The patient is a 35-year-old office worker and keen recreational squash player who has been struggling with lateral epicondylitis – tennis elbow – for nine months, despite the rest, ice and exercises prescribed by his doctor.
Tendinopathy, the general term for tendon overuse injuries such as tennis elbow and Achilles tendinosis, is notoriously difficult to treat despite a confusing array of treatment options. In a debate at last month's annual meeting of the Canadian Association of Sports and Exercise Medicine in Ottawa, top sports physicians and therapists were asked: Which therapy should the squash player try next?
The case for a program of strengthening exercises is simple, according to McGill University sports physician Dr. Ian Shrier: "An injury occurs when more stress is applied to a tissue than it can absorb." So for a chronic tendon injury, you either have to reduce the stress – not the preferred solution for a devoted squash player – or increase the stress the tissue can withstand.
Numerous studies have found positive outcomes when patients follow exercise programs, particularly "eccentric" strengthening programs, where you contract the muscle as it lengthens. For example, standing on tiptoes and slowly lowering your heels is an eccentric exercise for the muscles around your Achilles tendon.
But hasn't the patient been doing exercises for nine months? Not likely, Shrier said. When he asks patients to show him the exercises they've supposedly been doing every day for weeks, they usually have to consult a sheet of paper to remember them. Adherence is key, which is why an exercise program supervised by a therapist often turns out to be more effective.
Heart patients use nitroglycerin patches to ward off attacks of angina, since the patch delivers nitric oxide that relaxes blood vessels. It turns out that nitric oxide is also associated with tendon repair, so the patches are sometimes used in combination with other therapies. One study found that nitroglycerin patches plus eccentric exercise produced outcomes that were 30 per cent better than exercise alone.
The downside? "Almost all patients with the nitro patch do develop a headache," admitted Dr. Robert Foxford, a Montreal sports doctor who has served as Canada's chief medical officer at two Olympics. "But to be honest, some of them prefer the headache to the tendon pain if they're making progress."
When all else fails, why not stick a fine needle into the tendon to irritate it and spur healing? That's the basic goal of dry needling, which is directed at trigger points within the tendon.
While the evidence in favour of dry needling remains preliminary, a review published last month in the journal The Physician and Sportsmedicine identified four studies suggesting that it improves outcomes for tendon patients. Still, Dr. Jackie Whittaker, a physiotherapist and postdoctoral researcher at the University of Calgary, typically spends only 30 seconds out of a typical half-hour appointment on needling.
"You can't strengthen anything if people are in pain," she explained. "What dry needling allows me to do is decrease the pain so I can then get on to other things."
One caveat: There have been reports of tendon ruptures following dry needling, although these incidents appear to be very rare.
"How many of you have used cortisone for treating lateral epicondylitis?" asked Dr. Navin Prasad, a University of British Columbia sports physician.
Most of the sports doctors' hands went up.
"How many of you have found an improvement in the patient's pain?"
Again, most hands went up. Injections of cortisone, a steroid with anti-inflammatory effects, are an old standby because they work – at least, initially.
Lately, though, mounting evidence suggests that improvement in the initial weeks of treatment is followed by average or perhaps worse outcomes after six or 12 months, compared with doing nothing. It's possible the injections leave the tendon more fragile, or that the initial pain relief fools patients into pushing the tendon too hard before it has healed.
That trade-off may be worthwhile before an Olympic final. And the short-term pain relief may also give the patient a window to perform the strengthening exercises that will lead to a long-term fix. "If you break the pain cycle," Prasad said, "the patient can move forward."
The hottest tendon treatment has gained popularity in recent years thanks to its use by Tiger Woods and other prominent athletes. It involves extracting the patient's blood, spinning it in a centrifuge to concentrate the portion of the blood containing platelets and dozens or perhaps even hundreds of different types of "growth factors" that stimulate healing and then reinjecting the good stuff into the injured tendon.
Does it work?
"The truth is 50 per cent of studies say it's great, and 50 per cent say it doesn't work," said Toronto sports physician Dr. Doug Stoddard.
Part of the reason may be that researchers are still learning which blood components should be included or further concentrated, and which should be excluded. Test-tube studies show that the platelet-rich plasma has a positive effect on tendon cells, so the challenge now is to translate that success to a reliable clinical procedure.
So what should the poor squash player do? In the question period following the debate, most participants conceded that strengthening exercises are the path to long-term health. Depending on the specifics of your tendon injury, other techniques may provide relief to allow you to exercise, but they're not permanent cures.
"Remember," Shrier said, "the goal is not just to get them back on the court, but to keep them on the court."
Alex Hutchinson blogs about exercise research at sweatscience.runnersworld.com. His latest book is Which Comes First, Cardio or Weights?