Preventing and Treating Tennis Elbow in Tennis Players (Part V)

Rehabilitation of Injury: Combined Effects

A)     Therapy: Rest can help, but to correct the disorder at its root cause, rehabilitation therapy, if performed correctly, can greatly increase the rate of recovery.

1)      Massage.  This modality can help a lot with increasing flexibility and range-of-motion (ROM) back to the injured arm while reducing pain levels in the arm that is afflicted with both acute and latent Tennis Elbow myofascial Trigger Points. Be sure that you find a competent massage therapist that specializes in sports injuries.

2)      Physical Therapy. The tools used by a physical therapist can often be very beneficial, such as T.E.N.S, Ultrasound, Infra-Red Light laser, Sinewave, Phonophoresis and other modalities to help reduce pain and irritation, while increasing strength and flexibility. 

B)      Stretch: Making sure that overly short, taught muscles in the upper extremity are lengthened is important in order to increase flexibility and dexterity of the tissues which in turn reduces the amount of tensile stress imposed on the antagonist muscles (extensors) as they try to maintain equilibrium around the wrist, elbow and shoulder joints, thus reducing overall symptoms of Tennis elbow

1)      Shoulder: Anterior deltoid.

2)      Forearm: Finger and wrist flexors, forearm pronators and ulnar deviators of wrist through implementation of active Flextend stretches.

C)      Exercise: Strengthening the long, weak muscles is critical for not only injury prevention but rehabilitation of Tennis Elbow as well.  Strengthening the muscles surrounding the elbow joint provide stability to the joint in all directions and is a necessity for athletes of all types, especially tennis players, in order to prevent eliminate the existing disorder as well as prevent future damage to the extensor group.

1)      Shoulder: Posterior deltoid.

2)       Forearm: Finger, wrist and elbow extensors, forearm supinators and radial deviators of wrist, utilizing active Flextend exercises.

In summary, it is critical that tennis players have a multi-pronged approach in preparing for play, preventing an injury and rehabilitating it if one does occur.  Although preparation and prevention are the keys to avoiding injury (very important), knowing how to eliminate tennis elbow is equally valuable.  The reason for this is that even with the utmost preparation, circumstances can still happen where an injury occurs, and the individual will need to perform the “correct” steps to eliminate it in order to get back on the court pain-free, and as soon as possible.  Stay healthy!     

(1)    Runge F. Zur Genese und Behandlung des Schreibekrampfes. Berliner Klin Wochenschr. 1873;10:245–248.

(2)     Major HP. “Lawn-tennis elbow”. BMJ. 1883; 2:557.

(3)    Sports Medicine – Prevention, Evaluation, Management, and Rehabilitation.  Authors: Steven Roy / Richard Irvin

(4)    Priest JD, Braden V, Gerberich SG: the elbow and tennis. Part 1. An analysis of players with and without pain.  Phys Sportsmed 8.81-91, April 1980 and Priest JD, Braden V, Gerberich SG: the elbow and tennis. Part 2. A study of players with pain. Phys Sportsmed 8.77-85, May 1980

(5)    Priest JD, Tennis elbow. The syndrome and a study of average players.  Minn Med 59:367-371, 1976.

(6)    Travell and Simmons: Myofascial Pain and Dysfunction – The Trigger Point Manual Volume 1. The Upper Extremities. P. 487-488

(7)    Travell J, Rinzler SH: The Myofascial Genesis of Pain. Postgrad Med 11:425-434, 1952 (p. 428)

(8)    Sports Medicine – Prevention, Evaluation, Management, and Rehabilitation.  Authors: Steven Roy / Richard Irvin (P.222-224)

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Preventing and Treating Tennis Elbow in Tennis players (Part-IV)

Prevention of Injury: Methods

Certain measures need to be undertaken in order to prevent Tennis Elbow from occurring in those whom are novice, intermediate or expert tennis players.  These measures involve the following principals, and all should be considered important in preventing overuse and direct impact injuries:

A)     Preparation

1)      Warm up the muscles before you practice or play a match.  Warm muscles are much more            
 flexible, and flexible muscles are less likely to be injured. Utilizing a heating pad for 5-10 minutes before playing tennis, performing Flextend stretches and exercises or calisthenics exercises for 10-minutes  to warm up the body and get the blood flowing will help improve flexibility, dexterity and pliability of the muscles, thus reducing the chances of injury or re-injury if you have been affected with Tennis Elbow before.  For those that have suffered a previous injury, it is even more important to warm up before playing.

2)      Following the warm-up, practice for 5-10 minutes before actual play begins.  Doing so will further increase blood-flow to the muscles and reduce the likelihood of injury or re-injury.

B)      Muscle Strength and Length

1)      Strength.  A person can never be too strong when it comes to preventing injuries from occurring.  Upper extremity and grip strength are the most critical aspects of preventing Tennis Elbow or other injuries.  Even if someone has the greatest technique in the world, they are still highly susceptible to injury if the muscles being used are weak.  Activation of the hand extensors is essential to the power grip(7), and the power grip is the key to many sports activities, but is especially critical in the tennis backhand.
 
If a person strengthens their finger, wrist and elbow extensors to withstand 200 lbs. of force times fifty (50x) and they are only subject to 150 lbs. of force times twenty (20x), they will not become injured.  But, if these same muscles can only withstand 100 lbs. of force times ten (10x) and are subject to 150 lbs. of force one (1) time or 100lbs. of force twenty-one times (21x), they will become injured, and Tennis Elbow will result.  Properly strengthened muscles do not become injured; plus strong muscles can provide room for error where technique or equipment falls short.

a)      Strengthen Finger and Wrist extensor muscles

b)      Strengthen wrist /forearm Supinators

2)      Length is equally important. Short, tight restrictive muscles not only hinder range-of-motion (ROM), but are high risk for injury due to a lack of flexibility, dexterity and pliability. In short, stiff muscles tear at their weakest points, which are either at the musculotendinous junction or the tenoperiosteal junction. Less common, but can still happen, is that the tissues on either side of the muscle restriction can be affected with partial or micro tears.  

Those suffering with Tennis Elbow most often have short restrictive finger and wrist flexor muscles which put an undue tensile strain the extensor muscles, causing them to spasm, so it is important to be sure that the finger and wrist flexor and wrist pronator muscles are of adequate length.

Long, strong muscles provide for greater motion and a higher level of strength.  The longer a muscle is, the further it can contract and move, and the further it can move the greater the velocity and strength of the muscle contraction.

a)      Stretch finger and wrist flexors

b)      Stretch wrist/forearm pronators

C)      Modifications(8)

1)      Improve your technique.  No matter your level of tennis expertise, everyone can improve their backhand technique, such as; to stop leading with the elbow and/or switching from a one-handed backhand to a two-handed backhand.  Both of these greatly reduce stress to the wrist extensor and supinator muscle groups.

2)      Strength your muscles.  You can never be too strong!  Strong muscles are far less likely to become injured.  Make sure that all of your upper extremity muscles are strong and healthy, especially the finger, wrist and elbow extensors and wrist/forearm supinators, as these are the muscles that are usually weak and become injured in tennis players.

3)      Handle size.  A smaller handle is better than a larger handle, but it is best to pick a handle size that suites the size of your hand.   

4)      Use better equipment.  Choose a racquet that is light in weight and has a larger face in order to help hit the ball more “centered”, which reduces vibration and twisting of the racquet.

5)      Ball Speed.  As in golf, you can buy balls that are very fast or are very slow.  Choose the type of ball that matches your level of expertise.  If you are a novice, choose a slower ball.  If you are an expert, choose whichever ball you like to suit your purpose.

6)      Racquet Strings. For novice to intermediate players, it is important to use a racquet that is properly strung with the appropriate string gauge and tightness. Strings that are too tight can cause a lot of hand and arm vibration when the ball is hit off-center, so it is better to have strings that are more “loosely” strung, and leave the professional tennis racquets to advanced players.

(…to be continued.)

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Preventing and Treating Tennis Elbow in Tennis players (Part-III)

Muscles Affected: Extensors / Supinator

In Tennis Elbow, pain directly on the lateral epicondyle and/or one to two (1-2) inches distal to the lateral epicondyle in a more generalized area, are the most significant areas of complaint.  The location of the pain is likely to first appear at the lateral epicondyle, and then spread distally to the proximal forearm, then to the wrist and hand.  The epicondylar pain associated with Tennis Elbow is frequently a composite pain that is referred from the supinator, extensor carpi radialis longus and the extensor digitorum muscles. (6) 

When the carpi radialis longus and extensor digitorum are highly involved, the most common symptom experienced is severe pain when performing a firm grip with the hand, especially when the hand is placed in ulnar deviation, such as when shaking hands.  When the hand is placed in ulnar deviation, not only does pain increase, but weakness of grip is greatly pronounced, resulting in the inability to grasp or hold objects.  This is seen quite often when someone holding a tennis racquet drops their wrist into ulnar deviation, whereas the subject can no longer continue holding onto the racquet due to the increased pain and weakness in this position. Pain in these muscles is also greatly increased whenever a strong grip is combined with forceful supination or pronation (Tennis backhand/forehand) and when the subject grasps a large object rather than a small object (Tennis racquet handle). (6) 
(…Continued)

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The Prevention and Treatment of Tennis Elbow In Tennis Players (Part-II)

Mechanism of injury: Tennis

Those suffering from Tennis Elbow are often those that play frequently, or for long periods of time, are highly competitive, have bad technique, especially in the backhand, (3) and are usually over the age of thirty-five. (4) Tennis Elbow is also common in adult beginners, especially those who have poor technique and insufficient musculature. (5) 

Therefore it is critical that the wrist extensor muscle group is strengthened in order to withstand forceful impact that would occur with a tennis backhand return from a direct serve and/or repetitious backhand returns with a lesser degree of direct impact force but again, are high in frequency. Technique is also equally as important, as correct hand, forearm arm and body positioning can significantly reduce the amount of stress imposed on the wrist extensors when performing a backhand.

Here is a simple breakdown of how the muscles of differing strengths become injured when using both poor and good technique:

1)      Weak extensors / supinator – normal impact

2)      Normal extensors / supinator – repeated normal impact and/or sudden, forceful impact

3)      Strong extensors / supinator – repeated high impact and/or sudden, extreme impact

(…Article Series Continued)

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The Prevention and Treatment of Tennis Elbow In Tennis Players (Part-I)

Tennis Elbow, or Lateral Epicondylitis, is a condition where repetitive or direct trauma has resulted in micro-tears of the wrist extensor muscles at the musculotendinous or the tenoperiosteal junctions of the lateral epicondyle, or possibly both, leading to irritation, inflammation, swelling, weak grip, lack of hand coordination and pain at these locations of injury.

Of course this devastating injury does not just effect those that play tennis, but received its recognition in the late 1800’s, with Runge being the one most often credited for the first description of the condition in 1873.(1) The shortened version of the term “Tennis Elbow”, that we use today, was first used in 1883 by Major in his paper “Lawn-tennis elbow”.(2)

In today’s high-tech climate of typing, mousing, texting and gaming, Tennis Elbow is far reaching in a number of things that have nothing to do with “tennis”.  A fall, repetitive, jerky or sudden motions, heavy lifting of a briefcase or suitcase in the palm-down position, or the overuse of a screwdriver can all cause trauma and injury to the wrist extensor and supinator groups and the onset of symptoms. 

Although none of these mechanisms of injury have anything to do with playing tennis, the resulting condition is the same no matter what the “cause” of the injury is. So even though this article is specifically for Tennis players, the rehabilitation portion of it can be applied to anyone afflicted with this condition.
(…Article Series Continued)

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Trigger Finger – The Short of It

Trigger Finger is a physical disorder/injury that has gained greater attention in the medical industry over the last few years. Previously constituted as a disease, its relationship to cumulative trauma and blunt force has now been embraced by many healthcare professionals, revealing that many cases are simply another form of repetitive strain injury that can be corrected through simple, active finger and wrist flexor stretches and active finger and wrist extension exercises.

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Relief from Carpal Tunnel in 3-Easy Steps

Carpal Tunnel gadgets and gimmicks are a dime-a-dozen – attempting to capitalize on the misery of others for the past 30-years with minimal success.  It’s not so much that there are a ton of carpal tunnel products out there; it’s just that it is really annoying that 99% of them don’t work! 

With individuals suffering failure after failure, they finally choose carpal tunnel surgery as their last option for relief, but this too has minimal long-term success.  So what is a person to do?  Why isn’t there a device that can help get rid of it considering the fact that carpal tunnel syndrome has been recognized for decades, yet no advancements have been made and most physicians cannot agree as to how it even develops.  But I know.  

In 95% of the cases carpal tunnel syndrome is a muscle imbalance while the remaining 5% being edema due to pregnancy or a result of systemic disease such as rheumatoid arthritis.  If you fall in to the 95%, “muscle imbalance” category, here is what you do:

1) Stretch the finger and wrist flexor muscles that “close” the hands.
2) Strengthen the finger and wrist extensor muscles that “open” the hands.
3) Strengthen your back (latissimus dorsi) and posterior shoulder girdle (rear deltoid) so you don’t slouch.  Performing activities with poor posture significantly compounds the stress to the hands and wrists, which help increase the likelihood of developing carpal tunnel or exacerbates existing symptoms.

That’s it. The solution for many is to just quit being lazy, be proactive, and take your health into your own hands.  Performing stretches and exercises to make sure that the muscle surrounding any joint such as the wrist, finger, ankle, knee, are strong and “equal”, can correct imbalance issues that help eliminate the symptoms of carpal tunnel and many other repetitive strain injuries.  For more information about repetitive strain injuries, visit the Occupational Safety & Health Administration

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Cubital Tunnel or Golfer’s Elbow?

With all of the repetitive strain injuries out there these days, it is easy to get confused about which symptom goes with which injury and which tasks are at the top of the list for being the most “risky”. 

 It is very important for the injured to know what is what, as so many physicians are misdiagnosing the condition and then of course prescribing a treatment for the misdiagnosed condition, which equals, the “wrong treatment”. 

Cubital Tunnel and Golfer’s Elbow both involve the elbow, so how do you know what is what?  Here I will reveal the differences so that you know what to look for, thereby giving you the ability to choose the appropriate treatment(s).

Symptoms                           Cubital Tunnel                             Golfer’s Elbow

  • Location                           Elbow, ring & little finger                  Elbow
  • Numbness                       Ring & little finger                              No
  • Tingling                            Ring & little finger                              No
  • Paresthesia                      Ring & little finger                              No
  • Pain                                   Elbow, fingers                                     Elbow – Medial Epicondyle and/or 1-2 inches below elbow joint on front-side of forearm with possible referral to wrist.

The real differences between these two disorders are that with Golfer’s Elbow, there is NO numbness, tingling or paresthesia (pins and needles) in the ring or little finger and the pain is more of a muscle pain due to microtears in the soft tissues due to direct trauma or overuse (where the flexor muscles attach to the medial epicondyle of the elbow and/or one to two inches below the elbow joint in the belly of the flexor muscles at the musculotendinous junction, where the tendon and muscle come together), which most often present themselves as painful when attempting to grip an object or shake someone’s hand. 

Whereas, symptoms affecting the ring and little fingers only occurs in Cubital Tunnel Syndrome because the ulnar nerve is being impinged / compressed. The symptoms in the elbow in Cubital Tunnel are more along the lines of nerve irritation, often feeling like you hit your “funny bone”. Compression of the ulnar nerve is generally due to tight compressive flexor muscles causing a shift in the elbow joint, thus reducing the space of the Cubital tunnel and compressing the nerve.

Now that you know this information, you are all the wiser to make more appropriate decisions about possible treatment options….which are?  (Treatment Options Coming Next)

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A Correct Diagnosis Makes ALL the Difference

Common sense dictates that you cannot treat a repetitive strain injury until you know what it is.  But it happens time and time again, leaving behind a trail of lackluster results, and the patient highly discouraged.  There are three groups involved in this issue, and with a little foresight, patients can look forward to good results with long lasting effects. 

The first of these groups involve physicians that incorrectly diagnose a condition.  For example: The patient complains of pain, numbness, paresthesia and tingling in first three fingers (thumb, index and middle), with increased symptoms at night which causes them to awaken frequently. 

These are the “classic” symptoms of median nerve impingement within the carpal tunnel, thus by all reasoning, would be diagnosed as carpal tunnel syndrome.  Of course this could be easily cleared up with a few manual tests like Phalen’s, Reverse Phalen’s Tinel’s Sign and Compression Test. Instead, the physician Diagnoses it as Guyon’s Syndrome, an ulnar nerve disorder that affects the ring and pinkie fingers and has absolutely nothing to do with the thumb, index and middle finger symptoms that are presented to the physician. 

An incorrect diagnosis like this can easily lead to further damage as the individual begins rehabilitation and the prescribed therapy is addressing a condition that is not even present. Performing incorrect rehabilitation, such as massage, stretches and exercises for the wrong type of injury can exacerbate the “real” condition, resulting in possible irreversible damage to the affected muscles and nerve.

The second issue involves therapists that do not double-check the physician’s original diagnosis and then implement rehabilitation methods that exacerbate and increase the existing symptoms. 

When a therapist see’s a patient for the first time, they need to check the physician’s findings and perform the appropriate manual tests to double-check and be sure that the diagnosis they were presented with is correct. If they don’t, and the diagnosis is wrong, the therapists end up subjecting the patient to the incorrect rehabilitation program, possibly resulting in further damage to the patient.  

Even with a correct diagnosis and a manual retest by the therapist, the therapist still often employs the improper rehabilitation training methods anyway. For example: The patient again complains of pain, numbness, paresthesia and tingling in first three fingers (thumb, index and middle), with increased symptoms at night which causes them to awaken frequently.  Again these are “Classic” signs and symptoms of carpal tunnel syndrome.  The patient performs repetitive gripping and pincer motions with their hands all day in an assembly line.  It is clear that repetitive and prolonged finger and wrist flexion has caused the onset of the condition. 

So for therapy, the patient is subjected to a rehabilitation program consisting of “finger-walking” exercises, squeezing clay / putty and riding a hand bicycle.  Does is make any sense that the rehabilitation consists of performing the exact same exercises that the individual does that caused the injury?  That makes as much sense as having the patient work an extra few hours each night as part of their therapy in order to counteract the work they’ve done all day.  It is amazing how many therapists actually implement therapy techniques that mimic the motions that are at the source of the injury.

The last issue involves individuals self-diagnosing their own repetitive strain injury.  Although the track record of many physicians have given people plenty of reasons to think they can do just as good a job of diagnosing their conditions, if not better, they still need to get an accurate diagnosis. 

There is nothing wrong with looking into the condition yourself and taking the information you have found to your doctor.  And if you don’t like their answer, be sure to get a second, third, fourth or fifth opinion if necessary.  It is your health, not theirs and they are only human and are subject to making mistakes. The point here is that you need to be sure that more serious conditions are ruled out, and that you do in fact have a repetitive strain injury

Once you know what you are dealing with, find a good therapist that knows what they are doing and/or start your own therapy program at home, making sure that you are performing the appropriate corrective steps, such as self-massage, stretching and strengthening, that are necessary to correct the specific injury you have.

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Trigger Finger Syndrome: Top 5-Ways to Make it Go Away!

 Trigger Finger / Thumb Syndrome  is a VERY annoying Repetitive Strain Injury to say the least, with symptoms ranging from slight ”skipping” of the tendon as the finger is bent into flexion, to severe pain with the finger “jerking” and “locking” down into the palm of the hand, with the inability to straighten it again without assistance from the opposing hand pulling the finger back into extension…which by the way can also be quite painful. So when this condition begins to present itself, or you are already afflicted with it, what can you do that will help get rid of it or at least reduce its severity?

1) Heat up your hands first thing in the morning by running them under warm water for five (5) minutes, placing them between a folded-over therefore pad for five (5) minutes, or wearing microwaveable or electric heating mitts for five (5) minutes. It is important to heat up the hands as it increases the pliability of the tendon sheath, thus allowing the affected tendon and nodule to slide through the tendon sheath and pulley system easier.

2) Reduce the amount of finger flexion and gripping activities that you are performing. Also, if a therapist has recommended gripping, pincer-type movements or finger-walking exercises, stay away from them.  Increased finger flexion, especially with a high level of resistance, only irritates the tendon and its sheath more, thus increasing the level of symptoms for most people.

3) The most critical component of trigger finger recovery is to perform light stretches to the affected finger flexor tendon followed by finger extension exercises.  Doing this helps increase circulation and healing nutrients, break down scar tissue, reduce the size of the nodule on the affected tendon and assist in thinning it, allowing it to pass through the tendon sheath and pulley system with much greater ease.

4) If your condition is so severe that you cannot perform exercises without pain, get a cortisone injection.  Once the inflammation has reduced, start performing the appropriate stretches and exercises as listed in step-3.

5) If you’ve tried everything with no success…and I mean everything, have the surgery, but make sure you still follow up with steps 1-3 for a more effective / successful recovery.

Utilizing these methods in the order listed above should really make a difference.  Start with conservative and work your way towards non-conservative.  Give the conservative approach time though, at least 12-16 weeks before moving towards the more invasive methods.  Check out repetitive-strain.com for more information.

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