PLATINUM PPT “INJURY OF THE MONTH”

Tennis elbow - "Lateral Epicondylitis"
 

Tennis elbow, as many of you will have experienced or seen, is an extremely painful condition affecting the outer part of the elbow (when the palm is facing upwards). It literally means "inflammation of the lateral epicondyle", which is the bony protuberance at the outside of the elbow.

 The cause of tennis elbow can be sudden (acute) or chronic, however inevitably the tendon of the forearm extensor muscles are involved, as it is this that attaches to the area of pain. These are the muscles we use to lift objects such as bags, tools and of course the good old tennis racquet, hence the name! The backhand in racquet sports is played using these muscles, therefore tennis, squash and badminton are very common causes of the overuse type of tennis elbow. But do not underestimate other activities such as painting, typing and many other day to day activities; in my experience these far outweigh the racquet sports causes!

 Correct diagnosis of tennis elbow is absolutely essential, and I commonly come across mis-diagnosed elbow conditions that have been labelled "tennis elbow" just because of where the pain seems to come from. Other causes of elbow pain may be related to the neck, shoulder and other elbow conditions, so please have your pain assessed to avoid aggravating the symptoms.

 After correct diagnosis, the most effective treatment includes:

Ice: This will ensure the inflamed area can settle down to allow the extensor muscles to stretch and strengthen without aggravating the pain

Deep tissue massage: In my opinion this is the most important part of the treatment, loosening of the "belly" of the tight extensor muscles causes the tendon to pull less on the bone, therefore decreaesing the symptoms

Ultrasound/laser/acupuncture: All of these "local" treatments have been proven to be effective for the local inflammation/scarring that is produced where the tendon attaches to the bone. The choice of technique will vary according to the severity and history of the condition.

Stretching/strengthening programme: Each patient will receive a personalised program to ensure that the extensor muscles stay supple through stretching, and also strengthening if indicated (not always required and in fact sometimes people may be "too strong"!)

Education: Identification of the aggravating activity is the most imprtant key at the outset, as this will decrease the chances of recurrence. This may be related to sport, work, DIY activities and many other hobbies/chores. Modification of the aggavating activity is essential during the treatment, and this can be then increased again when the symptoms have settled

 You will note I have not commented on other "traditional" ways of tennis elbow treatment, including cortisone injections and tennis elbow braces. The reason is that the research behind the injection for long term relief is poor, in fact many people find the pain is worse after the effect of the steroids has worn off. Regarding the brace, again this can be used for short-term relief however without the treatment of the cause (i.e.tendon tightness/weakness/inflammation), the long term prognosis will not be as good.

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Injury of the month - Patello-femoral pain syndrome (PFPS)

 
So let’s all be honest…who has experienced something like the picture above? Along with Achilles and calf symptoms, the knee is the most common area affected in runners of all levels. The reasons are many and varied, ranging from tightness or weakness in the leg muscles, to lumbar spine (lower back) factors, a change of shoes to a change in training location or distance. And of course, the original shape of your spine and lower limbs, all the way to the foot!! 

The most common mis-diagnosis I come across is in the middle aged runner, who never really had problems until recently, so he/she is told by another medical professional/friend/family/”person in the street” that his new knee pain is “arthritic” and that he/she “should just stop running”…..WRONG! I would estimate that 9 out of 10 patients I see with this history have patella-femoral pain syndrome (PFPS), which is as common in this middle age group as it is in teenage girls, another common demographic for this condition.

 What is PFPS?
Patello femoral pain syndrome (PFPS) is the term used for non-specific pain around the patella (kneecap), when the other structures such as ligaments, cartilage and tendons have been cleared of physical damage. Aggravating factors tend to include squatting, descending stairs and running (especially downhill). PFPS is often insidious in onset (no apparent cause or “time”) but it may come on after an acute incident such as a fall on to the knee.
The diagram below shows the position of the knee with the patella in the middle. It can be seen that the patella is free to move up, down, inwards or outwards depending on the force provided by the structures that attach to it. Understanding this allows us to understand why PFPS may occur, especially in the athlete.

 What causes PFPS?
Although there is still much debate about the major cause of PFPS, it is widely accepted by many sports physiotherapists that there is an imbalance in the muscle groups around the knee. In my experience, the iliotibial band in PFPS is always tight, and this is the tight muscle that travels down the outside of the leg from the hip to the knee. The attachments that the ITB has to the outside of the patella do cause it to move outward (left in the picture above), creating a “tilt” effect between the patella and the femur (thigh bone) behind it. If the inner thigh muscles (“vastis medialis” - see picture above) are not strong enough to counteract this force then the patella can make uncomfortable contact with the knee joint, which can then cause inflammation and constant pain, especially with the activities listed above.

 How is PFPS treated?
Correct diagnosis is crucial at the outset, as many knee injuries can mimic PFPS and this has to be looked at. If it is PFPS, it may be lower back stiffness, foot bio-mechanics or running style that is the underlying factor. For the symptoms themselves, however, the most effective treatment is aimed at loosening up the tight iliotibial band and patellar stiffness through deep tissue massage and patellar mobilisations (this can be learnt by the patient when confident enough!). A strengthening program for the inner quads is then crucial to take advantage of the “new” position of the patella, and this includes half range squats/lunges, fitball exercises and exercise bike/cross trainer activities.

 Please contact us if you have any questions regarding PFPS or the above information.

ACHILLES TENDONITIS– August, 2009

What is the Achilles tendon?     The Achilles tendon is the strongest and largest tendon in the body, joining the calf muscle complex (which consists of two layers, gastrocnemius and soleus) to the heel bone or calcaneus. As a result, when the calf-Achilles combination contracts, the foot pushes off the ground to propel us forwards, therefore allowing us to walk, run, hop and jump. 
  
What is Achilles tendonitis?      Achilles tendonitis is an inflammation (swelling) of the tendon, which occurs as a result of repetitive contractions or "overuse" of the tendon. It usually occurs as a result of walking, running or any jumping activity/sport such as basketball or dancing, where larger forces are required.

What are the symptoms of Achilles tendonitis?
People with Achilles tendonitis may experience pain during and after exercising. Walking, running and jumping activities become painful and difficult. Symptoms include stiffness and pain in the back of the ankle when pushing off the ball of the foot. For patients with chronic tendonitis (longer than six weeks), x-rays may reveal calcification (hardening of the tissue) in the tendon. Chronic tendonitis can result in a breakdown of the tendon, or tendinosis, which weakens the tendon and may increase risk of  tear or rupture to the tendon.

What is the treatment of Achilles tendonitis? Accurate diagnosis of Achilles tendonitis is essential before commencing treatment, so that other conditions are ruled out which may require further investigation. The initial phase of treatment involves identification of the aggravating activity/sport to prevent further injury, and regular icing to address the acute or chronic inflammation. Massage and stretching of the tight calf muscles is then used in the next phase, as this focuses on the common "cause" of the injury. Deeper massage around the tendon will ensure the area returns to pre-injury flexibility, and then the next stage of strengthening of the Achilles commences. Specific exercises will be prescribed for each patient, depending on the severity of the tendonitis. Other treatment techniques may include ultrasound to break down chronic scar tissue, analysis of the shape of the foot/leg and footwear, and the use of heel supports/orthotics which again focus on any underlying cause, especially in chronic conditions.

How can Achilles tendonitis be prevented?

·          Including appropriate calf and Achilles stretches in your exercise program will minimise the risk of tightness and subsequent injury

·          Strengthening exercises including the calf raise, and higher level activities on a balance board or mini-trampoline, are an excellent way of strengthening the Achilles in a functional way

·          Your training regime, which needs to be balanced, is crucial to the prevention of Achilles tendonitis. It should combine different activities, duration and intensities to prevent overuse injuries from occurring.

·          Footwear is crucial, which means monitoring wear patterns on trainers, and of course ensuring the trainers you wear are appropriate for your foot shape.

·          For more advice or tips on this condition, please contact Platinum PPT.