

    And the exact way a treatment is administered varies from practitioner to practitioner.

    So this probably explains how a highly respected poster like Mikeler reports such a positive personal response to ultrasound, even though the likelihood of success does not sound promising reading the above review of all the studies:

    "Modalities are very helpful during this period; however, agreement on a superior modality does not exist.10,39,74 A meta-analysis of 185 studies on treatment of humeral epicondylitis showed glaring deficits in the scientific quality of the investigations, with no superior treatment approach.39 In a comprehensive review of the treatment for humeral epicondylitis, no significant difference was found with low-energy lasers, acupuncture, extracorporeal shockwave therapy, or steroid injection.10"
     
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  27. mikeler

    mikeler G.O.A.T.

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    The trigger point therapy workbook is also invaluable.
     
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  28. charliefedererer

    charliefedererer Legend

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    Interesting.

    And yet perhaps not surprising.

    Cortisone is such a powerful anti-inflammatory that it turns off the inflammatory response - so no pain!

    Isn't that great? - no pain!


    But of course in turning off the inflammatory response, there also no healing.

    No healing!?!

    Not so good.



    So there is an early return to tennis with no healing and continued bashing the ball.


    So is there really and surprise that 51% of those who get cortisone have a return in the severity of their symptoms, versus only 5% who did not get the cortisone shot?



    [Note:
    Even the above is probably an under estimation of the negative effects of cortisone.
    All the patients were under the care of a doctor and therapist - it should be clear from reading the Health and Fitness forum here that most do not go running to the doctor at the first little twinge in their elbow.
    So those getting the cortisone shot were only allowed to go back if their symptoms subsided.
    The shots didn't work in many (the cortisone is injected as best as possible around the inflamed site, but the liquid cortisone doesn't always settle around the inflamed tendon.
    So many were not allowed to return early after the injections(s) - hence they slowly got better over the 6 months.

    On the other hand, a 95% success rate with "conservative therapy" probably shocks those who have suffered from advanced cases of tennis elbow.
    But many with advanced cases never sought medical attention until their cases were very advanced.]
     
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  29. mikeler

    mikeler G.O.A.T.

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    I took the cortisone pills for my GE. It worked great for 3 weeks and I played tennis like a mad man pain free for that time period. After it wore off, my elbow hurt like never before. That is when I took 1.5 months off and did professional ultrasound therapy that got me back on the court.
     
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  30. BeHappy

    BeHappy Hall of Fame

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    Thanks for answering my post:

    A 30% improvement in pain and a 30% increased chance of a mild improvement in pain isn't that good is it?
     
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  31. Chas Tennis

    Chas Tennis Hall of Fame

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    In my opinion, the probability of curing tendinosis, once existing for a certain time, is not known. Certainly it has not been clearly explained to the public. See links in Reply #8. The existing research is hit and miss without that much clear concensus as to what an effective treatment, if any, is.

    Stop stressing the injury immediately is obvious.
     
    Last edited: Feb 1, 2013
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  32. BeHappy

    BeHappy Hall of Fame

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    One of your links shows that after 8 years 94% had recovered from chronic achilles tendinitis/osis/opathy/whatever.

    Since it's impossible they could have been resting their achilles' for 8 years, can you conclude that resting just alleviates short term symptoms of pain (aggravating the nerves in the scar tissue according to your other link), rather than actually speeding up recovery?

    Put another way, just because it hurts, that doesn't necessarily mean you aren't still healing? In which case maybe the best thing is to just ignore it and over the course of a decade it will gradually fade away?
     
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  33. Chas Tennis

    Chas Tennis Hall of Fame

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    I'm not confident in dealing with any of the tendon research that I see. I don't have enough credible information and I don't understand what I have. It often seems inconsistent and the research is often not from a neutral source. Some seems much more reasonable than others like the links in the earlier reply #8.

    Before I would consider the value of one conclusion such as the 8% number that you mention I would check out the original research, who sponsored it, how did they follow the parties for 8 years, usually a difficult thing for a study?, etc..

    By the way, eccentric treatment got much of its interest from some Achilles research in the early 2000's that seemed reasonable but preliminary. I believe that this is the report
    http://bjsm.bmj.com/content/38/1/8.full

    Also, just using the Achilles for normal motions has an eccentric nature to it. For example, lift foot, firm up Achilles & muscles and put all body weight on one Achilles. If it lengthens some, that is an eccentric contraction. Many times a day. For tennis elbow that type of exercise is not part of everyday life.

    I do believe probably that there are long term reductions in pain even with tendinosis but I have hardly seen any research on long term pathology.
     
    Last edited: Mar 16, 2013
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  34. Chas Tennis

    Chas Tennis Hall of Fame

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    My view is that if a chronic injury hurts with stress it may be because the injured part of the tendon is weakened. Worse, if the injured part of the tendon has poor strength and can't do its job, you may also be enlarging the volume of damaged tendon, farther injury. I sometimes view 'overuse' as probably meaning continually not allowing healing. Of course, I don't know, that is where research would be great.

    CF has posted many healing time gaphs and discussions associated with tendon injuries.
     
    Last edited: Feb 1, 2013
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  35. BeHappy

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    waste of breath
     
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  36. Chas Tennis

    Chas Tennis Hall of Fame

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    Yeah, it's a mess, we can agree.

    I believe more in avoiding high stress - large tensile forces that might tear the tendon - but not necessarily in any long term "rest". Remember that for TE, a tennis motion injured that same tendon by causing excessive tensile forces.

    You seem to be aware of the eccentric research. The Ellenbecker review and other sources seem to have a more positive view of the effectiveness of eccentric treatment than of some other treatments. But I don't clearly see its effectiveness. Also, many people that are injured want to exercise and stretch. Nobody knows if that is OK but a Dr who has examined them.

    Also, while the Flexibar seems like a well matched exercise for TE eccentric treatment I have not found a neutral source of research.
     
    Last edited: Feb 8, 2013
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  37. BeHappy

    BeHappy Hall of Fame

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    Well I'm going to try that theraband thing as it isn't that expensive, even though I tried eccentric excercise before and it didn't work
     
    Last edited: Feb 4, 2013
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  38. Chas Tennis

    Chas Tennis Hall of Fame

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    #38
  39. Chas Tennis

    Chas Tennis Hall of Fame

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  40. BeHappy

    BeHappy Hall of Fame

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    waste of breath
     
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  41. comeback

    comeback Professional

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    Hi Charlie, i tried everything and i am a certified trainer,4.5 tournament player and teaching pro..The flexbar is ok if your arm is 100% but if it is injured the flexbar will make it worse..i really had a bad case of TE but the glove rehabed it..as for your questions, there is another video https://www.youtube.com/watch?v=AVhlgBDy_F8
    which explains it better..email me if you have any further questions comeback@safe-mail.net
     
    Last edited: Feb 8, 2013
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  42. usta2050

    usta2050 Rookie

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    use gut and prokennex kinetic rackets and get a good coach (if u think ur techniqe is wrong)
     
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  43. the hack

    the hack New User

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    texas orthopedic hospital on main in the medical center is world class. many great doctors that specialize on the arm. Deep tissue massage on the arm has worked for me several times. A really good masseuse will find bad trigger points and hurt you but help you. 59# is kind of high on your string tension. Maybe you could drop it some. I have gone from 55 to 51 and now down to 47. lower tension really helped me. good luck.
     
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