Medical/Science Questions & Answers

What is Tennis Elbow?

Tennis Elbow has been called “lateral epicondylitis” since it occurs on the outside of the elbow and was previously thought to be inflammation of the tendon where it attaches to the outside of the elbow (lateral epicondyle). In actuality, it is not a true inflammation but is an abnormality of the tendon at that junction due to tiny tears of small tendon fibers. For this reason, it has been more accurately described as being a tendinosis rather than a tendonitis. The tiny tears occur when kinetic energy (“shock waves”) is transmitted from the hand and wrist repetitively to the elbow. The energy transmitted may exceed the tensile strength of the small tendon fibers and tears occur. Tensile strength is described as the “breaking point” of the tendon fiber. Improper technique has been described as causing a propensity to develop Tennis Elbow at least with playing tennis but Tennis Elbow may occur with perfect technique as well.

What is Golfer’s Elbow?
This is damage to the tendon on the inside of the elbow, similar to what happens on the outside of the elbow with “Tennis Elbow” (see above). This is also a tendinosis rather than a true tendonitis and occurs from the same root cause of Tennis Elbow in that the energy transmitted along the tendons from the fingers and wrist produce a “shock wave” at the elbow that exceeds the tensile strength of the tiny tendon fibers and micro-tears occur. The difference however, between Golfer’s and Tennis Elbow is that the tendons causing the former are the flexor tendons whereas those causing the latter are extensor tendons. Golfer’s Elbow can occur from playing tennis and from performing many household and work activities such as simply using a hammer.

What conditions mimic Tennis or Golfer’s Elbow?
Many conditions may mimic Tennis or Golfer’s Elbow. Orthopedic problems such as broken bones or tears of soft tissue different from the tendons at the lateral or medial epicondyles will cause elbow pain. There are many forms of arthritis that can affect the elbow. Bursitis also may mimic Tennis or Golfer's Elbow. Pinched nerves in the neck or elsewhere may cause pain in the elbow area. Finally, nerve entrapment near the elbow such as the ulnar nerve being pinched as if courses by the elbow may mimic Tennis or Golfer’s Elbow.

What causes Tennis or Golfer’s Elbow?
Tennis or Golfer’s Elbow may occur with playing either tennis or golf, using a hammer, or by holding an object or hitting implement that produces an energy wave or “shock “ from the hand and wrist along the forearm that is ultimately delivered to the outer or inner elbow. This usually is due to repetitive trauma to the elbow tendon but once present, it can be aggravated and perpetuated by even mild use of the hand. The shock up the forearm exceeds the tensile strength of very small tendon fibers and there are micro-tears. It is very rare for the tendon to tear or avulse completely. The tiny tears produce pain due to sensitive near endings.

How common is Tennis or Golfer’s Elbow?
It is estimated that there are over 10 million Tennis/Golfer's Elbow sufferers in the U.S. alone.

Who gets Tennis or Golfer’s Elbow?

People who engage in activities that direct force to the elbow along the tendons, those that overexert the forearm muscles and tendons either suddenly or from overuse have a greater tendency to suffer Tennis or Golfer’s Elbow. Direct injury to the elbow may also cause Tennis or Golfer’s Elbow. Tennis and Golfer’s Elbow affects people of all ages.

What are some of the known treatments for Tennis and Golfer’s Elbow?
Unfortunately, there are not many good large studies of treatment for Tennis or Golfer’s Elbow available. Initially, rest, elevation and ice may help. Anti-inflammatory and pain medication may help. Later on, physical therapy with various modalities may also help. Simple muscle strengthening and stretching exercises may also be of help. A recent treatment called the Tyler Twist Protocol, a physical therapy activity, has made some very positive claims. The use of elbow braces and straps may help but usually to mitigate the severity of recurrence after the sufferer has resumed the precipitating activity. Powerful ultrasound treatments, similar to those used to break up kidney stones may help in some cases. Injections of cortisone helps some. Surgery is a last resort and results have been mixed. One recent study showed good improvement with injecting PRP or platelet rich plasma into many areas of the elbow tendon at its insertion on the epicondyle. This is when blood is drawn from the patient and spun down and the part containing platelets is removed and injected into the elbow. During the procedure, many perforations of the tendon were performed and the study was done under ultrasonic guidance. Other treatments include Botox injections into the painful tendon, low level pulsed ultrasound, low level laser therapy, acupuncture, electrical stimulation, elbow immobilization for two to three weeks, among many others.

The plethora of treatments advocated is indicative of the high degree of difficulty in treating these conditions.

Up until now what has been shown to prevent Tennis or Golfer’s Elbow?
Decreased time performing the activity that aggravates or causes the Tennis or Golfer's Elbow may help prevent its recurrence. Using proper equipment may help. Some arm strengthening exercises may help as well. Using an elbow brace or strap may help to decrease the severity of recurrence of Tennis or Golfer’s Elbow.

Prevention is the key and is even more difficult than treatment since most people eventually improve by stopping the inciting activity. The real problem is that the inciting activity is often very pleasurable, helps the person stay healthy, and/or provides his or her livelihood. So ultimately, many sufferers experience a recurrence of symptoms after resumption of the inciting activity.

The area of prevention of recurrence may be one of the greatest strengths of the Shock Blocker.™

What is the TTR System and how does it work?
Kinetic Energy  (KE) transferring along a string is equal to half the mass (m) of the string times the square of the velocity (v) of the wave being propagated down that string. Our "string" of course is a tendon. 

So the formula is KE = (m)(v)(v)/2.
Wave velocity (v) is defined as the square root of [(string Tension) x (string Length) divided by (string mass)]. The formula for velocity squared is therefore (v)(v) =  TL/m.

Substituting the second formula for wave velocity squared into the first formula yields 
KE = (m)(T)(L)/(m)(2) = TL/2.
Therefore, Kinetic energy = TL/2. 
The tendon length roughly stays the same so the Kinetic Energy transmitted along a tendon to the point of connection at a joint such as an elbow is directly proportional to the tension (T) of the tendon.

The forearm tendons are either extensor tendons (lifts up a finger or the wrist) or flexor tendons (bends finger and bends the wrist downward). These tendons attach either to the fingers or the wrist but no one tendon attaches to both. The tendons that attach to the fingers go over or under the metacarpal phalangeal  (MCP) joints which are the large knuckles of the hands. 

When we make a fist or grasp an object with the hand, the MCP is bent or flexed. This creates a pulley for both those extensor and flexor tendons that attach to fingers. The less bent the MCP joint is, the looser the flexor and extensor tendons are. The degree of wrist bending or extension also has a great effect on the tension of the flexor and extensor tendons but in a different sense. Passively flexing the wrist increases tension on the forearm extensor tendons while simultaneously lowering tension in the forearm flexor tendons. Passively extending (also called dorsiflexing) the wrist does the opposite: it increases forearm flexor tendon tension while lowering forearm extensor tendon tension.

Focusing on the ring device for now, the Sorbothane® ring has elasticity but a finite compressibility which ultimately lifts up the proximal finger from the surface being grasped (hammer, tennis racquet handle, etc.). By doing so it creates less of an acute angle of the MCP and therefore less pulley tension on the extensor and flexor tensions. This lowers the string or tendon tension and therefore directly lowers the kinetic energy being transmitted along the tendon to the elbow. This is an effect which is in addition to and separate from any vibration dampening effect of the Sorbothane ring. 

This is the TTR System and is selective for the finger upon which the ring is placed. This selectivity is critical since fingers without rings will be able to exert more force so that the object being grasped will not fall out of the hand. Since pressure = force/area (P=F/A)  the fingers that are not required to have rings placed on them will enable the person to adequately hold the object. If we uniformly enlarge a grip of a hammer or tennis racquet too much, then we will lose the grasp on the object. This is the beauty of being able to place the ring on the specific finger or fingers in our efforts to abate the forces responsible for a medial or lateral epicondylitis.