Healthy Elbows

Most treatments for tennis elbow fail because they don't address the root problem.

Tennis elbow is technically a Repetitive Strain. Strain = Tear. That's right. The achy soreness that you feel after playing is actually tearing in either the muscle or the tendon. Sometimes it's a lot of tearing and sometimes it's just a little tearing (microtears) that just adds up over time.

This tearing leads to inflammation (tendonitis), weakness, soreness, swelling, bleeding and eventually scarring (adhesion / fibrosis). The typical treatments for tennis elbow address only the inflammation and weakness, but not the adhesion / fibrosis.

The key to fixing tennis elbow, though, is to reduce or eliminate all of the above symptoms plus the adhesion / fibrosis that comes from the tearing process. The adhesion and fibrosis is what keeps the elbow from healing properly and is usually involved in the high re-occurrence rate of tennis elbow.

What are fibrosis and adhesions and how do they occur?

The formation of fibrosis/adhesions or scar tissue is the body's response to healing a tear (see figure 2a). What actually occurs is that the spread of sticky fibrin, which is the sticky substance you feel when you bleed, seeps throughout the layers of the muscle and leads to scar tissue formation (see figure 2b). The scar tissue and adhesion that forms is made up of collagen. This creates a strong bond and binds the injured tissue back together (see figure 2c).

What goes wrong?

The scar tissue that binds injured tissue back together also binds the healthy tissue together. This causes decreased circulation (oxygen), inflammation and tightening of the muscles. The decreased oxygen and tightness causes more biochemical changes eventually leading to more and more fibrosis and adhesions. As adhesions develop within the muscles, they cause the muscle to become less elastic (like a rubber band) and more leathery (like a belt). The more leathery the muscle becomes the more stress is placed at the tendon (where muscles inserts into bone). Too much load or force can create tearing of the tendon!

Sequence of Injury

Different grades of tearing

There are different grades of tears that occur in the muscle and tendon. The most common is a Type I tear or 'Repetitive Strain'. This basically consists of micro-tears. The other grades of tearing are Type II (partial tear), which can typically heal without surgery and Type III, which can result in complete rupture of the muscles and ultimately require surgery.

How do you determine the degree/grade of tear?

There are many things involved in determining the grade or type of tear that has occurred. In general, the degree of tearing can be based on the extent of bleeding that will create swelling and bruising on the surface. A MRI can also be used. It is important to note that the degree of tearing is NOT based on the level of pain!!!

How can daily activities affect the injury if there is no pain?

Common daily tasks/activities, such as cleaning, picking up milk, combing hair, and more can easily aggravate and create further injury. In other words, a Type I tear can become a Type II and so on.

Figure 1. The Most Commonly Injured Muscles & Tendons

Figure 2a.

Figure 2b.

Figure 2c.

Treatments — What are your options?

There are many forms of treatments for tennis elbow. They can include:

  • Active Release Technique (A.R.T.)
  • Self-Treatment
  • NSAID's (Non-steroidal anti-inflammatory drugs)
  • Cortisone shot
  • Shockwave/OssaTron
  • Physical Therapy
  • Surgery


What is Active Release Technique (A.R.T.)?

A.R.T. addresses the scar tissue (adhesions & fibrosis) and makes leathery muscle elastic again. It is the most effective way to breakdown scar tissue.

How does A.R.T. work?

The doctor locates the scar tissue and traps the scar tissue with hand/thumb while the patient actively lengthens the involved muscle. The trapped scar tissue is held back as the muscle moves through. A.R.T. is so effective because it makes the muscle elastic again and gets to the root of the problem by reducing adhesion and increasing circulation to the injured muscle and tendon.

Pros and Cons of Traditional Therapies

Therapy Type Pros Cons
Self-Treatment Ice: helps lower inflammation
Rest: allows time to heal
Self-massage: temporary relief
Exercises (weights and stretches): Strengthens and conditions
Ice: less effective without other treatment
Rest: complete rest will de-condition muscles, significantly more prone to re-injury
Self-massage: may injure yourself, limited effectiveness
Weights: may injure self if timing is wrong
**Self-treatment without a proper diagnosis can be dangerous
NSAIDS (e.g. Advil, Alleve, Ibuprofen) Provides immediate relief
Reduces inflammation
Blocked pain signals fool you
Side effects with prolonged use
What is prolonged use?
How many people hospitalized per year?
How many die per year?
Cortisone Shot Works 50% of the time and for 1-3 months.
Limited treatments
Reduces inflammation
Weakens tissue so more prone to tearing/ rupture
Permanent destruction
Approximately 70% re-occurrence rate within 6-9 months
Shockwave/OssaTron None-it doesn't work Ineffective-studies demonstrate it is as effective as placebo
May destroy nerve endings and damage bone
Can cost up to $3000
Not readily available
Incomplete insurance coverage
Physical Therapy Promotes healing
Important part of treatment when done at the right time
How many of you have tried physical therapy? Results?
Exercises done before the body is ready can make you worse
Surgery Mends wounded tissue Need proper rehab: 9-12 months
Only recommended for larger tears- greater than 85%
Results in more scar tissue

Clinic Results with Active Release

We have a greater than 90% success rate for all forms of tennis elbow and less than 10% re-occurrence rate. Most people get better and we never need to see them again!

Overview of Ideal Treatment Plan

While ART is not a cure-all, removal of scar tissue is a key to a majority of cases. Also, addressing all hindrances to healing such as faulty mechanics of swing, racquet choice, poor ergonomics at work, hobbies (gardening, knitting, woodworking, etc.), and allowing proper rest and recovery is very beneficial. Most importantly, A.R.T. addresses the scar tissue.

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