Scott Webb (Host): Though you don't have to play tennis or golf to suffer tennis or golf elbow, these injuries are common in those sports. And my guests today are here to help us understand how we sustain these injuries and how they can help treat and even teach us to prevent these common elbow injuries. And I'm joined today by doctors Sami Ahmed and Kyle Pearce. They're both physical therapists with Orthopedic Associates of Central Maryland.

Hi, I'm Scott Webb, and I've got a bone to fix with you. I want to thank you both for joining me today. We're going to talk about tennis elbow versus golfer's elbow and whether they're similar, different, treatment options, and so on. And Sami, I'm going to start with you. I know we've all heard that term, tennis elbow. In fact, many of us may have experienced tennis elbow, but what does that mean exactly? And what are sort of the classic signs and symptoms?

Sami Ahmed: Tennis elbow, it's an inflammation or irritation really. It's a micro tear that happens at the tendon. In terms of from anatomy perspective, we call that the lateral epicondylitis on the outside of the elbow. And really to understand what it is and what we're doing, you kind of have to understand what tendons are and what tendinopathies actually consist of.

And when you think about what a tendon is, right? A tendon, it's a piece of connective tissue, some collagen fiber that connects bone to muscle, right? And so, you can imagine throughout your entire body, there are tons of different places on the outside of the elbow, the inside of the elbow, There's a bunch of different muscles that kind of work together to collaborate to join into a tendon site. And so when we talk about things like tennis elbow or lateral epicondylitis or elbow inflammation or irritation to the outside of the elbow, really what we're talking about is that we've got an irritation that happens. It's an overuse injury that usually happens to our extensor compartment.

So, the idea or the mechanism of injury is considered to be when you're holding a tennis racket, your wrist is slightly flexed a little bit,. When you're playing tennis and you have that ball hit the racket, there's a small muscle, your ECRB, that has to really work overtime to make sure that your elbow is able to stabilize your wrist to really hit a ball back consecutively, right? And so when that happens over and over again, over time, especially because we call it overuse injury, you can imagine there's some inflammation, some irritation that happens. And in some cases, it can become a chronic problem. And that leads to people to come see us. And we've got to figure out exactly how long it's been going on for, what things we can do. Can we stretch it? Can we ice it? Do we need take a break? There's a lot of things that we got to do from the PT perspective on how to treat that.

Host: Yeah. And of course, listeners can't see that I was actually sort of following along and air tennis playing. You know, I have my fake tennis racket out here and I was trying to follow along and I think I may have even suffered tennis elbow once when I threw my racket into the lake near the court, but that's maybe a different podcast. So Kyle, I want to bring you on and talk about golfer's elbow, and is that similar, different, what are the signs and symptoms? I'm more of a golfer now than a tennis player. But just wondering, when we talk about these tendons and the inside and the outside, how do you contrast tennis elbow with golfer's elbow?

Kyle Pearce: So when we look at the differences between tennis elbow and golfer's elbow, the primary difference is the direction of force that caused the injury and the location of where your pain is.

A tennis elbow is, like Sami mentioned, that tendon irritation, that inflammation that occurs in the extensor grouping. So, that's on the outside of your elbow and that's going to be more common with that backswing in tennis, okay? So when you're working on your backhand and that repetitive nature and developing some irritation, that's that famous tennis elbow was from an overworking on your backhand. Golfer's elbow is a lot like tennis elbow, but located on the inside portion of the elbow. That's going to be from your dominant hand swinging through in order to make contact with the ball. So, individuals who are doing way more golf than they used to or just have done it for years, and there's this micro-tearing, like Sami mentioned, it's just a different location of a very similar injury. So, golfer's elbow would be on the inside of the elbow and predominantly on your dominant hand swinging through and creating that overuse injury versus tennis being your dominant hand and being on the outside with that backhand motion.

Host: So if somebody comes in and says, "I'm a tennis player and my elbow hurts here," then you naturally probably know, "Okay, that's tennis elbow" or in the case, golfer's elbow. So, take us through that, Sami, diagnosis and then the treatment options. Is it the same for both, similar for both? How's that work?

Sami Ahmed: Diagnosis and treatment options are similar, but very different at the same time. And that kind of sounds convoluted when I say it. But if you really think about what we talk about with our patients here at the Orthopedic Associates, is we explain the anatomy, we explain the physiology, like what's actually happening, right? And so if you take a step back and look at it, all these fall under this category of tendinopathy, right? They're all tendon irritation. It's a general problem dealing with a tendon.

But within that realm, there's these two categories of someone having what we call a tendonitis versus a tendinosis, right? And so, an -itis is this acute inflammatory usually due to an overworking injury like Kyle described on the inside or the outside of the arm. And when you look at an MRI, pretty bright on the screen. It's pretty easily noticed, like this is an area of irritated tissue. Whereas a tendinosis, usually it's a bit more chronic in nature.

And so, it's something that has been happening over time. It's not like someone went out to play golf for the first time and they developed a tendinosis. It's something that, you know, "I play golf multiple times a day, multiple days a week. I have this, and I've been pushing through it for long periods of time." And so for us from a rehab perspective, we first got to figure out the longer the person had this for, sometimes the harder it is to treat, because they've developed habits, they may have already tried to treat it themselves. And so, we've got to use the science to think outside the box in those cases to say, "Okay, how can we help people?" Because we don't want to shut people down, right? We're therapists. We want people to move, we want to help you move better. And so, a lot of times, it's thinking outside the box about how can we retrain this tissue? How can we decrease the inflammation irritation to that area? And yeah, if it's on the outside of the elbow, we may strap you down and say like, "All right, we're going to avoid this motion for a few days so we can, you know, let it heal," versus being on the inside of the elbow, we got to do the same thing. And so, it could be tricky at times. We work as a team to figure out exactly how to make that happen.

Host: Yeah. And Kyle, I think I'm following here -itis versus -osis, right? So, it's a sort of, you know, acute versus chronic. Do you find, generally speaking, whether it's tennis or golfer's elbow, that it's one or the other? The people don't just rush in because they play tennis the first time and their elbow hurts. But over time, everything that they've been trying, whether that's ice, heat, over-the-counter meds, whatever it is, do you find, when folks finally come in, that they've been dealing with it for a long time?

Kyle Pearce: In general, yes. So, I want to break that down a little bit more too. So, Sami talked a lot about the itis- versus the-osis, the tendonitis versus the tendinosis. Generally, the people that are coming in to see us have been dealing with this for a while, like you mentioned. So, I want to go back a little bit. So, the tennis elbow and golfer's elbow aren't always caused from that specific sport. So, I remember a guy very specifically ended up with tennis elbow, it's just a common name, he ended up with a tennis elbow, both sides.

Host: You don't actually have to have been playing tennis, right?

Kyle Pearce: I'll tell you what this guy was doing. He ended up with tennis elbow on both sides at the same time. He was in his early 50s and he had spent the weekend splitting firewood, lifting that ax and it's this overextension injury. And yeah, it was repetitive. So, he's an exception. Usually, people have been dealing with something for a long time and we can diagnose which one is which pretty easily with a couple of special tests. We resist some wrist extensions, so cocking that hand up and resisting that causing some elbow pain. We can pretty much say, "All right, if you have pinpoint pain on the lateral elbow, yep, it's that tennis elbow." But it doesn't necessarily need to be from playing tennis. And I think that's a good distinction for people to not really get caught up in, "But I don't play golf. How do I have golfer's elbow?"

Host: "How's that possible?" It's just what we call it. It's just a shorthand kind of thing. Yeah. Okay. Yeah, it's really interesting. And I was mentioning what folks will try at home, right? Ice, over-the-counter meds, whatever it might be. But I know my experience both in hosting these and my own PT experience with me and my kids, you guys are great at helping folks to avoid injuries. Like I took my daughter for physical therapy to help her avoid the natural injuries that young basketball players, young female basketball players experience, to try to avoid those anyway. I want to have you guys talk about that and maybe start with you, Kyle, when we think about how to avoid these injuries, whether that's, you know, acute or chronic. How do you help folks? What kind of plans do you develop to help them avoid "tennis or golfer's elbow"?

Kyle Pearce: Avoiding tennis elbow and avoiding golfer's elbow usually would happen after you've experienced some level of it. So if you know that you're prone to having some irritation of that elbow and you've gotten it to calm down over time, likely you're getting it to calm down by doing specific stretches and some strengthening. So once you get back to that normal state of, "I don't have a tennis elbow anymore," the best way to avoid it occurring again in the future is to maintain a good level of strength in our wrist extensors, in our wrist flexors, and in our gripping muscles. So, your grip muscles are the same group that come up and contribute to golfer's elbow. But we can't ignore finger extension strength, so creating good balance in strength on the front side of your forearm and the back side of your forearm. You know, I don't know the ordinary person who does wrist extension and wrist flexion exercises daily to avoid something. But if you know you're prone to it, then the best way to avoid it happening again in the future is to maintain that good strength.

When we are talking about a strengthening program, it's going to be important to emphasize an eccentric control program. So, what that means is a lot of times we will get somebody positioned with their forearm propped at the edge of a table or their knee lifting the weight at normal speed, but controlling that weight on the way down is what the eccentric motion is. Emphasizing that is actually one of the best supported activities according to research that we can do to help people help the tendon heal where it attaches to the bone.

Host: Yeah. And Sami, I'm sure you'd echo that, right? That while many of us don't do these types of exercises to build strength and balance and so on, if we are avid golfers or tennis players or wood splitters, that we may need to do these things, right?

Sami Ahmed: Absolutely. I tell everyone that, you know, in PT, especially here at the Orthopedic Associates, we joke around, we say, our goal is to build better bodies to help shape healthier lives. And it's this ironic joke of the matter. I tell patients all the time, "Man, look, if you really want to avoid all these injuries, just bring me with you. Take me in your back pocket. I'll stay with you when you get hurt, or I'll tell you not to do this and not to do that." And of course, we can't physically actually do that with every one of our patients. But a lot of times teaching them and preemptively, like Kyle said, doing screens, we do screens quite often. Especially pre-season and pre-nature, we've got golfers that come in all the time, or tennis players or basketball players that come in to do these prescreens. And as we go through and do these muscle tests and special tests to determine if someone is at a higher likely chance of falling into one of these categories of having a tendinopathy, whether it's tennis elbow or golfer's elbow or whatever it may be. We'll teach them like, "These are the stretches that we want you to do. These are the strengthening activities we want you to do to potentially try to avoid these things in the future. And that is a huge part. Preventative maintenance is a huge thing of what we do in PT. And, you know, we wish that more people would understand the importance of that. Just like you said with your daughter, going out ahead of time and getting that screen and getting a little one-two knowledge of these are the things we want you to look out for would go a long way in trying to avoid that ankle sprain or whatever that injury may be down the line.

Host: Yeah. The last time I golfed, I went from the car to the cart to the tee. I took three practice swings and off we went. And I just thought to myself when I was done, I shouldn't be surprised that at my ripe old age of 54 why everything hurts, right? Everything hurts because I'm old and I have osteoarthritis, but I also didn't stretch. I didn't do anything. And I'm sure you experienced that a lot, Kyle, where folks maybe forget that they're not 20 anymore, that they're 30, 40, 50. And it would help us all if we would have you in our back pockets or in our head saying, "Hey, before you go out there and play 18, stretch a little bit." Do yourself that favor, whether it's because of the golfer's elbow, tennis elbow, or everything else that might hurt, right?

Kyle Pearce: Right. And so, we think of golf as a not high-intensity activity, but when you get into that repetitive activity, it can be strenuous for those tissues that aren't quite used to it, that can happen. Sami mentioned the people who are playing two rounds of golf a day, multiple days a week, I've worked with those people. But there's also the people, like you're saying, they go out there, they're not accustomed to playing the whole 18 holes. And they do three swings to warm up. And I think the main lesson to learn is definitely take your physical therapist to the golf course with you.

Sami Ahmed: Yeah. I'll play a few rounds I'm down to do that. Take me with you. I'll play a little bit. I'll play some pickleball too. You know, that's tennis elbow, pickleball elbow, same thing. You know, I'm down to play a little bit if they want to.

Kyle Pearce: But definitely those proper stretches ahead of time and they don't have to be extensive. A little bit of proper stretching, some good warmup skills, maybe you do start with putting, do a couple gentle swings going through half speed swings, and then do a couple on the driver range and then get out there.

Host: Yeah. I've appreciated this so much as someone who used to play tennis, who occasionally plays golf now. And it's just one of those things where I have to remind myself like, sure, 30 years ago, I could play 36 holes in two days. And now, 18 holes and I might not be able to walk very well for a week, and I have to do myself a favor. And I think we could all remind ourselves our age, whatever age you are, you're doing yourself the favor by listening to experts like you guys, doing those stretches, not just running right up to the tee and swinging as hard as we can, right, Sami?

Sami Ahmed: Absolutely. We tell everyone all the time. If that does happen and something does bad happen, God forbid, knock on wood, we don't want anything to happen to anybody. You know, that's the beauty behind us here at the Orthopedic Associates. We've got the docs, we've got PTs, we've got MAs, we've got PAs. And our area, the state of Maryland, we do have direct access. And so, you can just walk on in and we'll be able to help you out and get you going in the right direction and making sure that you leave better than you came in.

Host: Yeah, that's the dream, right? Well, I just want to thank you both. I love the anatomy lesson, -itis versus -osis. Really good stuff today. Really educational. It makes me want to get out there and golf. And of course, I will stretch before I do that. So, I just want to thank you both. You both stay well.

Sami Ahmed: Thank you. You too.

Kyle Pearce: You too.

Sami Ahmed: Thank you so much, Scott.

Host: And check out OACM Physical Therapy for conservative care. We have eight convenient locations.

Find out more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. And that's all for today. I'm Scott Webb. And that was a bone that's fixed.