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  1. Swinging With Moxy

    superbowl-xlv-2011

    Swinging With Moxy

    Dr. Kenneth C. Thomas BS, MS, DC, CCSP

    “Tennis Elbow” is the common name describing the painful condition Lateral Epicondylitis (LE), speculatively caused by overuse of the forearm resulting in elbow pain. [8] To no surprise, playing tennis and other racquet sports can be a culprit for its development. However, a variety of other activities or sports can also be the cause of this painful condition. Painters, plumbers, carpenters or others frequently and repetitively employing the use of forearm extensor muscles with gripping objects are prone to developing tennis elbow.

    Keep in mind the diagnostic term phrase “Lateral Epicondylitis” is a slight misnomer, as the condition is not entirely inflammatory in nature, but rather degenerative by way of micro-tearing between the common extensor tendon and periosteum of the lateral epicondyle of the humerus. [1;2;8] In some literature, this same condition is identified as Lateral Epicondylalgia. [3]

    Here we define the parameters surrounding the condition, as well as provide general procedures for properly detecting, diagnosing, and treating tennis elbow with conservative and natural therapies.  Additionally, our discussion leads to a discussion of possible means of preventing the condition from developing.

    Probably create a version where the following paragraph is more of a consumer focus

    Chances are most people complainof pain on the outside (lateral) portion of their forearm near or at the elbow.  While there are many causes of forearm or elbow pain, LE will stand out and is relatively easy to distinguish from other conditions. With observation and a concentrated upper extremity examination of the elbow, you may identify the exact location of the pain and during which motions the pain is reproduced. With someone suffering from LE, the common extensor tendon of the forearm will present as either painful or dysfunctional, or both.  [4-6]

    Involvement

    The four muscles sharing the common extensor tendon origin site at the lateral epicondyle include the Extensor Carpi Radialis Brevis, Extensor Carpi Radialis Longus, Extensor Digitorum, and Extensor Carpi Ulnaris; more deep muscle, the Supinator muscle also originates at the lateral epicondyle.

    The specific tendon involved with LE is that of the Extensor Carpi Radialis Brevis (ECRB), which acts to stabilize the wrist when the elbow is straight.  With its small origin, it transmits large forces through its tendon during repetitive grasping of objects. The repeated biomechanical motion of a tennis groundstroke is an example of the type of motion that could lead to the gradual wearing of the muscle at its origin. In some instances the sheer stress of all movements of the forearm gradually causes micro-tearing of the tendon, resulting in the buildup of scar tissue and thickening of the tendon. [7;8]

    The Extensor Digiti Minimi, responsible for extension of the little finger (5th phalanx) and some extension of the wrist, has a small origin site at the anterior portion of the lateral epicondyle of the humerus.  Its action allows for a flicking motion of the wrist associated with the swinging of a racquet.

    Etiology

    The etiology of the condition described in literature suggests it arises from repetitive overuse, strenuous activity requiring speed and/or repetitive eccentric contraction of forearm muscles, and the controlled lengthening of the wrist extensor muscle group. Non-inflammatory, chronic degenerative changes of the common extensor tendon are identified in surgical pathology specimens. [8] Without delving too deeply into the energetics of muscular activity, it is poignant to mention that the energy demands of contracting even small skeletal muscles containing thousands of muscle fibers are enormous.  In a continually contracting muscle, the fibers require specific nutrients and oxygen to sustain its continued use before it ultimately deteriorates.

    Perhaps because of a lack of a fueling nutrient supply, available literature discussing this injury identifies overuse as a common indicator. [8] The form of overuse most aptly implied is through repetitive hand movements, especially the biomechanics necessitating excessive deviation of the wrist from its neutral position into extension, or even the high levels of physical strain to the wrist we described. [10-12]

    Mental chronometry, the response time in perceptual-motor tasks, is implicated as a possible factor for LE. [13] This points to the function of the nervous system and its transmission of information from the brain to the physical motor activity of a given body part. The processing of input and the resulting execution of an action is measured for efficiency of processing information to perform the biomechanical operations needed for the task at hand.

    Subjective Findings

    • The pain experienced with tennis elbow may have begun as the result of an abrupt injury to the elbow, but more commonly is described as developing over time, insidious in nature.
    • Pain about 1-2 cm down from the bony area at the outside of the elbow, more specifically at the lateral epicondyle of the humerus.
    • Weakness in the wrist with difficulty doing simple tasks such as turning (external torqueing) a doorknob, shaking hands with someone, or pouring a glass of water from a pitcher.
    • Pain on the outside of the elbow when trying to straighten the fingers against resistance.
    • Morning stiffness felt in the forearm and around the elbow.

    Objective Analysis

    • The symptoms for this injury are very similar to entrapment of the radial nerve, which is recommended to consider as a possible cause for a presenting condition of the elbow.
    • In addition, it is important to examine the neck as well, as elbow pain may be a referring symptom from vertebral subluxation or other problems in the cervical region, specifically at the level of C5, C6 and C7.
    • Observe the person perform the natural ranges of motion of the wrist and elbow to determine any limitations as well as which motions, if any, cause apprehension or reproduction of the reported pain.
    • Examine for pain on the outside of the elbow when the hand is bent back in wrist extension against resistance.
    • Palpation just below the lateral epicondyle on the outside of the elbow to identify point tenderness at the origin of the common extensor tendon.

    Diagnosis

    Although diagnostic imaging is not considered an essential diagnostic procedure for diagnosing LE, it may be considered if a more serious pathology is suspected. With LE, an MRI will reveal common extensor tendon thickening at the lateral epicondyle. [11;14]

    Several other clinical tests reported to be moderately valid for diagnosing LE include:

    • Patient-Rated Forearm Evaluation Questionnaire
    • Pain Free Grip Strength
    • Resisted Wrist Extension (Mill’s Test) [15]
    • Pressure Pain Threshold
    • Tenderness to palpation at the lateral epicondyle

    Note that palpation a fingerbreadth distal to the lateral epicondyle revealing tenderness, although accepted as a reliable and valid procedure, is based on traditional indication rather than scientific investigation.

    Treatment

    In light of one surgeon’s review of non-therapeutic modalities being “unproven at best,” [1] the efficacy of conservative treatment procedures have not distinctly been demonstrated, even through rigorous clinical trials. However, in several randomized controlled trials (RCT’s) improvements in the LE conditions were noted.  Of these conducted, you’ll be delighted to learn that mobilization/chiropractic manipulative adjustments to the wrist prove statistically superior to other treatment protocols including (i.) the combined use of ultrasound, friction message, exercise and stretching, and (ii.) corticosteroid injections.  [1;3] Perhaps due to wrist segmental dysfunction – where the extensor muscle group inserts at the metacarpals and proximal phalanges – the biomechanics of normal muscle function are altered. [17-20]

    Although controversial in the most recent reviews of orthotic wraps and bracing, a top rated treatment of LE was the implementation of the orthotic device known as the “Dynamic Extensor Brace,” [21] which holds the wrist in its extended position and reduces the electromyographic activity of the wrist extensor muscle group during gripping activity.

    Exercise and stretching as an intervention shows that eccentric contraction exercises are more effective than contract-relax stretching exercises for complete recovery of the condition. [18-20] Yet stretching of the extensor muscle group also proves to assist with ameliorating the condition to some degree.  [20]

    Light elastic taping techniques are advocated for chronic musculoskeletal conditions such as lateral epicondylalgia. Although little evidence exists supporting the effects of taping techniques on musculoskeletal pain, the few studies conducted demonstrate its efficacy. [17] Perhaps because the light elastic taping is effective in providing support to muscle function, as well as improving circulation and oxygen supply to the surrounding area where applied, it allows muscles and tendons to repair more quickly. [9] A preliminary study demonstrated an initial ameliorative effect of a taping technique for LE and suggests that it should be convoluted as an adjunct in the management of this condition. [9]

    Conservative therapies that were rated low on efficacy included Ultrasound, and Low Level Laser.  [22-25]

    Because laser therapy as well as light elastic taping techniques are relatively new therapeutic technologies, not too many studies examining their implementation have been conducted. Thus, the lack of evidence-based research is likely the basis for their lack of being considered the most effective treatments. [27]

    Prevention

    As it relates to playing sports - experience, ability, technique and the use of appropriately sized equipment may all be factors to consider when preventing LE.  [16]

    Other preventative measures to consider include:

    • Remaining in overall good physical condition.
    • Reducing the time spent doing the activity that causes the condition to develop.
    • Increase muscular strength of the muscles surrounding the joint to provide stability to the elbow.
    • Strengthen the muscles of the forearm (pronator quadratus, pronator teres, and supinator muscle), the upper arm (biceps, triceps, deltoid muscle), the shoulder and upper back (trapezius).
    • Maintain proper biomechanics during activity.
    • Maintain proper joint positioning. [26]
    • Maintain a healthy nutrient supply to the body through diet and supplementation to assist the body with its natural function and repair processes.

    As one might suspect, insufficient dietary nutrient intake can contribute to the deterioration of any of the body’s parts.  Thus, diet is a factor when considering the presentation of any ailment involving muscles, ligaments, and tendons. Nutritional supplementation shows enormous benefits with generally supporting the body in its natural functions. As it pertains to supporting tendons, supportive nutrient supply may benefit from some of the following:

    • Pea vine juice contains nutrients to assist in the proper formation of ligaments and tendons, assists with tissue repair, and promotes health circulation.
    • Manganese supports the health and maintenance of connective tissues, ligaments and tendons; it promotes bone growth, as well as the synthesis of cartilage and synovial fluid lubricating synovial joints.
    • Calcium is required for the body’s ability to form strong bones, and for proper muscular growth and contraction.
    • Carbamide, flavonoids, phosphorous, as well as B and C vitamins all synergistically aid in the body’s natural anti-inflammatory response.
    • B complex vitamins and amino acids assist the body through its natural repair process of connective tissue.
    • Enzyme CoQ-10 assists with oxygen delivery to muscles and tendons.



    References

    1. Boyer MI, Hastings H. Lateral tennis elbow: "Is there any science out there?". J Shoulder Elbow Surg 1999; 8(5):481-491.
    2. Struijs PA, Damen PJ, Bakker EW, Blankevoort L, Assendelft WJ, van Dijk CN. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Phys Ther 2003; 83(7):608-616.
    3. Cleland JA, Whitman JM, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis. J Orthop Sports Phys Ther 2004; 34(11):713-722.
    4. Newcomer KL, Martinez-Silvestrini JA, Schaefer MP, Gay RE, Arendt KW. Sensitivity of the Patient-rated Forearm Evaluation Questionnaire in lateral epicondylitis. J Hand Ther 2005; 18(4):400-406.
    5. Overend TJ, Wuori-Fearn JL, Kramer JF, MacDermid JC. Reliability of a patient-rated forearm evaluation questionnaire for patients with lateral epicondylitis. J Hand Ther 1999; 12(1):31-37.
    6. Leung HB, Yen CH, Tse PY. Reliability of Hong Kong Chinese version of the Patient-rated Forearm Evaluation Questionnaire for lateral epicondylitis. Hong Kong Med J 2004; 10(3):172-177.
    7. What is tennis elbow? BBC Sport Academy website.
    8. Boyer MI, Hastings H (1999). "Lateral tennis elbow: "Is there any science out there?"". Journal of Shoulder and Elbow Surgery 8 (5): 481–91. doi:10.1016/S1058-2746(99)90081-2. PMID 10543604.
    9. The Journal of orthopaedic and sports physical therapy. ISSN  0190-6011. CODEN JOSPDV. 2003, vol. 33, no7, pp. 400-407 [8 page(s) (article)]. Anglais. JOSPT, Alexandria, VA, ETATS-UNIS  (1979) (Revue). INIST-CNRS, Cote INIST : 19155, 35400011257970.0040.
    10. Mackay D, Rangan A, Hide G, Hughes T, Latimer J. The objective diagnosis of early tennis elbow by magnetic resonance imaging. Occup Med (Lond) 2003; 53(5):309-312.
    11. Martin CE, Schweitzer ME. MR imaging of epicondylitis. Skeletal Radiol 1998; 27(3):133-138.
    12. 12.Newcomer KL, Martinez-Silvestrini JA, Schaefer MP, Gay RE, Arendt KW. Sensitivity of the Patient-rated Forearm Evaluation Questionnaire in lateral epicondylitis. J Hand Ther 2005; 18(4):400-406.
    13. Jensen, A. R. (2006). Clocking the mind: Mental chronometry and individual differences. Amsterdam: Elsevier. (ISBN 978-0-08-044939-5)
    14. Mackay D, Rangan A, Hide G, Hughes T, Latimer J. The objective diagnosis of early tennis elbow by magnetic resonance imaging. Occup Med (Lond) 2003; 53(5):309-312.
    15. Smidt N, van der Windt DA, Assendelft WJ, Mourits AJ, Deville WL, de Winter AF et al. Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis. Arch Phys Med Rehabil 2002; 83(8):1145-1150.
    16. "Tennis Elbow - MayoClinic.com." Mayo Clinic Medical Information and Tools for Healthy Living - MayoClinic.com. 15 Oct. 2008. Web. 10 Oct. 2010.
    17. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 2005; 39(7):411-422.
    18. Martinez-Silvestrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P, Arendt KW. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther 2005; 18(4):411-9, quiz.
    19. Svernlov B, Adolfsson L. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports 2001; 11(6):328-334.
    20. Solveborn SA. Radial epicondylalgia ('tennis elbow'): treatment with stretching or forearm band. A prospective study with long-term follow-up including range-of-motion measurements. Scand J Med Sci Sports 1997; 7(4):229-237.
    21. Faes M, van den AB, de Lint JA, Kooloos JG, Hopman MT. Dynamic extensor brace for lateral epicondylitis. Clin Orthop Relat Res 2006; 442:149-157.
    22. Stasinopoulos DI, Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg 2005; 23(4):425-430.
    23. Binder A, Hodge G, Greenwood AM, Hazleman BL, Page Thomas DP. Is therapeutic ultrasound effective in treating soft tissue lesions? Br Med J (Clin Res Ed) 1985; 290(6467):512-514.
    24. van der Windt DA, van der Heijden GJ, van den Berg SG, ter Riet G, de Winter AF, Bouter LM. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain 1999; 81(3):257-271.
    25. D'Vaz AP, Ostor AJ, Speed CA, Jenner JR, Bradley M, Prevost AT et al. Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial. Rheumatology (Oxford) 2006; 45(5):566-570.
    26. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006; 333(7575):939.
    27. Bisset L, Paungmali A, Vicenzino B, Beller E (July 2005). "A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia". British Journal of Sports Medicine 39 (7): 411–22; discussion 411–22. doi:10.1136/bjsm.2004.016170. PMID 15976161.
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