※ Tendinitis－ increased number of lymphocytes and neutrophils
※ Angiofibroblastic tendinosis－ hypertrophy of fibroblasts, vascular hyperplasia and
disorganized collagen
※ Tennis Elbow－
1. is Angiofibroblastic Tendinosis, not tendinitis
2. is angiofibroblastic degeneration, not an inflammatory condition
3. is the result of failed tendon-healing
4. is a connective-tissue disease that involves the production of collagen that is not remodeled
into normal tendon
5. Primary site－ origin of extensor carpi radialis brevis m.
1/3 of patients－ origin of extensor digitorum communis m.
6. due to genetic predisposition: mesenchymal syndrome （have two or more of following conditions: bilateral lateral tennis elbow, carpal tunnel syndrome, medial tennis elbow cubital tunnel syndrome, de Quervain tenosynovitis, trigger finger or rotator-cuff tendinitis）
※ Risk Factors of tendon injury（overuse injuries, microtears）：
1. transmit loading under eccentric condition
2. wrap around a joint
3. cross two joints
4. areas of scant vascular supply
5. are subjective to repetitive tension
6. eccentric movement
7. increase of more than 8% of length of the tendon
8. maybe due to cortisone injection
※ 4 Stages of Tendinosis：
Stage 1－ inflammatory condition, non-pathological alteration
Stage 2－ pathological alterations, angiofibroblastic degeneration
Stage 3－ Stage2 + complete structural rupture
Stage 4－ Stage2,3 + fibrosis and soft matrix calcification
※ Principles of Treatment：
Anti-inflammatory medications（nonsteroidal drugs）
1. control of pain and inflammation
2. Indomethacin study－increased protein synthesis by fibroblasts, benefiting the remodeling phase of repair but have no beneficial effect on the mechanical and material properties of tendon
Local injections
1. control of pain
2. use of cortisone injection for patient who are unable to perform rehabilitative exercise because of pain
3. 3/8 studies demonstrated that injection had long-term efficacy
5/8 studies－injection of cortisone were associated with deleterious effects, including tendon rupture
4. Stahl and Kaufman（6 cases study）－lidocain and cortison injection keep 6 weeks effect but than no beneficial effect..
Physical Therapy
1. control of pain－preservation of motion, flexibility and strength－improve endurance
2. complete immobilization weakens a tendon（exercise with brace）
3. resistance-based exercise（controlled rehabilitation program）helps to align the collagen fibers
4. if the muscle endurance is not developed and the muscle-tendon unit becomes fatiqued, the muscular portion can no longer absorb the stress and greater stress are absorbed by the tendon
5. proprioception training
6. antagonist muscle training
7. kinetic-chain exercise（rotator cuff especially the external rotators）
Operative Treatment
Handshake Test: resisted forearm supination test at elbow flexion and full extension
Goals of OP: to resect pathological materials, to stimilate neurovascularization by producing focused local bleeding, and to create a healthy scar while doing the least possible structural damage to surrounding tissue
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