I am presently treating a patient who has been suffering from a chronic case of tennis elbow. This is the generic term for an ailment that affects the lateral (outside) area of the elbow. It can occur as the result of an acute strain or from chronic, repetitive stress to one or more of the tendons that connect the muscles that extend the wrist and fingers to the elbow.
The conventional wisdom has been that these tendons become inflamed (referred to as tendinitis), so the conventional treatments have always been directed toward reducing that inflammation. Typical strategies include anti-inflammatory medications, steroid injections, icing, rest, and immobilization. Physical therapists may add electrical stimulation and ultrasound to this regimen.
Unfortunately, this patient realized only about 50% improvement with the application of most of these interventions, as well as a few others. Subsequently, his physician decided a few weeks ago to try a new treatment, in which a small amount of the patient’s own blood was injected around the tendon. Understandably, some might question the reasoning behind this technique; since most inflammatory conditions resulting from injury initially involve bleeding, why would anyone want to replicate those circumstances? Wouldn’t this just create the same situation you’re trying to heal?
The answer to this question lies in the change in thinking about this condition that has occurred over the last few years. Many experts now believe that, while an acute injury may very well cause inflammation, chronic injuries (ones that last more than six weeks, generally speaking) such as this one (as well as many running-related tendon injuries) do not exhibit the hallmarks of inflammation. Instead, these are thought to be conditions of gradual degeneration of the collagen fibers that make up most of the substance of the tendon. This degeneration (which gives the condition the name tendinosis) becomes progressive over time, often reaching a point at which healing on its own is difficult, if not impossible. Perhaps the most important reason for this recalcitrance is the poor blood supply to tendons in general, which becomes even more compromised when degeneration occurs.
Blood is the most important element in maximizing the healing of any body tissue. Without it, necessary nutrients and chemical stimulators of cellular activity cannot reach the injured area. Degenerated tissue needs to regenerate for healing to occur; blood delivers the ingredients required for that rebuilding process.
The authors of the seminal study on this technique [Edwards SG, Calandruccio JH: Autologous Blood Injections for Refractory Lateral Epicondylitis. Journal of Hand Surgery 2003; 28A: 272-278] hypothesized that the introduction of the patient’s own blood into the tendon would induce a “healing cascade” that would result in recovery of normal tendon tissue. (The results of the study are encouraging, with most patients showing significant improvement in pain levels after a few weeks, with continued pain relief at 9.5 month average follow-up. Unfortunately, there was no control group for comparison.)
What makes this of interest to physical therapists is the evidence supporting the stimulation of circulation to injured tissue to enhance healing. One of the most common physical therapy interventions for chronic tendinitis (now more accurately designated tendinosis) is a technique referred to as cross-friction massage. When I described this procedure several years ago (Article #14), I noted that the purpose of this treatment is to “…both break down the scar-tissue and promote circulation.”
Looking at what we’ve learned ten years later, it seems apparent that the latter of those two objectives may be the more valid reason for performing this type of massage. Those who have argued for some years against using cross-friction techniques for fear that it only serves to aggravate an already inflamed condition may want to reconsider their position.