Tennis Elbow Part 2
Welcome back to the new series of articles about physiotherapy and common injuries and pathologies seen by physiotherapists. Last time we took a brief look at one of the most common musculo-skeletal conditions that a physiotherapist will encounter – tennis elbow (also known as lateral epicondylitis, lateral epicondylosis and lateral epicondylalgia). This article will now look at the anatomy of the elbow and the muscles connected to it in detail so that we can have a good idea of what is hurting or being injured in tennis elbow and can maybe start to have an idea of what causes it.
Elbow Anatomy:
Elbow Joint
The elbow is an amazing piece of biomechanical design and is comprised of 3 bones – the humerus which is the upper arm bone and two bones in the forearm called the radius and ulna. The radius runs from the elbow to the thumb and the ulna starts at the bony prominence on the back of your elbow (olecranon process) and runs down to the wrist. To make it easy to remember which bone is which, when I was a student I used to repeat “the ulna is underneath the radius”. Simple I know but effective nonetheless when you are a physio student desperately trying to cram in your anatomical knowledge.
Now as we are looking at tennis elbow we are not going to look or worry too much about the actual elbow joint itself except to say that it has two ways of movement – flexion and extension (basically straightening and bending) and pronation and supination (pronation is rotating the hand palm down and supination palm up). It may seem strange that in a condition called tennis elbow we will be ignoring the elbow joint itself but hopefully the reason why will become clear soon.
Tennis Elbow
The key part of the elbow in tennis elbow that we really need to examine is the lateral epicondyle – this is the point where all of the wrist extensors and finger extensors start from and is the point at which pain is felt in tennis elbow, it is also called the common extensor origin (for reasons which will become apparent soon) and is the site of attachment for the common extensor tendon. Pain here is the cardinal sign for tennis elbow that all physiotherapists look for.
Forearm extensor muscles
Running from the lateral epicondyle and the common extensor origin are all of the muscles that extend the wrist and the fingers – extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum, extensor indicis and extensor digiti minimi. Two other muscles have attachments at the lateral epicondyle – supinator and anconeus. All of these muscles merge together here to form what is known as the common extensor tendon which then attaches to the lateral epicondyle. So it is fairly obvious that this common extensor origin is an important point in wrist and finger extension and may well be a likely site of injury that physiotherapists will need to examine.
Before moving on it is worth considering the actions of a couple of these muscles in more detail extensor carpi radialis brevis and extensor carpi ulnaris have an important synergistic role in stabilising the wrist – they both act at the same time in concert with their flexor brothers (flexor carpi ulnaris and flexor carpi radialis) to prevent side to side movement at the wrist (ulnar and radial deviation). The two extensors also act together at the same time you grip an object to hold the wrist in extension a bit and prevent the finger flexors from flexing the wrist. In fact studies have shown that extensor carpi radialis brevis is the tendon most commonly injured in tennis elbow and the most common point that it is injured at is the common extensor tendon.
So hopefully from the above brief anatomy lesson we can now see that any extension or even flexion of the wrist is going to put a large amount of stress through the common extensor tendon and in turn if this tendon receives any injury we are likely to feel pain at the lateral epicondyle – which is where patients with tennis elbow will normally describe to their physiotherapist that they feel pain when they pick things up.
The next article will look at the physiology and some of the reasons why tendons get injured and why tennis elbow can often become chronic and last for a long time.
Tennis Elbow – Introduction
This will be the first blog post in an upcoming series about physiotherapy and common pathologies or injuries seen by physiotherapists. We will be examining in detail the causes and nature of various pathologies, who they affect, treatment options, self-management and how physiotherapy can help. The first pathology that I would like to deal with is an extremely common but frustrating and painful condition called tennis elbow that as a physiotherapist I encounter regularly in practice.
Tennis Elbow
Tennis elbow has several other more complicated sounding names such as lateral epicondylitis, lateral epicondylosis and lateral epicondylalgia. All of which basically try to describe the fact that the pain people feel is at the outside (lateral) bony bit of the elbow (epicondyle). The pain normally comes on when picking up heavy objects, twisting items such as screwdrivers and can be quite sharp and uncomfortable.
It is one of the most common musculo-skeletal conditions that a physiotherapist will see and affects approximately 3 – 11/1000 patients per annum (Dingenmanse et al 2012). It is thought to occur in 1.4% of the population (Shiri et al 2006), now these do not sound like huge numbers but when you consider the size of the UK population (roughly 60 million) then 1.4% of the whole population is a lot of people! It is 7 – 9 times more common than the next most common elbow injury: golfer’s elbow (medial epicondylitis) (Walz et al 2010) and causes prolonged time off work especially in chronic sufferers (Walker-Bone et al 2012). Numerous studies have shown that it is associated with handling tools and repetitive twisting and lifting actions of the forearm (Van Rijn et al 2009) basically meaning that if you are an electrician, carpenter, manual labourer or a housewife then you are at an increased risk of developing the condition.
So… what causes it? Well that is a common question for physiotherapists and seemingly a simple question. Unfortunately it is a complicated answer and will need us to look in some detail at both the anatomy of the elbow and physiology of tendons. Which will be covered in the next blog post.
Reference List:
Dingenmanse R., Randsdorp M., Koes B., Huisstede B. (2012) Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review British Journal of Sports Medicine Published Online
Shiri R., Viikari-Juntura E., Varonen H., Heliovaara M. (2006) Prevalence and determinants of lateral and medial epicondylitis: a population study. American Journal of Epidemiology 164 (11): 1065 – 1074
Van Rijn R., Huisstede B., Koes B., Burdorf A. (2009) Associations between work-related factors and specific disorders at the elbow: a systematic literature review Rheumatology 48: 528 – 536
Walker-Bone K., Palmer K., Reading I., Coggon D., Cooper C. (2012) Occupation and epicondylitis: a population-based study. Rheumatology (Oxford) 51 (2): 305 – 310
Walz D., Newman J., Konin G., Ross G. (2010) Epicondylitis: Pathogenesis,
Imaging, and Treatment Radiographics 30 (1): 167 – 185
Unless you fall off, cycling is a sport that causes very little, if any impact injury and is relatively body-friendly. On the road, there’s no impact to jar your joints as you would find in running. In mountain bike riding, although there is still no direct impact there is an element of vibrational force depending upon the type of terrain you ride. Like any endurance sport however, cycling can produce a catalogue of niggling aches and pains, which unless diagnosed and properly treated can often lead to something more serious.
If you are a regular cyclist, maybe training for you first charity ride or even a sportive, it is important that you know how to spot the signs of an injury and that you get the correct treatment and advice to correct any problems.
Avoiding Injury
When you start to increase the amount of riding you do you will be adding stresses and strains on your body. You might be tempted to ignore slight niggles and stick to you training programme at all costs. BEWARE. Riding through the pain is very likely to turn what may be a minor problem into a major one.
If you get injured, take it seriously. Take some time off the bike or adapt your training regime but do not ignore it. If the problem does not ease after rest, it is wise to be assessed by a physio or sports injury therapist. Whatever you do, don’t ignore a potential injury when it’s still in the niggle stage.
Common Injuries
Other than the obvious flesh wounds and trauma caused by falling off there are the less impressive but no less painful sprains and strains caused by overtraining/overuse injuries often resulting from biomechanical stress caused by muscle imbalances or incorrect bike setup.
Knee
One of the most common injuries reported by cyclists is pain in/around the kneecap. This is often likely to be an overuse injury. Patellofemoral pain syndrome or Chondromalacia patellae are two possible causes and are usually found because of tightness or weakness in associated muscles that causes unwanted movement of the kneecap (patella) as you pedal. If the patella rubs on the bones behind it, this can irritate and inflame the cartilage at the back of the cap causing pain.
Similar symptoms can be caused by your illiotibial (IT) band becoming tight and pulling the kneecap out of line causing it to rub against underlying bones. If you consider the repetitive nature of the pedalling action – up to 5,000 pedal revolutions an hour – it’s no surprise that a problem like this can quickly escalate into a clinical injury.
The stabilising muscles of your hip/pelvis play a big part in preventing your knees rolling inwards, and can be weakened by an over tight IT band. This is one factor that may lead to a number of painful problems, including medial knee pain, anterior knee pain and even lower back pain, in cyclists and also runners.
Hip
A number of issues can give rise to hip pain one of the most common is Piriformis syndrome. This is often caused by overtraining (particularly if there is a muscle imbalance) and by overworking the gluteus maximus muscles in your buttocks. If overstressed and tight, the piriformis can put pressure on the sciatic nerve, causing pain or numbness down the back of the leg or in the hip and is a common cause of sciatica.
Neck
Pain caused by neck hyperextension can be exacerbated by positional issues on the bike combined with lack of flexibility and core strength. The deep muscle of the neck ( flexors/extensors) help to hold your head up, when they become weak it is left to the trapezius and other muscle groups to support your head as you lean forward. When these muscles get fatigued, you can get the aches and pains in the back and sides of your neck.
Lower Back
After knees, the back is probably one of the biggest causes of pain reported by cyclists. Again lack of flexibility and a poor posture/set up are often the cause. The neutral position for the spine in a standing position allows for the curves of the spine to take your bodyweight and for the muscles to be relaxed. Sitting and reaching forward causes tension in some of the muscles of the spine and can stress the joints causing aches and pains particularly in the lower back and across the shoulders. In extreme cases long periods of being in a bent forward position can damage the intervertebral discs causing them to herniate.
Any exercise causes a small amount of inflammation in muscles, due to microscopic amounts of damage. After a long ride it is normal to ache for a day or so as the muscle repairs. This is often referred to as Delayed Onset Muscle Soreness (DOMS)
Hands
Numbness, tingling, or pain in your arm, hand, wrist, or little finger is all common symptoms especially following a long ride. Approximately one-third of all bicycling overuse injuries involve the hands. The two most common are handlebar palsy and carpal tunnel syndrome. By making some adjustments to your bike and by wearing some protective equipment, you can help prevent these injuries from occurring.
Handlebar palsy
Ulnar neuropathy (sometimes known as handlebar palsy) is caused by compression of the ulnar nerve at the hand and wrist. The ulnar nerve controls sensation in your ring and little finger and some of the muscular function of your hand. Compression of the ulnar nerve is a common problem for cyclists and is the result of direct pressure on the ulnar nerve from the grip on the handlebars and sometimes overstretching of the nerve when using the drop-down handlebar position for an extended period.
The pressure placed on the ulnar nerve results in numbness and tingling in the ring and little fingers, hand weakness, or a combination of both. Symptoms can take from several days to months to resolve. Rest, stretching exercises, and anti-inflammatory usually help relieve the symptoms. Applying less pressure or weight by adjusting your position will help prevent the condition
Carpal tunnel syndrome
Although it is less common than Ulnar neuropathy, carpal tunnel syndrome (compression of the median nerve) is another overuse injury that cyclists often experience. This often occurs when a cyclist holds the handlebars on top and applies pressure directly on the median nerve. Symptoms include numbness and tingling in the thumb, index, middle, and ring fingers and weakness of the hand. Although pressure from this riding position contributes to the symptoms of carpal tunnel, there can be other causes for hand pain and numbness, therefore, an evaluation for other possible causes should be performed by your health-care professional.
If you think you may have any of these conditions, it would be worth getting in touch with the clinic to make an appointment to have it checked out. Call on 01889 881488 now.
Orthotics, when properly prescribed, can reduce pain and improve athletic performance.
Orthotics are footwear inserts custom designed and made specifically for you to correct imbalances in your body. Such imbalances may
- Cause you pain
- Affect your sporting performance
- Cause potential problems in the future
Orthotics can help correct fallen arches or high arched feet, leg length discrepancies and help resolve ankle pain, knee pain, hip pain, lower back pain, and they even make an impact all the way up the body to the shoulders, neck and jaw. Not surprisingly, for most of us, it is difficult to see that our back pain could be caused by a foot problem, and we will never make this link without assessment.
You may be wondering if you require orthotics or not, or may think that you can buy some insoles from a high street or online shop. It is important to realise such insoles are totally different to prescribed orthotics as they are not specifically designed for your feet and are generally made from a soft, short-lived material. While insoles can be helpful in certain circumstances, most of the time they are offering no relief to your problem and sometimes can make the problem worse.
We all have or own unique foot shape and movement problems. To make this complex structure perform correctly requires an orthotic to be made exactly to your needs. A custom-made orthotic will put your foot in an ideal position at every stage of walking, running and pivoting.
Would I benefit from orthotics, you may be asking yourself? If you fit into one of the groups below, then you will most likely benefit from orthotics:
- You know you have different leg lengths.
- You stand more than 6 hours a day, especially on hard surfaces.
- You are overweight.
- You suffer from arthritis.
- Sports players and runners exert much higher forces and are likelier to have problems.
If you feel you may require orthotics, then we can assess you here at the clinic. This is called a biomechanical assessment, and it involves a mixture of looking at your posture and a variety of special static and dynamic tests. This would include digital foot pressure measurement and looking at you walking on the treadmill. If, during the assessment, we spot any imbalances, then orthotics will most likely be needed.
If you wish to know more or feel that you may benefit from orthotics then feel free to contact us here at the clinic.