Stem Cell Use in the Surgical Treatment of Tennis Elbow

Herbert Sandick
Retired Orthopedic Surgeon

ABSTRACT
This paper discusses how thermal imagery can provide new understanding of diagnosis, cause and treatment
of medical conditions. In this instance, the thermal image of a tennis elbow seen at a recent Inframation
Conference visualized a hot spot at the location of the small tear in the tennis elbow tendon which I had
always assumed but could not prove without infrared imagery. Forty years previously I had developed a
treatment based upon the assumption that the tendency to recurrence was due to blood supply insufficient to
heal the tear in the tendon. The tear just happens to occur at the bony origin of the tennis elbow tendon at
the elbow and this is always a dry and circulation scarce area. Expecting to find capillary buds, and finding
what we now know as stem cells resulted in the unwitting use of stem cells, which may have been their first
specific surgical use. This technique offers unlimited potential for future medical and surgical applications.
To be able to see what could not be seen otherwise, like the invisible hot spot, is an earth-shaking advantage.
Today there is very little use of infrared in medicine but I predict that it will be the wave of the future.

INTRODUCTION
The questions I will discuss are:

1. Why am I presenting this paper here at an Inframation Conference?

2. Why am I presenting it now, when I did this work about 40 years ago?
3. Why present it at all for that matter? What is its value?

The answers to these questions will be the substance of the discussion.

WHY HERE?
It was at this meeting two years ago that my socks were blown off by a totally surprising thermogram of tennis
elbow as part of a presentation on veterinary and human physiology. I was here as a spectator with my
daughter who has long been involved with infrared technology. What astounded me about that thermogram
was that it pictured the cause of tennis elbow, exactly what I had always theorized, but could never prove.
This is that tennis elbow is due to a usually invisible tear of the bony origin of the tennis elbow tendon.

The tear shows as a hot spot on the thermogram (Figure 1). I always located it as the point of maximal
tenderness. The striking coincidence of the hot spot and tender spot is what caught my attention.

It is only in rare cases that the tear is large enough to be visible at surgery. Standard surgical treatment is
reconstruction of the tendon (Figure 2) and is unnecessarily destructive, in my opinion. Most cases involve
small or micro tears that are not visible, even at surgery. My theory is that healing is slow due to a normal
lack of rich blood supply at the tendon bone junction where the tear occurs. This is a dry vascular area where
healing is impaired by lack of adequate circulation. By contrast, tears in the meaty vascular belly of a muscle
in mid-thigh or calf heal without delay in a week or two because of the rich blood supply that is normally in this
muscle belly.

InfraMation 2008 Proceedings ITC 126 A 2008-05-14

Figure 1. Thermogram of a person with tennis elbow of the right side facing us. The rainbow palette shown on
the right was used in white-hot mode.

WHY NOW?
In the forty years since my work was started, stem cells have been described and identified and they play an
important part in my procedure. My purpose in operating is to puncture the cortex of the bone to allow bone
marrow blood to seep into the site of the tear. The result of this surgery was spectacularly successful and
confirmed for me the fact that bone marrow blood contains the ingredients to form new blood vessels in
tissues where needed. At the time in the early 1970's I called these cells "capillary buds" and we now know
that they are stem cells.

The usual surgical treatment for tennis elbow, then and now, when the tear is large is a very extensive
reconstruction of the tendon origin at the elbow (Figure 2). This has always seemed to me to be much too
destructive in that the entire origin of the tendon is cut off and re-attached surgically. The recovery period is
prolonged to about six months and often recovery is incomplete.

InfraMation 2008 Proceedings ITC 126 A 2008-05-14

Figure 2. Diagram of the usual surgical treatment for recurrent tennis elbow leading to unsatisfactory results.

The minor surgery that I devised is quicker, less risky, and more effective even for large tears. I call this
procedure cortical perforation. It is a less destructive operation restoring a circulation greater than existed
prior to the injury. It was my assumption that surgically creating an avenue for bone marrow to seep into the
area of tear produces a new more effective and richer circulation. And such was the case.

After scrubbing the skin over the spot of tenderness, the hot spot on the thermogram, a tiny stab wound is
made to puncture the skin. A stiff but thin nail is used to tap into the underlying bone marrow five times in a
small circle as shown in Figure 3. During the procedure, the surgeon sees the marrow blood ooze from these
puncture holes and a suture is not usually needed. Only a band aid is applied and the patient is allowed to
play tennis as tolerated after two to three weeks. This was the usual outcome in thirty cases over the next
fifteen years of follow up.

My recommended treatment for recurrent tennis elbow leads to the creation of richer blood supply at the site
of the tear. In contrast to the previously mentioned radical surgery of reconstruction, there is no interference
with the normal mechanics of the elbow.

And now for a personal story of how the operation of cortical perforation was devised:

It was in the early 1970's that I was experiencing low back pain after building a stone wall at my home. I did
not wish to cancel the tennis date with my wife because I planned to stretch my arm rather then my back to
avoid aggravation of the back pain. The immediate result was a recurrence of the tennis elbow pain, worse
than ever.

I decided it was time to devise a new treatment for recurrent and persistent tennis elbow. The following
morning while making rounds at the hospital, I stopped a friend who happened to be a plastic surgeon and
asked him to do a little surgery on my elbow. He agreed and came with me to the emergency room where he

InfraMation 2008 Proceedings ITC 126 A 2008-05-14

performed the surgery according to my instruction. Three weeks later I was playing tennis without pain. Six
weeks later I was all better.

I call the surgery “cortical perforation of the elbow” and it is performed as already described.

Figure 3. The tender area is found by palpation and five perforations are created through the bone into the
bone marrrow deep to the tear around the tender area. This allows marrow blood to reach the tear and these
"capillary buds" result in prompt improvement and healing. It is now known that the stem cells from the bone
marrow create a rich circulation to the needy area. This is why healing is prompt and recurrence free.

Stem cells are primitive tissue cells which will become specialized cells when needed. They originate in
places where blood cells are formed such as the bone marrow and spleen. They began to be used for
specific purposes in the 1980's though they were known to exist for some years previously.

I performed this cortical perforation surgery during my practice in Pittsfield, Massachusetts in the early 70’s
through the mid 80‘s. In a series of 30 patients there were uniformly good results in practically all of the
patients done in the course of 17 years. Little did I know that the discovery of stem cells would explain the
mechanism of blood vessel formation in such situations.

Stem cell awareness apparently began in 1961 when James Edgar Till and Ernest Armstrong McCulloch
proved the existence of stem cells. In the 1980's, the first bone marrow transplantation was carried out for
leukemia at that time, the basis being the known pleuripotential of bone marrow cells. For the same reason it
was also developed for aplastic anemia. My reference to capillary buds was theorized by me before stem
cells were known.

InfraMation 2008 Proceedings ITC 126 A 2008-05-14

AND FINALLY, WHAT IS ITS IMPORTANCE AND WHY PRESENT IT AT ALL?
It is important because of the overwhelming usefulness this technique offers for future medical and surgical
applications. To be able to see what could not be seen otherwise, like the invisible hot spot is an earth-
shaking advantage. Today there is very little use of infrared in medicine but I predict that it will be the wave of
the future.

Figure 4. A copy of the original program cover from the conference

at which the cortical perforation procedure was presented.

InfraMation 2008 Proceedings ITC 126 A 2008-05-14

Figure 5. This is a copy of the agenda from the original meeting where this surgical procedure was presented.

The surgery for tennis elbow devised by me was not widely adopted because I did not take advantage of the
offer to publish at the time of presentation (Figure 6). A death in the family and my retirement put an end to
my work until this reawaking at the Inframation conference two years ago.

I intend to present a follow up on this presentation in the medical literature by publication in the future on the
use of infrared in diagnosing tennis elbow. This should include a large number of cases demonstrating the
hot spot on the infrared image as a sign of tennis elbow.

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Figure 6. Letter from 1980 inviting a publication of the presented paper.

REFERENCES
Sandick, Herbert.; “Cortical perforation for tennis elbow”; Presented at the Alumni Association Conference of
the Hospital for Joint Diseases, New York, Oct, 1980.
Gardner, Richard.; “13 years experience with an operation for tennis elbow”; Presented at the Alumni
Association Conference of the Hospital for Joint Diseases, New York, Oct, 1980.

ACKNOWLEDGEMENTS
The authors wish to thank the Infrared Training Center for the conference and clinics, which were so helpful in
developing this paper.

ABOUT THE AUTHOR

Herbert Sandick, M.D. is a retired orthopedic surgeon from Pittsfield, MA. His daughter, Barbara O’Kane,
introduced him to thermal imagery and he has a keen interest in how thermal cameras will be used in the
future.

InfraMation 2008 Proceedings ITC 126 A 2008-05-14

InfraMation 2008 Proceedings ITC 126 A 2008-05-14