How Long After Elbow Tendon Injury Can I Play Sports Again
Sports Health. 2013 Mar; v(ii): 186–194.
Current Concepts in Test and Treatment of Elbow Tendon Injury
Todd S. Ellenbecker
†Physiotherapy Assembly, Scottsdale Sports Clinic, Scottsdale, Arizona
Robert Nirschl
‡Nirschl Orthopaedic Eye for Sports Medicine and Joint Reconstruction, Arlington, Virginia
Per Renstrom
§Centre for Sports Trauma Inquiry, Karolinska Constitute, Stockholm, Sweden
Abstruse
Context:
Injuries to the tendons of the elbow occur often in the overhead athlete, creating a pregnant loss of office and dilemma to sports medicine professionals. A detailed review of the anatomy, etiology, and pathophysiology of tendon injury coupled with comprehensive evaluation and treatment information is needed for clinicians to optimally blueprint treatment programs for rehabilitation and prevention.
Evidence Acquisitions:
The PubMed database was searched in January 2012 for English-language articles pertaining to elbow tendon injury.
Results:
Detailed data on tendon pathophysiology was found forth with incidence of elbow injury in overhead athletes. Several prove-based reviews were identified, providing a thorough review of the recommended rehabilitation for elbow tendon injury.
Conclusions:
Humeral epicondylitis is an actress-articular tendon injury that is mutual in athletes subjected to repetitive upper extremity loading. Enquiry is limited on the identification of handling modalities that can reduce pain and restore function to the elbow. Eccentric do has been studied in several investigations and, when coupled with a complete upper extremity strengthening programme, tin produce positive results in patients with elbow tendon injury. Further enquiry is needed in high-level study to delineate optimal treatment methods.
Keywords: humeral epicondylitis, rehabilitation, elbow tendon injury
Tendon injuries to the human being elbow occur frequently, especially in the overhead athlete due to the repetitive loads and forceful muscular activations inherent in throwing, hitting, serving, and spiking.26,63 The most mutual injuries in the athletic elbow include humeral epicondylitis, valgus extension overload, and ulnar collateral ligament injury.21,52 The initial upper extremity evaluation, including baseline radiographs and clinical testing of the entire upper extremity kinetic chain, forms the critical first step in early on recognition and diagnosis of elbow injury and allows for the evolution of a comprehensive rehabilitation to restore function.
Etiology and Pathophysiology of Tendon Injury
One of the nigh common tendon injuries of the elbow is humeral epicondylitis,53,55 referred to as "tennis elbow," "golfer's elbow," and "thrower's elbow" by laypersons and the sports medicine literature. The repetitive overuse is peculiarly axiomatic in the history of many athletic patients with elbow tendon injury. Classic epidemiological enquiry on adult tennis players shows incidences ranging from 35% to 50%.12,32,35,36,38,59 This incidence is actually far greater than in elite-level junior tennis players (11%-12%).81
As early equally 1873, Runge described humeral epicondylitis, or "tennis elbow," as it is more popularly known.62 Cyriax and Cyriax in 1936, listed 26 causes of tennis elbow,14 while an all-encompassing study by Goldie in 1964 reported hypervascularization of the extensor aponeurosis and increased free nerve endings in the subtendinous space.29 Leadbetterforty later described humeral epicondylitis as a degenerative time-dependent process including vascular, chemic, and cellular events that atomic number 82 to a failure of the cell matrix healing response in human tendon. This clarification of tendon injury differs from earlier theories where an inflammatory response was considered a primary factor; hence, the term tendonitis was used, as opposed to the term recommended by Leadbetter40 and Nirschl and Sobel.53
Humeral epicondylitis is an extra-articular tendinous injury characterized by excessive vascular granulation and an impaired healing response in the tendon, "angiofibroblastic hyperplasia."52,51,55 In a thorough histopathological analysis, specimens of injured tendon from areas of chronic overuse did not incorporate large numbers of lymphocytes, macrophages, and neutrophils.38 Instead, tendinosis is a degenerative process characterized by large populations of fibroblasts, disorganized collagen, and vascular hyperplasia.38 It is non articulate why tendinosis is painful, lacks inflammatory cells, and does not mature. The primary tendon in lateral humeral epicondylitis is the extensor carpi radialis brevis.52-53,55 Approximately 1-third of cases involve the tendon of the extensor communis.38 The extensor carpi radialis longus and extensor carpi ulnaris can be involved equally well. The master sites of medial humeral epicondylitis are the flexor carpi radialis, pronator teres, and flexor carpi ulnaris tendons.52-53,55 The incidence of lateral humeral epicondylitis is far greater than that of medial epicondylitis in recreational tennis players and in the leading arm (left arm in a right-handed golfer), while medial humeral epicondylitis is far more common in elite tennis players and throwing athletes due to the powerful loading of the flexor and pronator muscle tendon units during the valgus extension overload inherent in the acceleration phase of those overhead movement patterns.52-53,55 The trailing arm of the golfer (right arm in a right-handed golfer) is more than likely to have medial symptoms than lateral.
Mechanical loading of tendon tissue is anabolic by upregulating collagen cistron expression and increasing synthesis of collagen proteins peaking 24 hours after exercise and remaining elevated for upwards to seventy to 80 hours.33,48 However, exercise also degrades collagen proteins. This results in a net loss of collagen 24 to 36 hours after training, followed by a cyberspace gain in collagen.44 Thus, a restitution time interval between practise bouts is critical for the tissue to adapt and avert a net catabolic state of affairs. The tissue's adaptive factors are linked to tenocytes, extracellular matrix, and nerve receptors.44
Repetitive strain causes tenocytes to produce inflammatory molecules and engenders microrupture of collagen fibrils.78 Increased inflammatory mediators (eg, prostaglandin E2 [PGE2]) are found in tendons later repetitive mechanical loading.78 Intratendinous injections of PGE2 cause intense degenerative changes, and peritendinous injections of PGE1 result in a histological blueprint of tendinopathy.36,70 Today, several studies confirm an inflammatory background in tendinopathy: granulation of capillary vessels and an inflammatory infiltrate of macrophages, mast cells, and B and T lymphocytes.46,66 Inflammatory cells activate a pour of proinflammatory cytokines (eg, interleukin-eighteen, -15, and -6) found in tendinopathy.47
Tendon cells and fibroblasts, subjected to repetitive mechanical stress in combination with proinflammatory cytokines and transforming growth gene β (TGF-β) stimulation tin transform into myofibroblasts.72 Myofibroblasts are important for tendon healing, mayhap for tissue adaptation.72 Later healing is completed and the mechanical stress is released on the myofibroblasts, these cells undergo programmed cell death (apoptosis).72 If this machinery fails, the myofibroblasts will propagate a hyperproliferative process: fibrosis—a prominent feature of tendinopathy.72
Another factor that may crusade fibroblast hyperproliferation is hypoxia.27 This upregulates matrix metalloproteinases, which alters the material properties of tendon.threescore Hypoxia upregulates vascular endothelial growth factor, increasing microvessel ingrowth (angiogenesis), a major finding in tendinopathy.60
Angiogenesis may cause pain since sclerotherapy relieves pain in tendinopathy.54 However, blood vessels per se are non painful, but ingrowth of sensory nerve fibers in tendinopathic patients may be.1,41,66 Salubrious nonpainful tendons are almost aneuronal.1,41 Chronic painful tendons show ingrowth of sensory nerves from the paratenon with release of nociceptive substances.1,41,76 Restricting pathological nervus ingrowth by denervation (eg, mini-invasive surgery or release of the paratenon) can relieve pain.76
Sensory nerve ingrowth in the tendon may be a reaction to repetitive loading and a response to injury.45 In normal tendon repair, sensory nerve ingrowth correlates with increased nociception, followed by autonomic nerve ingrowth, coinciding with decreased nociception and subsequent nerve retraction.one,2 In tendinopathy, the ingrown sensory nerves do not retract.41 Neuronal dysregulation, characterized by aberrant sensory nerve sprouting, may reflect a failed healing response, increased pain signaling, and the hyperproliferation of tendinopathy.41
In addition to pain transmission, peripheral nervus fibers react to mechanical stimuli and release several chemical substances in healing and homeostasis. During prolonged release, these cause fibrosis.2 Essential neuromediators are present in tendon.2,67 Tendinopathic tendons exhibit increased sensory neuropeptide substance P (SP), which plays a role in nociception and proinflammatory and trophic actions.2,3,41,66 SP regulates vasodilation, plasma extravasation, and release of cytokines past binding to neurokinin 1 in tendon and is upregulated by loading.2,6,xi,34,42,65 SP stimulates proliferation of fibroblasts and endothelial cells and may transform fibroblasts into myofibroblasts by increasing the production of TGF-β in fibroblasts.2,34 Upregulation of SP may contribute to tendinosis—that is, fibrosis (tenocyte transformation, hypercellularity, and hypervascularization).
The neurotransmitter glutamate and its receptor, NMDAR1, are in morphologically transformed tenocytes, endothelial and adventitial layers of neovessel walls, and sprouting nervus fibers.4,49,64
Anatomic Adaptations of the Throwing Athlete'due south Elbow with Ramifications for Rehabilitation
Adaptation occurs in the overhead athlete'southward elbow in range of motion, laxity, and muscular compensation. Comparison to the contralateral nondominant extremity is often complicated by these asymmetric anatomic developments.
Range of Motion Adaptations
Fifty percent of pitchers have a flexion contracture of the ascendant elbow, with 30% demonstrating a cubitus valgus deformity.37 Elbow flexion contractures averaging 5° were common in 40 healthy professional baseball pitchers.22 Directly related to elbow function was wrist flexibility, which was three° less on the dominant arm for extension and iii° greater on the dominant side for flexion compared with the nondominant extremity.22 In 33 throwing athletes prior to the competitive flavour, the average loss of elbow extension was vii°, and the average loss of flexion was five.5°.82
Several studies have shown consistent alterations of shoulder rotation in the overhead athlete, with statistically greater dominant shoulder external rotation and less internal rotation in professional person baseball pitchers.24,68,80 Despite these differences in internal and external rotation, the total rotation (internal + external) betwixt extremities remained equal such that whatever increases in external rotation were matched past decreases in internal rotation in this uninjured population. Elite-level tennis players had significantly less internal rotation and no pregnant departure in external rotation on the ascendant arm, as well as an overall decrease in total rotation range of motility on the ascendant arm of approximately 10°.24 Conscientious monitoring of glenohumeral range of motion is recommended for the athlete with an elbow injury. Decreases in ascendant arm internal rotation (glenohumeral internal rotation deficits) often occur in throwing athletes with ulnar collateral ligament injury.16 The comprehensive evaluation of the throwing athlete must include measurement of shoulder internal and external rotation with 90° of abduction, scapular stabilization, and management of internal rotation range of move loss.24
Ligamentous Laxity
Manual examination of the elbow for medial and lateral laxity can exist challenging; humeral rotation and small increases in joint opening are frequently present with ulnar collateral ligament injury. A critical-level increment of 0.v mm in medial elbow articulation opening in elbows with ulnar collateral ligament injury has been suggested with stress radiography.61 Increases in medial joint laxity can increase stress to the medial muscle tendon units to compensate for medial ligamentous laxity.v
Muscular Adaptations: Wrist and Forearm Forcefulness Profiles in Elite Throwing Athletes
Professional throwing athletes have significantly greater wrist flexion and forearm pronation strength on the dominant arm (15%-35%) compared with the nondominant extremity with no difference in wrist extension or forearm supination strength betwixt extremities.21 In professional baseball pitchers, there is 10% to xx% greater elbow flexion strength on the ascendant arm, as well as 5% to fifteen% greater elbow extension strength.79
Clinical Evaluation of the Athlete'south Elbow
A thorough evaluation of the athlete's elbow is necessary to rule out other concomitant injured structures and, most important, to identify the underlying crusade of the tendon injury. Evaluation of the entire upper extremity kinetic chain with a particular focus on shoulder and scapular strength, motion, and stabilization, coupled with diagnostic imaging and clinical tests for the distal upper extremity, is needed (Figure ane). Overuse injuries in the elbow frequently occur with shoulder or scapular dysfunction.xviii,21,43,l,52,55
Example of scapular pathology seen in an aristocracy junior tennis player with medial elbow pain on clinical exam.
Nonoperative Treatment Concepts
Based on the healing response of the human tendon, several specific phases can exist followed during nonoperative handling of elbow tendinosis: protected function, total arm strength, and return to activity. Each plays a critical function in the comprehensive treatment of elbow tendinosis.
Protected Office
During this first phase, care is taken to protect the injured muscle tendon unit of measurement from stress but non from role. Often, all sport activity must terminate temporarily to let the muscle tendon unit of measurement time to heal and to allow formal rehabilitation to progress. Immobilization can atrophy the musculature and negatively affect the upper extremity kinetic concatenation.51,55 Abeyance of throwing and serving for medial-based humeral symptoms is indicated. Allowing batting and fielding activities in baseball or hitting double-handed backhands in lawn tennis continues activity while minimizing stress to the injured expanse. Continued work or sports may slow the progression of resistive practise and physical therapy.
Modalities are very helpful during this period; withal, understanding on a superior modality does non 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
Cortisone injection has been used during the hurting-reduction stage of recalcitrant conditions. Traditional physical therapy and cortisone injection were compared in 70 patients with humeral epicondylitis.15 The cortisone injection produced initial relief in 91% of patients compared to 47% undergoing concrete therapy. After 3 months, 51% of the cortisone injection group and merely 5% in the physical therapy grouping had a render of primary symptoms. Similar findings were reported with Mills manipulation and cross-friction massage and corticosteroid injection in a prospective randomized controlled clinical trial in 106 patients with humeral epicondylitis.77 At 1 year, there were no differences between treatment groups.
In a double-blind randomized controlled trial of autologous platelet-rich plasma in patients with humeral epicondylitis, 49% had a successful response (25% reduction in visual analog score and Disabilities of the Arm, Shoulder and Hand score) in the cortisone group compared with 73% in the platelet-rich plasma group.56
In 199 patients with humeral epicondylitis treated with iontophoresis with dexamethasone, 52% improved, with only 33% of the placebo group reporting improvement after ii days.52 At that place was no statistical difference in the overall improvement 1 month following treatment. Greater pain relief was seen with six treatments in a 10-day menstruation.
In a multicenter prospective randomized control study, extracorporeal shockwave therapy was ineffective in 272 patients with humeral epicondylitis.31 Similarly, low-intensity Nd:YAG laser irradiation at vii points along the forearm, 3 times a week for 4 weeks, was ineffective.8
A standardized modality or modality sequence has not been identified that is statistically more than effective. Cryotherapy post-obit increases in daily activity is recommended.51,55 Therapeutic modalities and cortisone injection can only be one part of the handling sequence; increasing evidence favors progressive resistive exercise.13,28,57,71,75
30-eight patients with lateral humeral epicondylitis were randomly assigned to a contract-relax stretching or eccentric do treatment group.71 Seventy-one percent reported full recovery in the eccentric practise group, with 39% in the contract-relax stretching group. Eccentric exercise produced a significant reduction in pain and eliminated force deficits in the wrist extensors and forearm supinators.xiii
Rubberband flexible bar (Thera-Ring 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 (Effigy 3). The FlexBar preloads the wrist and finger musculature, followed by a slow eccentric contraction. Multiple sets of xv repetitions are recommended75 with discomfort (visual analog scale levels 3-iv).71
Tyler twist for lateral humeral epicondylitis includes eccentric loading of the wrist extensors moving from a position of wrist extension to wrist flexion.
Tyler twist for medial humeral epicondylitis includes eccentric loading of the wrist flexors moving from a position of wrist flexion to wrist extension.
80-1 patients with a 3-month history or greater (mean elapsing, 107 weeks) of chronic lateral elbow pain were randomly allocated to a concentric and eccentric exercise or command grouping for a 3-month period.58 Starting with a water container (ane kg for women; 2 kg for men), wrist flexion and extension were increased by one-tenth when subjects performed 45 repetitions (three sets of xv repetitions). After 3 months of preparation, 72% of the exercise group had a 30% reduction of pain with the maximal voluntary muscle provocation examination, as compared with 44% in the control group.
Specific Applications of Exercise for Elbow Tendon Rehabilitation: Total Arm Strength Rehabilitation Approach
Resistive exercise for humeral epicondylitis focuses on the principle that "proximal stability is needed to promote distal mobility."69 Initially, focus is on the rotator gage and scapular musculature (Table 1).vii,9,17-nineteen,23,73 A low-resistance, high-repetition exercise format (ie, 3 sets of fifteen-20 repetitions) is followed to better strength and local muscular endurance.25 Gage weights allow rotator cuff and scapular exercises to be performed with the weight proximal to the elbow to minimize overload at the elbow and forearm.
Table 1.
Proximal exercises used in rehabilitation of elbow tendon injury.
| Side-lying external rotation |
| Prone extension with external humeral rotation (thumb-out position) |
| Prone horizontal abduction with external humeral rotation (thumb-out position) |
| Decumbent external rotation with scapular retraction |
| Scaption (scapular airplane pinnacle with thumb-upwards position) |
| External rotation with scapular retraction (standing with elastic resistance) |
| Supine serratus punch |
Distal Upper Extremity Exercise
Initially (for lateral elbow tendon injury) practice of the distal extremity stresses the injured muscle-tendon unit of measurement last: wrist flexion and forearm pronation. Gradual addition of wrist extension and forearm supination, as well as radial and ulnar divergence exercises, are added as signs and symptoms permit. Initially, near patients tolerate the exercises better in slight elbow flexion with light weights. Eccentric exercise may have a greater benefit than the concentric portion.13,71 Multiple sets of 15 to twenty repetitions are recommended to promote muscular endurance.
Once the patient tolerates the most basic series of distal exercises, simultaneous wrinkle of the wrist and forearm musculature is added during elbow flexion/extension (brawl dribbling [Bodyblade, Hymanson, Texas]; FlexBar oscillation [Thera-Band]; seated rowing). Additionally, closed kinetic concatenation exercises (quadruped rhythmic stabilization) are added to promote cocontraction and mimic functional positions with joint approximation.20 Gentle passive stretching and supine combined stretches are indicated to optimize the muscle tendon unit length to elongate the biarticular muscle tendon units of the elbow, forearm, and wrist using a combination of shoulder, elbow, wrist, and forearm positions.21
When the patient tolerates the distal isotonic do progression pain-costless (3-5 lb or medium elastic tubing or bands) and oscillatory-type exercises, he or she progresses to isokinetic and plyometric exercise (Effigy 4). Contractile velocities ranging betwixt 180° and 300° per 2d with 5 or half-dozen sets of 15 to 20 repetitions are used to foster local muscular endurance25 in athletic patients with slower contractile velocities (120° to 210° per second). Plyometric wrist snaps (Figure 5) and wrist flips (Figure six) train the active elbow for functional and sport-specific demands.79
Isokinetic wrist extension/flexion practise setup used during rehabilitation of humeral epicondylitis.
Wrist snaps using a plyo ball to improve wrist and forearm strength.
Wrist flips using a plyo ball to amend wrist and forearm strength.
Return to Activity
The return-to-activity phase is often ignored or cut short, resulting in serious consequences or reinjury (Table 2). Objective criteria for this phase are strength equal to the contralateral extremity and a pain-free range of movement.
Table 2.
Nirschl tendonosis pain phases.
| Phase 1: Mild pain afterward exercise activity, resolves within 24 hours |
| Stage two: Pain later on exercise activity, exceeds 48 hours, resolves with warm-up |
| Phase 3: Pain with exercise activeness that does not alter activity |
| Phase iv: Hurting with exercise action that alters activity |
| Phase 5: Hurting caused past heavy activities of daily living |
| Phase half-dozen: Intermittent pain at residue that does non disturb sleep, hurting acquired past low-cal activities of daily living |
| Stage vii: Abiding residue pain (dull aching) and pain that disturbs sleep |
Interval sport return programs utilize alternating days, gradual progressions of intensity, and repetitions of sport activities. For the interval tennis plan, low-compression tennis balls decrease impact stress and increase the tolerance of action (Effigy 7). Supervision of the interval programme allows for biomechanical evaluation and guards confronting overzealous intensity levels, a common error in well-intentioned, motivated patients. The alternate-day return plan, with residue betwixt sessions, enhances recovery and decreases reinjury.21,23,79
Examples of low-pinch lawn tennis assurance that can be used to decrease impact shock during the interval tennis program. These balls are available commercially.
Inspection and modification of the patient'southward lawn tennis racquet or golf clubs is of import. Lowering the cord tension and a softer string (coreless multifilament synthetic string or gut) are widely recommended for patients with upper extremity injuries.18,51,53,55 Grip size is also very important, as muscular activity changes can change handle or grip size.three Proper grip size should correspond to the altitude measured with a tape from the distal tip of the ring finger, along the radial border of the finger, to the proximal palmar crease or allow for the width of the contralateral 5th finger to be placed between the thenar eminence and the longest finger while gripping the racquet21,51,53,55 (Effigy 8). A counterforce brace tin decrease stress on the insertion of the flexor and extensor tendons during piece of work or sport activity.thirty
Apply of the contralateral fifth digit to gauge proper grip size. The width of the fifth digit should fit between the longest finger and the thenar eminence in an optimally sized tennis racquet grip.
The biological goals of nonoperative physiotherapy are neovascular enhancement and mature collagen production with associated comeback in muscular strength, endurance, and flexibility. Failure of a quality program may warrant surgical intervention. Nigh patients with elbow tendinosis respond to the nonoperative program.
Surgical Concepts
The principles of surgical intervention are full excision of the unhealthy pain producing angiofibroblastic tendinosis tissue, enhancement of vascular access to the surgical site, and preservation of normal tissue.51 Techniques that fail to place and excise tendinosis tissue and release normal tendons are not recommended. Failed surgery is well-nigh always related to inadequate excision of tendinosis tissue with or without excessive release of normal tissue (eg, lateral epicondyle, extensor digitorum communis, and lateral ligaments).51,54 The mini-open techniques have reported success rates of 95% and 97% for medial and lateral tissue, respectively.55 The key pathological tissues are in the extensor carpi radialis brevis and extensor digitorum communis lateral, pronator teres and flexor carpi radialis medial, triceps posterior, and distal biceps anterior.51,55
Ulnar nerve neurapraxia is oft associated (fifty%) with medial elbow tendinosis and may require decompression of the cubital tunnel.51,55
Summary
Identifying the specific tendon pathology and understanding the healing mechanism will help clinicians guide patients through the rehabilitation process.
Footnotes
The following authors declared potential conflicts of interest: Todd South. Ellenbecker, DPT, MS, SCS, OCS, CSCS, is a consultant for the Theraband Inquiry Advisory Committee and is an employee of the Physiotherapy Associates Scottsdale Sports Clinic and the ATP World Bout; Robert Nirschl, Md, is a corporate officer at Medical Sports Inc., a stock holder at Tenex Corp., and received grants from Smith & Nephew; Per Renstrom, MD, PhD, received payments and royalties for published work and university lectures.
References
1. Ackermann Pow, Li J, Lundeberg T, Kreicbergs A. Neuronal plasticity in relation to nociception and healing of rat achilles tendon. J Orthop Res. 2003;21(iii):432-441 [PubMed] [Google Scholar]
ii. Ackermann PW, Salo PT, Hart DA. Neuronal pathways in tendon healing. Front end Biosci. 2009;14:5165-5187 [PubMed] [Google Scholar]
3. Adelsberg S. An EMG assay of selected muscles with rackets of increasing grip size. Am J Sports Med. 1986;14:139-142 [PubMed] [Google Scholar]
4. Alfredson H, Forsgren Southward, Thorsen K, Fahlstrom M, Johansson H, Lorentzon R. Glutamate NMDAR1 receptors localised to nerves in human Achilles tendons: implications for treatment? Genu Surg Sports Traumatol Arthrosc. 2001;9(two):123-126 [PubMed] [Google Scholar]
5. An KN, Hui FC, Morrey BF, Linscheid RL, Chao EY. Muscles across the elbow joint: a biomechanical analysis. J Biomech. 1981;fourteen:659-669 [PubMed] [Google Scholar]
half dozen. Andersson G, Danielson P, Alfredson H, Forsgren Due south. Presence of substance P and the neurokinin-1 receptor in tenocytes of the human being Achilles tendon. Regul Pept. 2008;150(i-iii):81-87 [PubMed] [Google Scholar]
7. Ballentyne BT, O'Hare SJ, Paschall JL, et al. Electromyographic activity of selected shoulder muscles in commonly used therapeutic exercises. Phys Ther. 1993;73:668-682 [PubMed] [Google Scholar]
viii. Basford JR, Sheffield CG, Cieslak KR. Laser therapy: a randomized, controlled trial of the effects of depression intensity Nd:YAG laser irradiation on lateral epicondylitis. Arch Phys Med Rehabil. 2000;81:1504-1510 [PubMed] [Google Scholar]
9. Blackburn TA, McLeod WD, White B, et al. EMG analysis of posterior rotator cuff exercises. J Athl Train. 1990;25:forty-45 [Google Scholar]
ten. Boyer MI, Hastings H. Lateral lawn tennis elbow: is at that place any science out at that place? J Shoulder Elbow Surg. 1999;8:481-491 [PubMed] [Google Scholar]
xi. Bring DKI, Reno C, Renstrom P, Salo P, Hart DA, Ackermann PW. Joint immobilization reduces the expression of sensory neuropeptide receptors and impairs healing after tendon rupture in a rat model. J Orthop Res. 2009;27(2):274-280 [PubMed] [Google Scholar]
13. Croisier JL, Foidart-Dessalle 1000, Tinant F, et al. An isokinetic eccentric program for the direction of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007;41:269-275 [PMC free article] [PubMed] [Google Scholar]
14. Cyriax JH, Cyriax PJ. Illustrated Manual of Orthopaedic Medicine. London, Britain: Butterworth; 1983 [Google Scholar]
15. Dijs H, Mortier G, Driessens Yard, DeRidder A, Willems J, Devroey T. A retrospective study of the bourgeois treatment of tennis elbow. Medica Physica. 1990;13:73-77 [PubMed] [Google Scholar]
16. Dines JS, Frank JB, Akerman K, et al. Glenohumeral internal rotation deficits in baseball players with ulnar collateral ligament deficiency. Am J Sports Med. 2009;37(three):566-570 [PubMed] [Google Scholar]
17. Ekstrom RA, Donatelli RA, Soderberg GL. Surface electromyographic assay of exercises for the trapezius and serratus inductive muscles. J Orthop Sports Phys Ther. 2003;33(5):247-258 [PubMed] [Google Scholar]
18. Ellenbecker TS. Rehabilitation of shoulder and elbow injuries in lawn tennis players. Clin Sports Med. 1995;14:87. [PubMed] [Google Scholar]
xix. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an prove based review. Br J Sports Med. 2010;44:319-327 [PubMed] [Google Scholar]
twenty. Ellenbecker TS, Davies GJ. Airtight Kinetic Concatenation Practise: A Comprehensive Guide to Multiple Joint Exercises. Champaign, IL: Human Kinetics; 2001 [Google Scholar]
21. Ellenbecker TS, Mattalino AJ. The Elbow in Sport. Champaign, IL: Human being Kinetics; 1997 [Google Scholar]
22. Ellenbecker TS, Mattalino AJ, Elam EA, et al. Medial elbow laxity in professional baseball pitchers: a bilateral comparing using stress radiography. Am J Sports Med. 1998;26(3):420-424 [PubMed] [Google Scholar]
23. Ellenbecker TS, Reinold MM, Nelson CO. Clinical concepts for treatment of the elbow in the adolescent overhead athlete. Clin Sports Med. 2010;29(4):705-724 [PubMed] [Google Scholar]
24. Ellenbecker TS, Roetert EP, Bailie DS, Davies GJ, Brownish SW. Glenohumeral joint full rotation range of movement in elite tennis players and baseball pitchers. Med Sci Sports Exerc. 2002;34(12):2052-2056 [PubMed] [Google Scholar]
25. Fleck S, Kraemer West. Designing Resistance Training Programs. Champaign, IL: Human Kinetics; 2004 [Google Scholar]
26. Fleisig GS, Andrews JR, Dillman CJ, et al. Kinetics of baseball pitching with implications nearly injury mechanisms. Am J Sports Med. 1995;23:233. [PubMed] [Google Scholar]
27. Freeman TA, Parvizi J, Dela Valle CJ, Steinbeck MJ. Mast cells and hypoxia drive tissue metaplasia and heterotopic ossification in idiopathic arthrofibrosis after total articulatio genus arthroplasty. Fibrogenesis Tissue Repair. 2010;3:17. [PMC free commodity] [PubMed] [Google Scholar]
28. Gam AN, Warming S, Larsen LH, et al. Handling of myofascial trigger points with ultrasound combined with massage and exercise: a randomized controlled trial. Pain. 1998;77(1):73-79 [PubMed] [Google Scholar]
29. Goldie I. Epicondylitis lateralis humeri. Acta Chir Scand Suppl. 1964;339:1. [PubMed] [Google Scholar]
30. Groppel JL, Nirschl RP. A biomechanical and electromyographical analysis of the effects of counter force braces on the tennis player. Am J Sports Med. 1986;14:195-200 [PubMed] [Google Scholar]
31. Haake M, Konig IR, Decker T, et al. Extracorporeal shock wave therapy in the handling of lateral epicondylitis: a randomized multi-eye study. J Bone Articulation Surgery Am. 2002;84:1982-1991 [PubMed] [Google Scholar]
32. Hang YS, Peng SM. An epidemiological report of upper extremity injury in tennis players with particular reference to lawn tennis elbow. J Formos Med Assoc. 1984;83:307-316 [PubMed] [Google Scholar]
33. Heinemeier KM, Olesen JL, Haddad F, et al. Expression of collagen and related growth factors in rat tendon and skeletal muscle in response to specific contraction types. J Physiol. 2007;582(pt 3):1303-1316 [PMC free commodity] [PubMed] [Google Scholar]
34. Hoffmann P, Hoeck K, Deters Due south, Werner-Martini I, Schmidt WE. Substance P and calcitonin gene related peptide induce TGF-alpha expression in epithelial cells via mast cells and fibroblasts. Regul Pept. 2010;161(1-3):33-37 [PubMed] [Google Scholar]
35. Kamien M. A rational direction of tennis elbow. Sports Med. 1990;nine:173-191 [PubMed] [Google Scholar]
36. Khan MH, Li Z, Wang JH. Repeated exposure of tendon to prostaglandin-E2 leads to localized tendon degeneration. Clin J Sport Med. 2005;fifteen(i):27-33 [PubMed] [Google Scholar]
37. King JW, Brelsford HJ, Tullos HS. Analysis of the pitching arm of the professional baseball bullpen. Clin Orthop Relat Res. 1969;67:116-123 [PubMed] [Google Scholar]
38. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (lawn tennis elbow). Clinical features and findings of histopathological, immunohistochemical and electron microscopy studies. J Bone Joint Surg Am. 1999;81:259-278 [PubMed] [Google Scholar]
39. Labelle H, Guibert R, Joncas J, Newman North, Fallaha M, Rivard CH. Lack of scientific testify for the handling of lateral epicondylitis of the elbow. J Bone Joint Surg Br. 1992;74:646-651 [PubMed] [Google Scholar]
40. Leadbetter WB. Cell matrix response in tendon injury. Clin Sports Med. 1992;11:533-579 [PubMed] [Google Scholar]
41. Lian O, Dahl J, Ackermann PW, Frihagen F, Engebretsen L, Bahr R. Pronociceptive and antinociceptive neuromediators in patellar tendinopathy. Am J Sports Med. 2006;34(11):1801-1808 [PubMed] [Google Scholar]
42. Ljung BO, Alfredson H, Forsgren S. Neurokinin ane-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyles of the humerus: studies on tennis elbow and medial epicondylalgia. J Orthop Res. 2004;22(ii):321-327 [PubMed] [Google Scholar]
43. Magee DJ. Orthopedic Concrete Assessment. 3rd ed. Philadelphia, PA: Saunders; 1997 [Google Scholar]
44. Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 2010;6(five):262-268 [PubMed] [Google Scholar]
45. Messner Grand, Wei Y, Andersson B, Gillquist J, Rasanen T. Rat model of Achilles tendon disorder: a airplane pilot study. Cells Tissues Organs. 1999;165(i):30-39 [PubMed] [Google Scholar]
46. Millar NL, Hueber AJ, Reilly JH, et al. Inflammation is present in early homo tendinopathy. Am J Sports Med. 2010;38(10):2085-2091 [PubMed] [Google Scholar]
47. Millar NL, Wei AQ, Molloy TJ, Bonar F, Murrell GA. Cytokines and apoptosis in supraspinatus tendinopathy. J Os Joint Surg Br. 2009;91(3):417-424 [PubMed] [Google Scholar]
48. Miller BF, Olesen JL, Hansen M, et al. Coordinated collagen and muscle protein synthesis in human patella tendon and quadriceps muscle after exercise. J Physiol. 2005;567(pt iii):1021-1033 [PMC gratuitous article] [PubMed] [Google Scholar]
49. Molloy TJ, Kemp MW, Wang Y, Murrell GA. Microarray analysis of the tendinopathic rat supraspinatus tendon: glutamate signaling and its potential part in tendon degeneration. J Appl Physiol. 2006;101(6):1702-1709 [PubMed] [Google Scholar]
fifty. Morrey BF. The Elbow and Its Disorders. 2nd ed. Philadelphia, PA: Saunders; 1993 [Google Scholar]
51. Nirschl RP, Ashman ES. Tennis elbow tendinosis (epicondylitis). Instr Course Lect. 2004;53:587-598 [PubMed] [Google Scholar]
52. Nirschl RP, Rodin DM, Ochiai DH, et al. Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis: a randomized, double blind, placebo controlled report. Am J Sports Med. 2003;31(2):189-195 [PubMed] [Google Scholar]
53. Nirschl R, Sobel J. Bourgeois treatment of tennis elbow. Phys Sportsmed. 1981;ix:43-54 [PubMed] [Google Scholar]
54. Ohberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot written report of a new treatment. Br J Sports Med. 2002;36(3):173-175 [PMC costless article] [PubMed] [Google Scholar]
55. Ollivierre CO, Nirschl RP. Tennis elbow: current concepts of treatment and rehabilitation. Sports Med. 1996;22(ii):133-139 [PubMed] [Google Scholar]
56. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive outcome of an autologous platelet concentrate in lateral epicondylitis in a double blind randomized controlled trial. Am J Sports Med. 2010;38(ii):255-262 [PubMed] [Google Scholar]
57. Penimaki T, Karinen P, Kemila T, Koivukangas P, Vanharanta H. Long term follow-upward of conservatively treated chronic tennis elbow patients: a prospective and retrospective analysis. Scan J Rehabil Med. 1998;30(3):159-166 [PubMed] [Google Scholar]
58. Peterson M, Butler S, Eriksson M, Svardsudd Thousand. A randomized controlled trial of do versus wait-list in chronic tennis elbow (lateral epicondylosis). Ups J Med Sci. 2011;116(iv):269-279 [PMC free article] [PubMed] [Google Scholar]
59. Priest JD, Jones HH, Tichenor CJC, et al. Arm and elbow changes in expert tennis players. Minn Med. 1977;60:399-404 [PubMed] [Google Scholar]
sixty. Pufe T, Petersen WJ, Mentlein R, Tillmann BN. The role of vasculature and angiogenesis for the pathogenesis of degenerative tendons affliction. Scand J Med Sci Sports. 2005;fifteen(iv):211-222 [PubMed] [Google Scholar]
61. Rijke AM, Goitz HT, McCue FC. Stress radiography of the medial elbow ligaments. Radiology 1994;191:213-216 [PubMed] [Google Scholar]
62. Runge F. Zur genese unt behand lung bes schreibekramp fes. Berl Klin Woschenschr. 1873;10:245 [Google Scholar]
63. Ryu KN, McCormick J, Jobe FW, et al. An electromyographic analysis of shoulder function in tennis players. Am J Sports Med. 1988;16:481-485 [PubMed] [Google Scholar]
64. Schizas 50, Frihagen E, Bahr A. Coexistence of upwards-regulated NMDA receptor ane and glutamate on nerves, vessels and transformed tenocytes in tendinopathy. Scand J Med Sci Sports. 2010;20(2):208-215 [PubMed] [Google Scholar]
65. Schizas N, Andersson T, Fahlgren A, Aspenberg P, Ahmed K, Ackermann P. Compression therapy promotes proliferative repair during rat Achilles tendon immobilization. J Orthop Res. 2010;28(seven):852-858 [PubMed] [Google Scholar]
66. Schubert TE, Weidler C, Lerch M, Hofstadter F, Straub RH. Achilles tendinosis is associated with sprouting of substance P positive nervus fibres. Ann Rheum Dis. 2005;64(7):1083-1086 [PMC free article] [PubMed] [Google Scholar]
68. Shanley Due east, Rauh MJ, Michener LA, Ellenbecker TS, Garrison JC, Thigpen CA. Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high schoolhouse softball and baseball game players. Am J Sports Med. 2011;39:1997-2006 [PubMed] [Google Scholar]
69. Sullivan PE, Markos PD, Minor Medico. An Integrated Approach to Therapeutic Exercise: Theory and Clinical Application. Reston, VA: Reston Publishing Co; 1982 [Google Scholar]
lxx. Sullo A, Maffulli N, Capasso G, Testa V. The effects of prolonged peritendinous administration of PGE1 to the rat Achilles tendon: a possible animal model of chronic Achilles tendinopathy. J Orthop Sci. 2001;vi(4):349-357 [PubMed] [Google Scholar]
71. Svernl AB, Adolfsson L. Non-operative handling regime including eccentric preparation for lateral humeral epicondylalgia. Scand J Med Sci Sports. 2001;11(vi):328-334 [PubMed] [Google Scholar]
72. Tomasek JJ, Gabbiani Thousand, Hinz B, Chaponnier C, Chocolate-brown RA. Myofibroblasts and mechano-regulation of connective tissue remodelling. Nat Rev Mol Cell Biol. 2002;3(5):349-363 [PubMed] [Google Scholar]
73. Townsend H, Jobe FW, Pink Thou, et al. Electromyographic analysis of the glenohumeral muscles during a baseball rehabilitation plan. Am J Sports Med. 1992;19:264-272 [PubMed] [Google Scholar]
74. Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Manus Ther. 2004;17(two):243-266 [PubMed] [Google Scholar]
75. Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Improver of isolated wrist extensor eccentric do to standard handling for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg. 2010;19(6):917-922 [PubMed] [Google Scholar]
76. van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc. 2011;nineteen(8):1367-1375 [PMC free commodity] [PubMed] [Google Scholar]
77. Verhaar JAN, Walenkamp GHIM, Kester ADM, Linden AJVD. Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. J Bone Articulation Surgery Br. 1995;77:128-132 [PubMed] [Google Scholar]
78. Wang JH, Jia F, Yang K, et al. Cyclic mechanical stretching of human tendon fibroblasts increases the production of prostaglandin E2 and levels of cyclooxygenase expression: a novel in vitro model study. Connect Tissue Res. 2003;44(3-4):128-133 [PubMed] [Google Scholar]
79. Wilk KE, Arrigo CA, Andrews JR. Rehabilitation of the elbow in the throwing athlete. J Orthop Sports Phys Ther. 1993;17:305-317 [PubMed] [Google Scholar]
80. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation arrears and total rotational move to shoulder injuries in professional person baseball pitchers. Am J Sports Med. 2011;39:329-335 [PubMed] [Google Scholar]
81. Winge S, Jorgensen U, Nielsen AL. Epidemiology of injuries in Danish championship tennis. Int J Sports Med. 1989;10:368-371 [PubMed] [Google Scholar]
82. Wright RW, Steeger May K, Wasserlauf BI, et al. Elbow range of movement in professional baseball pitchers. Am J Sports Med. 2006;34(ii):190-193 [PubMed] [Google Scholar]
Articles from Sports Health are provided hither courtesy of SAGE Publications
mullinsiturettem72.blogspot.com
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658379/
0 Response to "How Long After Elbow Tendon Injury Can I Play Sports Again"
Post a Comment