I have a client who has been playing baseball for 18 years. He is 21 years old, and for the past five years, he has had terrible tendonitis in his throwing elbow. It gets so bad apparently he cannot move his whole arm. He has taken time off, yet it still comes back. What exercises can you recommend to alleviate this pain, or could it be a muscular imbalance causing the pain? If so, what would you recommend (exercises, sets, reps, duration, etc.)?
Tendonitis is a hard thing to fix in a short period of time. Usually, it takes months for this inflammation and scaring to diminish to a degree where it will not cause any pain. Following is some information on what it seems is taking place. Tendonapothies are tough work and require time on the athlete and trainer.
Tendonitis usually refers to an acute episode of inflammation in a tendenous region. An acute tendonitis episode lasts from a few minutes to a few days. During this time, blood vessels dilate and leak fluid into the surrounding tissue causing swelling and pain; neutrophils also enter the now inflamed tissues to help "clean up" the debris of trauma. Your client does not seem to fall under this category. He falls under the chronic tendonitis, which can be more accurately referred to as tendonosis.
Tendonosis is when the connective tissue of the tendon is aggravated and inflamed for long periods of time (weeks and months). The repeated insults to the area stimulate the release of vasoactive amines (i.e., prostaglandin, histamines, serotonin) that cause the tissues to contract and swell repeatedly. This chronic wear and tear changes the response mechanism of the tissues to have a blunted effect. When this occurs, the tendon starts to degenerate and the tissues become disorganized, necrotic and calcified and scar tissue is formed. The scar takes place in the collagen fibers and changes from a normal, white, hard and glossy tissue into an abnormal, brown, soft and dull cross fibered problem. This may be where your client is.
Tendonopathies are largely degenerative and need the tendonosis cycle broken. How is this done? Well, there seems to be a difference of opinion on taking care of tendonosis. The most reasonable method starts with long-term rest (three to six months) from the mechanism of injury (throwing). During this rest phase, alternating hot and cold packs on a daily basis is needed: heat before exercises and ice after training, on a religious basis. The use of NSAIDs is where the controversy takes place. Some research says yes while others say no. Sodium Naproxen (Naprosyn) seems to be the most respected NSAID for cellular healing without collagen interference. A reasonable suggestion is to use whatever the health care professional (HCP) prescribes for the first few weeks and then taper off to only when needed.
While resting the arm from throwing, start a good general conditioning program. Aim at pain-free range of motion exercises with light to moderate resistance. If a motion causes pain, stop and try something else. The specific exercises will depend on your athlete and can be found in the PTN Exercise Library. There is also a specific conditioning articles for baseball in the Research section of the site (under keyword "Baseball").
The real point to make here is to re-condition your client. He may not want to scrap a year to re-condition, but his alternative is less attractive. If you reform the connective tissue, massage out some of the scar tissue with cross fiber massage work, use heat/ice therapy consistently, recondition slowly and consult his HCP for medication suggestions then a year from now he may be throwing better than ever. If you do not break the tendenosis cycle completely, you will have a lingering problem like you have now.