Monday, 30 July 2012

How To Solve Your Tennis Elbow


It’s ironic that the number of tennis players that suffer from tennis elbow are said to account for 5% of all cases (Peterson and Renström, 2001). In fact those most at risk of developing this condition are people in manual trades (carpenters, builders, electricians, painters etc) that involve repetitive wrist flexion and extension (imagine painting a wall) and also pro and supination (think of turning a screwdriver). I guess ‘Painter’s Elbow’ didn’t catch on but the terms you will commonly here used to describe this injury are: lateral elbow tendinosis, lateral epicondylitis and lateral epicondylalgia. Each of these is an attempt to describe the underlying pathological process, but what is actually going on inside that elbow of yours? 

“What causes it?” Aetiology/Pathophysiology

Ljung et al (1999) conducted biopsies on patients with tennis elbow and found no evidence of inflammatory markers while Nirschl et al (1989) and Regan et al (1992) discovered degenerative changes in the wrist common extensor tendon, synonymous with other chronic tendiopathies (achilles, and patella etc). There are still several hypotheses as to what the main cause of the pain is: raised glutamate levels (Alfredson et al, 2000); secondary hyperalgesia (Wright et al, 1992) or my favourite ‘angiofibroblastic hyperplasia’ (Brukner and Khan, 2000). 

This basically suggests that in response to the micro-damage to the tendon, the body deploys cells called fibroblasts that begin to lay down repair tissue (granulation tissue) which contain a lot of painful nerve endings (potentially accounting for the pain).
So what does all this mean and what’s important for you to know? Tennis elbow is essentially an overuse injury where the wrist extensor tendon (mainly extensor carpi radialis brevis) undergoes microscopic tears. The tendon has a poor blood supply leading to a continuous failed healing response as the tissue healing struggles to keep up with the demands placed upon it. 

“How do I know I’ve got it?” Signs & Symptoms 

  •   Gradual onset of pain (24-72 hours after training or manual work) 
  •  History of overuse or return to training after a prolonged break
  •  Pain over lateral aspect of elbow (+ or – radiating pain down forearm
  •  Pain shaking hands or opening doors (turning door handle) 

"Who's most likely to get it?" Predisposing Factors 
  • Age 35-50
  • Tennis player: overtraining or sudden increased frequency of play
  • Faulty technique (poor back hand)
  •  Manual work involving repetitive wrist motions

(Peterson and Renström, 2001)

“What else could it be?” Differential Diagnosis

Before commencing on any treatment regime, it’s important to confirm that the injury is actually tennis elbow by ruling out other potential conditions first. Other causes of lateral elbow pain are:
  •     Referred pain from cervical or upper thoracic spine  Radial nerve tension
  •      Radiohumeral bursitis
  •      Synovitis of the radiohumeral joint 
  •     Posterior interosseous nerve entrapment 
  •         Osteochondritis dissecans (flaking of the articular cartilage and subchondral bone) of the captiellum or radius

Brukner and Khan (2000)

“How can I avoid it?” Prevention

If you’re a tennis player correcting/adapting technique will definitely play an important preventative role in reducing abnormal stresses placed on the wrist extensor muscles (e.g. adopting a double handed back hand rather than single arm), along with ensuring adequate recovery between training sessions. 

Other preventative measures include checking the grip width of your racket (should be equal to the distance from the middle of your palm to the top of your middle finger) and replacing tennis balls on a regular basis.
If you’re in a manual trade, factory worker or in any job that involves repetitive stress on the forearm muscles I’d advise taking breaks when able and to regularly alternate arms i.e. not relying purely on dominant side to do all your work. 

“How do I get rid of it?” Treatment

Once a diagnosis of tennis elbow (lateral epicondylitis) has been confirmed your physiotherapist can talk you through a range of treatment options available to you, offer advice and education as to what movements and activities to avoid and inform you when it’s safe to return to activity. Which ones are most appropriate will depend on the severity and stage of the injury. 

Treatment options include:
  • Graduated therapeutic strengthening and stretching programme
  • Mobilisations with movement (MWM)
  •  Sports taping / Counterforce bracing
  • DTF (Deep Transverse Frictional Massage

Non-Conservative Measures 

If your symptoms persist for more than 6-12 months and you’re unable to return to your activity/sport despite rehabilitation from a registered physiotherapist then surgery may be indicated. The surgery is an arthroscopic debridement of the extensor carpi radialis brevis tendon that is generally uncomplicated and completed within 30 minutes. 80-85% of patients regain full strength and complete relief of pain although the surgery is always followed by a post-operative rehabilitation programme on week 3. Steroid injections are also another option prior to surgery if conservative measures fail to reduce pain. 


·         Brukner, P., Khan, K (2000) Clinical Sports Medicine, Australia, McGraw-Hill

·         Greene, J (1992) Cost-conscious prescribing of nonsteroidal anti-inflammatory drugs for adults with arthritis, Archives of Internal Medicine, 152:1995-2002

·         Peterson, L., Renström, P (2001) Sports Injuries: Their Prevention and Treatment (3rd Ed), United Kingdom, Taylor and Francis.

·         Ljung, BO., Forsgren S., Friden, J., (1999) Substance P and calcitonin gene-related peptide expression at the extensor carpi radialis brevis muscle origin: implications for the etiology of tennis elbow, Journal of Orthopaedic Research, 17: 554-559.

·         Nirschl, R (1989) Patterns of failed healing in tendon injury. In: Leadbetter W., Buckwalter, J, Gordon S (eds) Sports-induced Inflammation, American Academy of Orthopaedic Surgeons, Illinois, pp 577-585.

·         Regan, W., Wold, LE., Coonrad, R., Morrey., BF (1992) Microscopic histopathology of chronic refractory lateral epicondylitis, American Journal of Sports Medicine, 20: 746-749. 

Tuesday, 24 July 2012

Frozen Shoulder

Frozen Shoulder

Mainy stiff and painful shouders can be mis-takingly diagnosed as frozen shoulders. Painful shoulder impingements and pain referred from the cervical spine can have presentations in common with a frozen shoulder but respond very poorly to treatment directed at a frozen shoulder. A mis-diagnosis can lead to a delay in appropriate physiotherapy intervention  and a prolonged period of discomfort for the patient.
Frozen Shoulder
Frozen Shoulder
So what is a frozen shoulder?  Adherent bursitis, adhesive capsulitis, pericapsulitis are just some of the terms used to define the condition of a ‘stiffening or frozen shoulder’, each is a description of
the potential underlying disease process (Siegel et al, 1999). The term ‘Frozen
shoulder’, first used by Codman in 1934, describes a gradual onset of shoulder
pain, progressive reduction of range of motion and discomfort sleeping on the
affected side (Pearsall and Speer, 1998).
The exact cause of frozen shoulder remains unclear. Some theorized that the disease results from a thickening and tightening of the normally flexible and elastic joint capsule leading to a contracture (Neviaser and Neviaser, 1987) while other suggest the cause
originating from an inflammatory response leading to scar tissue formation (Hanafin
and Chiaig, 2000).
Frozen shoulder usually occurs with no prior injury or notable cause but can follow traumatic injuries such as fractures where the arm is immobilised for a prolonged period of time. You may be more likely to develop the condition if you have one or more of the
following risk factors:
3:1 female to male ratio (Walker et al, 1997)
Most presenting cases 40-60 years of age
History of diabetes, thyroid or heart disease (Walker et al, 1997)
Dupuytren’s contracture (Schaer et al, 1936; Smith et al, 2001)
The two types of frozen shoulder are defined by whether the
cause is known or unknown:
Primary (insidious)
Primary adhesive capsulitis is
characterised by an insidious progressive painful loss of active and passive
glenohumeral joint motion (Hannafin and Chiaia, 2000).
Secondary (traumatic)
Secondary adhesive capsulitis presents
in the same way as primary but stems from a known underlying illness or extrinsic
cause (Hannafin and Chiaia, 2000)
Freezing ‘Painful’ Phase: Pain increases with movement, often worse at night, progressive loss of motion with increasing pain (Duration approx: 2 to 9 months)
Frozen ‘Stiff’ Phase: Pain begins to diminish,significantly reduced range of motion (as much as 50% less than in the other arm) (Duration approx: 4 to 12 months)
Thawing ‘Recovery’ Phase: Condition may begin to spontaneously resolve, most patients experience a gradual restoration of motionover the next 12 to 42 months
Apply heat or cold packs to help reduce and manage the pain
Consult your GP for advice regarding pain medication/anti-inflammatories
See your physiotherapist for advice and treatment
Physiotherapy treatment for frozen shoulder aims to restore normal range of motion to the joint, increase tissue extensibility and improve strength of the muscles around the shoulder:
Pain management
Graduated stretching programme
Passive joint mobilisations
Ultrasound/Soft tissue massage
Specific home exercise programme
Postural re-education
Some evidence suggests that physiotherapy intervention can have a more profound impact on the condition in the earlier stages (Mao et al, 1997). However most patients do not seek help until pain and loss of range of motion begin to affect day to day tasks. If you begin to notice any symptoms, seek advice from your physiotherapist or local health care professional.
JA., Chiaia, TA (2000) Adhesive capsulitis: A treatment approach, Clinical Orthopaedics and Related Research,
372, 95-109.
Mao,. CY.,
Ja., WC., Cheng., HC (1997) Frozen shoulder: Correlation between response
to physical therapy and follow-up shoulder arthrography, Archives of Physical Medicine and Rehabilitation, 78: 857-859.
Neviaser , RJ.,
Neviaser  TJ (1987)  The frozen shoulder: Diagnosis and management.
Clinical Orthopaedics,
Pearsall., AW.,
Speer., K P (1998) Frozen shoulder syndrome: Diagnostic and treatment strategies in
the primary care setting, Medicine
and Science in Sports and Exercise,
30: 33-39.
Schaer, H (1936) Die aetiologie der
periarthiritis humeroscapularis, Ergebn Chir Orthop, 29: 11.
Siegel, L., Cohen, N., Gall, E (1999)
Adhesive Capsulitis: A Sticky Issue’, American Family Physician,
Smith et al (reference in Watson’s shoulder manual)
Walker, K., Gabard, D., Bietsch, E., Masek-VanArsdale,
D., Robinson, B (1997) A profile of patients with adhesive capsulitis, Journal
of Hand Therapy, 222-228.
Image sourced from