Lateral Epicondylitis (Elbow Pain)

Lateral Epicondylitis (Elbow Pain)

Lateral elbow pain is one of the most frequent non-traumatic elbow disorders. The most frequent diagnosis is lateral epicondylitis (LE), otherwise referred to as “tennis elbow”. LE is usually caused by the involvement of chronic degeneration of the wrist extensor muscles/tendon as they attach onto the lateral epicondyle of the elbow. There are a small group of forearm and wrist muscles that make up the common extensor tendon of the elbow, and of these muscles the most frequently affected is the extensor carpi radialis brevis. It is reported that repetitive activity may cause the tendon to become inflamed, leading to a tendinosis of the common extensor tendon, which is a progressive degenerative process of the tendon. The picture below demonstrates the injured muscle/tendon fibres involved in lateral epicondylitis.

How does it all begin?
Tendons stretch easily in response to gradually increasing forces. However, if the stress exceeds the tendon’s capacity to stretching, a small tear called a micro-tear will occur. These micro-tears can multiply and grow over time accelerating the degenerative process, often causing weakening, underuse, weakening at the tendon-bone junction, and poor blood supply (Ahmad et al. 2013).

What are the signs?
It usually starts off with some localized pain, near the lateral aspect of the elbow, radiating down the side of the elbow and outside of the forearm. It can vary between intensity depending on activity, and often is bothersome at sleep (Vaquero-Picado 2016) . It often accompanies with point tender pain, weakness, pain increase with various elbow motions, bony prominences can form along the lateral elbow, and can present with reduced muscle tone and skin turgor. There is no bruising, redness or hotness to the local tissue, and should be revaluated if seen. It is important to also consider other areas of the body that can contribute to elbow pain such as: injuries to the neck that may increase your elbow pain, overuse injuries that are making you use your elbow more (ie, shoulder injury), nerve entrapment, and degenerative disease of bone and cartilage.Shoulder Complex Injuries in Hockey

Recommended Treatment Options
Rehabilitative therapies such as stretching, strengthening, eccentric loading exercises are favorable, as well as activity modifications (Vaquero-Picado 2016). Neuromuscular stabilization techniques of the shoulder, scapula is also important to add to accelerated exercise programing.

Acupuncture has demonstrated very strong evidence in the outcome on short-term treatment and effectiveness (Trinh et al. 2004).

There is some evidence on the short-term use of an elbow strap/brace to reduce pain associated with the tension on the wrist extensor muscles, however, prolonged use is highly cautioned against.

Speaking with your family doctor about alternative to conservative management, that include: corticosteroid injections, PRP injections, medication use.

Most patient’s symptoms resolve with conservative management including manual therapy, activity modifications and exercise. Remember, always try to start your treatment early.

Dr. Nourus Yacoub, DC
Medical Director and Chiropractor
Royal Chiropractic and Sports Injury Clinic

References

Ahmad Z, Siddiqui N, Malik SS, et al. Lateral epicondylitis: a of pathology and management. Bone Joint Journal. 2013; 95-B:1158-1164.

Trinh KV, Phillips S-D, Ho E, Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford) 2004;43:1085-1090.

Vaquero-Picado, A., Barco, R. and Antuña, SA. Lateral epicondylitis of the elbow. EFORT Open Rev. 2016 Nov; 1(11): 391–397.

 

Achilles Tendon Injury

Achilles Tendon Injury

Achilles tendon is located at the back of the leg near the heel. It makes up the confluence of the posterior superficial leg muscles and is regarded as one of the strongest and largest tendon in the human body. Despite its strength, it is frequently subjected to injury and accounts for one of the most common sports injuries, an Achilles tendinopathy. It is important to distinguish between the type of tendon injuries associated with the Achilles.

An Achilles tendinopathy (AT) involves localized pain, swelling near the back of the leg near the heel with impaired physical function. There are two types based on location of injury: the mid tendon, and the distal insertional attachment. An Achilles tendinopathy is usually found in physical activities such as running, sprinting, and jumping, which are common athletic movements in a training program. Some factors to consider which may lead an athlete to higher risk of an Achilles injury include: leg length discrepancy, hyperpronation (flat feet), limited ankle mobility, various health systemic conditions, overloading the tendon, over training, excessive hill training, training on hard surfaces, increasing millage without progressive adaptation, poor shock absorption, and poor choice of footwear. Of course, the latter most risks are potentially avoidable with proper strength and training programs, whereas the former need medical guidance.

When one sustains a Achilles Tendon injury, consistent with a tendinopathy, it is important to consider rehabilitation options and medical management immediately, otherwise if the source of pain persists, the area of degeneration of the tear may worsen overtime, and can lead to an Achilles Tendon rupture (briefly discussed below). While there are no gold standards to treatment, research has suggested these non-operative managements to be helpful: initial rest, walking boot with modified activity, orthotics with specific modifications, graduated heel lifts/wedges that reduce dorsiflexion of the ankle, low level laser therapy, eccentric exercise program, and shockwave therapy, deep friction massage and tendon mobilization. Between a mid tendon and an insertional Achilles tendinopathy, there are specific eccentric exercises that studies have shown to be helpful for an individual’s recovery which will further improve healing and reduce the likelihood of re-injury, or potential rupture if left untreated.

In some cases, an Achilles tendon can undergo a traumatic injury in which the tendon can rupture, causing significant deficits. While one would immediately jump to the conclusion that surgery is automatically necessary, advances in non-operative management for acute Achilles tendon ruptures are on the rise. There has been a common consensus in literature to reduce the need to intervene with surgery in Achilles tendon ruptures, where functional outcomes show that there are similar results with pain management and function in the presence of rehabilitation. It appears that early loading has been shown to decrease tendon elongation, improve mechanical properties, and improve functional outcomes. Research has shown that a stepwise progression of tendon loading with exercise, working within tolerable ranges of motion, weaning off mobilizations, and advanced exercise and proprioceptive exercises are all helpful in post injury management.

In all regards, the Achilles tendon, one of the most powerful and strongest tendons in the human body can succumb to injury, and more often in sport related incidents such as running and jumping. It is important to consider rehabilitation options in non-operative management first, as research shows significant results to improving outcome and function when addressed quickly. Next time you, your athlete or loved one complains of pain in the heel/lower part of the leg, be sure to get it checked out!

Dr. Nourus Yacoub, DC
Medical Director and Chiropractor
Royal Chiropractic and Sports Injury Clinic

References

Alfredson H. and Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine. 2007 Apr; 41(4): 211–216.

Shapiro E, Grande D, and Drakos M. Biologics in Achilles tendon healing and repair: a review. Curr Rev Musculoskelet Med (2015) 8:9–17.

Li, H and Hua H. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BioMed Research International (2016) Volume 2016, 1-9.

 

Importance of a Warm-up

Every elite athlete knows that an effective warm-up is an important tool in preventing injury and improving performance. I would like to introduce to you the importance of a warm up, why it is important to have both a static and dynamic component to warm ups and briefly touch on today’s research.

Why Warm up

Warm-ups are important in helping muscle, joints, the heart, and the entire nervous system have a chance to loosen up, and become primed before sport or exercise. As your heart rate increases during a warm up, your blood circulates to internal organs, muscles, tendons and joints, and of course to your brain, which gives your mental game some much added sharpness. It is important to identify sport specific movement patterns and then organize your warmup around these movements. By recognizing these movement patterns, you can then begin to create a warmup specific to your sport which can help activate and prime the joints, muscles and soft tissue involved in sport specific movement.

In private practice, I often run into many young athletes who simply skip the warm up entirely, or don’t adopt an effective routine, which can lead to unwanted injuries. Now that I have illustrated what a warm-up can provide and the specifics of tailoring it to your sport, we must understand the types of warmups there are.

The Dynamic Warm-Up and the Static Warm-Up

When we think of warm-ups, we usually default to a simple hold and stretch type of exercise, that helps loosen some muscles and make us feel good. However, there is much more to a warm-up. There are two types of warm-ups, the dynamic and static warm-up, and they should be used in tandem.

A dynamic warm-up involves actively moving your muscle and joints through cycles of repetition, thus priming movement and preparing muscles for movement in healthy ranges. A static warm-up involves keeping the muscle and joint(s) in motionless position to achieve an increase in flexibility. Let us take the example of an ice hockey goalie who needs to perform splits in a butterfly stance. This athlete’s hip motion needs to have both flexibility and power to properly get in and out of this stance. Training hip flexibility would be achieved using a static warm-up, while a dynamic warm-up can help improve power output and explosive performance of the hip muscles which are needed to achieve proper positioning. While I have illustrated merits to using both methods, it is important to include both, as dynamic warm-ups have been identified in helping reduce any deleterious effects caused by using static warm-ups in isolation. Studies have identified that using only a static warm-up can reduce power output of muscles. So using it just before sport, is not highly recommended, especially in isolation.

What does research tell us

Much of today’s research suggests that static stretching, when used alone, can lead to a reduction in peak power performance and muscle force output. Some researchers suggest that anywhere from 30-90 second hold static stretching can induce these deleterious effects. When a dynamic warm-up is added with a static stretching warm-up, we see much of these deleterious effects reduced. Some research on the use of dynamic warm-ups showed an increase in muscle temperatures, improvements in nerve conduction, an increase in muscle motor unit recruitment, and an increase in the frequency of which fast twitch muscles fire, thus improving force output of the muscle (Layec et al., 2009, Bishop, 2003). Combining a dynamic and static warm-up are both important in helping sport specific movement patterns which can help athletes recover and prevent injuries. Overall incorporating a warm-up with both static and dynamic techniques is extremely important in helping the athlete with flexibility and power output.

A warm-up should include exercises like body weighted lunges, squats, and deadlifts, 20 minutes of cycling, band work, foam rolling, stretches. A common exercises routine that I find a lot of my soccer athletes perform, is the Fifa 11. Try this out, and see if you feel a difference. If you are a follower of my blog, stay tuned to a upcoming program that I am developing with Team Shut Out goalie school.

Dr. Nourus Yacoub, DC
Medical Director and Chiropractor
Royal Chiropractic and Sports Injury Clinic

Resources:

Bishop, D. (2003) Warm up I: potential mechanisms and the effects of passive warm up on exercise performance. Sports Medicine 33, 439-454.

Layec, G., Bringard, A., Le Fur, Y., Vilmen, C., Micallef, J.P., Perrey, S., Cozzone, P.J. and Bendahan, D. (2009) Effects of a prior high-intensity knee-extension exercise on muscle recruitment and energy cost: a combined local and global investigation in humans. Experimental Physiology 94, 704-719.

Samson M, Button DC, Chaouachi A, and Behm, D. Effects of dynamic and static stretching within general and activity specific warm-up protocols. Journal of Sports Science and Medicine (2012) 11, 279-285