Welcome back to the series of articles about physiotherapy and tennis elbow (also known as lateral epicondylitis, lateral epicondylosis and lateral epicondylalgia). So far we have covered who is affected by tennis elbow, the anatomy of the elbow and which muscles or tendons are most likely to be injured. This article will try to give an overview of a huge subject: the physiology of tendons and why they get injured, now this is a massive topic in physiotherapy and has been the subject of huge amounts of research (and in fact our knowledge on this topic is still developing) so I will only be touching the surface.
Firstly we need to look at what tendons actually are and why they might get injured in tennis elbow. Simply put a tendon is a piece of connective tissue that joins muscle to bone and is comprised of well organised mostly one directional collagen fibres (Wang et al 2003). Unlike muscles tendons can not contract themselves and are relatively inelastic (with a much lower proportion of elastin – only about 1-2% Jozsa & Kannus 1997). So basically muscles do the contraction and force generation but tendons, because they connect to the bones and are relatively inelastic, transfer that force over to the bones and move our joints. A key fact about tendons is that they generally will have a much lower blood supply than muscles and in turn have a lower metabolic rate which affects their ability to heal and makes an injury to a tendon much slower to recover and heal properly (Abate et al 2009). Furthermore the point at which muscle turns into tendon (the musculo-tendinous junction) is the point which is most often injured and is subject to large mechanical forces (Abate et al 2009).
Okay – how does this affect tennis elbow? Well, as we found out in the last article, extensor carpi radialis brevis (ECRB) is the most commonly injured muscle in tennis elbow and this muscle is most commonly injured at either the musculo-tendinous junction or at the lateral epicondyle (bony bit of the elbow) where the common extensor tendon inserts into the bone. Therefore understanding tendons and how they react and function is key to understanding tennis elbow.
The common extensor tendon as shown above is the continuation of all the extensors of the wrist and fingers and therefore any time you extend your wrist or your fingers to pick anything up it is put under stress. So it isn’t really a surprise that if you do too much of anything like picking things up then this tendon may get irritated and sore and that your physiotherapist will be able to find fairly easily a very sore spot on the lateral epicondyle of your elbow.
Next blog post will look in more detail at the physiology of what happens when the tendon gets injured in tennis elbow and hopefully manage to summarise and simplify decades of research on tendinopathies.
Abate M., Gravare-Silbernagel K., Siljeholm C., Di Iorio A., De Amicis D., Salini V., Werner S., Paganelli R. (2009) Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Research and Therapy 11 (3): 235
Jozsa, L., and Kannus, P., Human Tendons: Anatomy, Physiology, and Pathology. Human Kinetics: Champaign, IL, 1997
Wang J., Jia F., Yang G., Yang S., Campbell B., Stone D., Woo S., (2003) Cyclic Mechanical Stretching of Human Tendon Fibroblasts Increases the Production of Prostaglandin E2 and Levels of Cyclooxygenase Expression: A Novel In Vitro Model Study Connective Tissue Research 44: 128 – 133
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.
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.
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.
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.
Massage has a history which dates back thousands of years and for much of this time has been a primary medical treatment by Doctors, recognised for its ability to reduce stress, anxiety and pain, plus both help prevent and heal injuries and illnesses.
Earliest records of the use of massage in medicine were in Egypt, India and China thousands of years ago. Since then its use has expanded around the globe, with inevitable cultural variations, so we see Shiatsu from Japan, Tuina from China, Ayurveda from India and Swedish from Europe and so on.
Original concepts from India and China were to consider disease and illness as a manifestation of the body being out of balance and not in harmony with the environment. Massage was considered an important treatment to help restore balance and harmony.
In the West massage spread through Europe and was noted by Hippocrates, the Greek Physician, in 400 BC as an important part of overall health maintenance. The use of massage started to decline with the emergence of newer medical techniques and also suffered greatly due to the more unsavory euphemism for sexual services.
This very concern in fact led to the formation in the UK of the Society of Trained Masseurs, later to become the Society of Chartered Physiotherapists that we know today. Thus physiotherapy has its roots in the power of hands on healing.
In more recent years massage has had a new dawn and become available in a many forms. You can now take your pick from intensely relaxing treatments on warm water beds, to deep pressure for the less faint hearted. The basic aim remains the same: to help heal on both the physical and emotional level and enhance the overall quality of life.
Unfortunately, the true value of massage is not widely recognised in the UK and for many it is still pigeon holed as an occasional luxury, or for many men, not something they would do. But let’s go back briefly to history again. Hippocrates recognised the importance of exercise, healthy diet, rest and massage as the ingredients for maintaining or restoring health. Certainly evidence exists for example that through the ages, the Olympics have made use of this philosophy.
Now fast forward to the present day. In the 1984 Olympics, massage was listed as a medical treatment to be provided. In fact many top athletes have their own masseur. For these, diet, exercise and rest go without saying. The message is no different to that proposed by Hippocrates 2400 years ago. You can be sure massage was intensely used in the London Olympics.
In the East, massage is considered a normal medical treatment and we can look much nearer home for cultural differences to perhaps break down British prejudice. In Germany, massage is considered an important part of their preventative and treatment health care. It is quite normal for a German Doctor to prescribe a course of massage, and not drugs, for the treatment of conditions such as back pain, neck stiffness and stress.
Stress we all know is on the increase and quite simply can be a killer. The body cannot heal itself if it is continually stressed. Scientific studies have shown that excessive and uncontrolled variation in heart rate caused by stress leads to increased sickness and disease. Furthermore, just relaxing at the end of the day with your favourite tipple, cannot undo the damage caused by a full day of stress. At the clinic we measure heart rate variance (HRV) and many patients are shocked by the result. Modern technology such as HRV merely amplifies just how accurate our ancient forefathers were about health.
Time and again we see patients at our clinic, who for either physical or emotional reasons would greatly benefit from regular massage, but will not as they cannot get over the stigma of it being either a luxury or not really of therapeutic value. Without doubt, many patients would retain a more pain free existence and be less stressed, if they could overcome these barriers and adopt the attitude of many other countries.
Perhaps it is time to look again with a new perspective at massage and all it can offer you.
If you would like more information on the massage we offer or our HRV technology, then please contact the clinic on 01889 881488 or visit www.painreliefclinic.co.uk
With our hectic modern lifestyle, there can be so many reasons why we don’t have a healthy spine and as a result suffer back and neck pain. As I have explored in my previous articles, keeping healthy involves four key things; state of mind, diet, exercise and posture.
The spinal cord and nerve roots are housed in a bony structure, the spine, to minimise fraying and compression to sensitive neural structures, further protected by cushioning discs and strong muscles.
If you are unable to eat a healthy diet or have chronic stress, the gut cannot absorb nutrients effectively. The body then starts to crave these missing nutrients and literally rapes the spinal bones of minerals to sustain the vital organs. This accelerates wear and tear in the small finely chiseled spinal facet joints that allow us to twist and turn. They become prematurely arthritic and fire off pain receptors.
Daily impacts due to heavy footsteps on solid surfaces, cause faster wear and tear. Furthermore with sustained poor posture in walking and sitting, amplified by not drinking enough water, the cushioning discs will crack and bulge. Then the fragile nerves are put at further risk by weak muscles. They turn into sensitive dysfunctional nerves which cause muscle contractures, accelerating arthritis, disc damage and general aging.
Hence the way we move will affect the harmonious flow of movement up through all the small joints in the spine. The correct structural alignment of feet, legs, pelvis and spine is very important, especially if you are very active and sporty. The science of how we move is called biomechanics, a physical expression of health, and a predictor of future problems.
So many times symptoms appear totally unrelated to the spine and yet unless recognized and treated the culprit lies dormant and the problem keeps reoccurring. Many times the symptoms of pain, numbness, weakness and pins and needles can be anywhere else in the body but the spine. So often, seemingly unrelated painful conditions such as osteoarthritis, tendinitis or unrelenting sports injury can only be resolved specialist neuropathic treatment to the spine. I firmly believe if anyone has a problem anywhere in the body the neural link to the spine must be assessed. Furthermore with shortened muscles compressing nerves such as sciatica in the leg, or brachialgia in the arm, the best way to quickly release the tight muscle contractures is with laser and a specialist pain treatment called Gunn IMS. We are the only centre in Europe to offer teaching internships in IMS pain relief, after being awarded the highest accolade in treatment and lecturing internationally on this subject.
We very much embrace this approach in the clinic, with our specific diagnostic physical and functional tests . We may also need to arrange an MRI to look inside the spine, and if we want to know if the bone or cartilage cells are healthy enough to repair and hydrated now we have leading technology to tell us.
It’s so exciting the way science is progressing, as now it is possible to repair sports injuries and arthritis at the cellular level. German scientists have pioneered a therapeutic version of MRI that can regenerate cartilage and bone cells throughout the body, including the disc and spine. Following a visit to the German research facility with our inhouse surgeon, we are proud to have joined over 150 European orthopaedic consultants who have helped over 150,000 patients with this non invasive technology.