TENNIS ELBOW

1. Shockwave Therapy for Elbow Pain Treatment Shockwave treatment for tennis elbow is a relatively new form of therapy in which gentle pressure waves are released into the skin around the lateral epicondyle, a bony protrusion of the outer elbow. When used in combination with conventional treatments such as elbow supports and pain relief exercises, shockwave treatment for tennis elbow has proven an effective treatment in the fight against lateral epicondylitis. Elbow Pain Diagnosis Bilateral elbow pain is a term used to describe any condition in which pain afflicts both elbows at the same time rather than just one. There are nearly 50 different conditions that can cause simultaneous burning elbow pain, among them bursitis, osteoarthritis, and lateral and medial epicondylitis (tennis elbow and golfer’s elbow, respectively). Because some of these conditions have similar symptoms, patients should consult their physician for a proper elbow pain diagnosis. Bursae are sacs made of slippery tissue, lubricated with a small amount of fluid, that help reduce friction when skin, muscles, and tendons are sliding over bones. The olecranon bursa, which is located between the tip of the elbow (the olecranon) and the overlying skin, allows the elbow to bend and straighten. When the olecranon bursa becomes irritated and inflamed, a patient develops elbow bursitis. This may occur because of a direct blow to the elbow that tears the blood vessel tissues that make up the bursa, causing the vessels to bleed into the bursa sac. When this happens, the bursa swells up like a balloon. The influx of blood into the bursa causes an inflammatory reaction, and the walls may remain thick and swollen even after the blood has been reabsorbed. This condition of thickness and swelling is the chief characteristic of olecranon bursitis. However, olecranon bursitis may also develop more gradually. Individuals who are constantly resting their elbows on a hard surface may unknowingly be causing trauma to the elbow. Over time this may lead to irritation and swelling of the bursa. The olecranon bursa can also

2. become infected, in which cause the bursa will fill up not with blood but with pus, causing the surrounding tissue to become warm and tender. Elbow osteoarthritis is a condition involving degeneration of the articular cartilage in the elbow joints. Although this typically occurs over a period of many years, in some cases it can happen as a result of a bad sprain or fracture. Too much pressure placed on the cartilage surface may also bruise the cartilage. Symptoms of elbow osteoarthritis may include pain and stiffness. Initially the pain only occurs during periods of intense activity. It may lessen in the rush of activity and increase during rest. Over time as the condition grows more severe, a patient may experience pain when at rest or asleep. There may be swelling and tightness around the elbow and an audible squeaking of the articular cartilage. Eventually the stiffness caused by osteoarthritis will limit the elbow’s range of motion, making it difficult for patients to straighten and bend their arms. Loss of motion will ultimately lead to loss of function. Lateral epicondylitis (tennis elbow) is characterized by pain over the bone on the outside of the elbow, while medial epicondylitis (golfer’s elbow) is characterized by pain over the bone on the inner side. When the tendons attached to the lateral epicondyle become strained from overuse, they can deteriorate, resulting in damage to the extensor muscles in the forearm that are indispensable to gripping. In spite of its name, tennis elbow can result from a number of different factors, including repetitive arm motions in activities as varied as raking, rowing, painting, playing golf, and using a screwdriver. Symptoms include outside elbow pain, pain when swinging, tightness in the forearm muscles, and stiffness in the elbows. When the tendons attached to the medial epicondyle become strained from overuse, golfer’s elbow may ensue. This happens as a result of excessive use of the flexor muscles in the forearm. Activities that contribute to golfer’s elbow may include improper golfing technique, advanced age, and repetitive arm motions in activities like hammering and golfing. Among the symptoms associated with golfer’s elbow are pain and tenderness on the inner side of the elbow, sometimes

3. extending to the forearm; stiffness of the elbow; numbness or tingling in one or more fingers, and weakness of the hands and wrists. Elbow Pain Exercises Elbow pain exercises done under the supervision of a trained therapist can relieve elbow pains while increasing strength and flexibility. Wrist extensor exercises are a form of elbow pain support for patients suffering from tennis elbow. These exercises can alleviate medial elbow pain by stretching the wrist muscles. In the wrist extensor stretch, a patient kneels on all fours and places her hands knuckle-side down with her fingers directed at her knees. Then, keeping her elbows straight and the backs of her hands on the floor, she leans forward until the heels of her feet touch her buttocks. In the wrist flexor stretch, the patient begins in the same position, though with her palms to the floor and hands facing to the sides. Then, while carefully maintaining straight elbows, she leans backwards until her buttocks touch the heels of her feet. This is a great exercise for those suffering the effects of golf elbow on the lateral epicondylitis. The hammer rotation is an exercise designed to improve circulation and lubricate the connective tissues in the elbow. Sitting in a chair and clenching an object like a hammer in her hands, the patient props up her forearm with her leg while hanging her wrist over her knee. Then, holding the hammer upright, she slowly turns it toward the left, then upright, then towards the right. This strengthening exercise is ideal for patients who are slowly re-acclimating themselves to their regular activities. In the “bend and straighten” exercise, a patient bends his elbow back as far as it can go without feeling pain or excessive resistance. This can be repeated between 10 or 20 times in a sitting and should be done at least three times daily. In the forearm rotation, the patient begins with his elbow at his side, bent to 90 degrees. He then turns his palm up and down as far as it can go

4. without feeling pain. For best results this exercise, too, should be performed between 10 and 20 times. The elbow extension and elbow flexion are advanced exercises designed to strengthen muscles. In the elbow extension, the patient uses one hand to straighten the elbow on the opposite arm. In the elbow flexion, he uses the other hand to bend the elbow on the opposite arm as far back as it can go. When stretching the biceps and triceps, the patient should begin with back and neck straight. In the biceps stretch, his arm should be supported behind him on an accompanying table. Lowering his body, he allows his arm to move behind him until he feels a stretch. In the triceps stretch, he places one hand behind his lower neck and the other on his elbow. He then pushes his elbow backwards so that his hand moves down the back until he experiences a mild stretch. In both exercises, he should hold for 15 seconds and then repeat at least four times. For best results, physical therapy should be undertaken in conjunction with physical treatments like icing and anti-inflammatory painkillers. Special elbow pain supports such as armbands or bandages may help support and protect the elbow until symptoms subside. Wrist splints may also lessen pain by resting the muscles that pull on the elbow. Wearing elbow supports in conjunction with physical therapy may ultimately provide better and more lasting pain relief. Shockwave Therapy for Elbow Pain Shockwave treatment for tennis elbow involves the use of pressure waves on the injured tissue. These waves pass through the skin, initiating a healing response that accelerates blood flow and the delivery of nutrients. Depending on the severity of the injury, shockwave therapy for tennis elbow may employ either low-intensity or high-intensity shockwaves. Low-intensity waves may provide a slight sensation of discomfort, but are generally effective except in cases where the damage is severe. High-intensity shockwaves are considerably more painful and should

5. only be taken in conjunction with some form of anesthesia. The advantage of high-intensity shockwaves, however, is that they are tremendously effective. In a study reported in the American Journal of Sports Medicine in 2002, the long-term effects of shockwave therapy for tennis elbow were tested on 57 patients with lateral epicondylitis. In addition, a designated control group of six patients was unknowingly given a sham treatment. The study found that after one to two years of follow-up, 61 percent of patients receiving therapy were free of all complaints; 29.5 percent were significantly better; and one person was unchanged. The six members of the control group, on the other hand, reported significantly more pain and less range-of-motion. The study’s conclusion? “Shock wave therapy is a safe and effective therapy for the treatment of patients with lateral epicondylitis of the elbow.” Elbow Pain Relief at the New York DNR Patients seeking relief from burning elbow pain or bilateral elbow pain will find it at the New York DNR. Shockwave treatment for elbow pain is an innovative biological treatment that promotes self-tissue healing on a cellular level by activating the body’s own healing processes. The mechanical pulses we employ during shockwave treatment for elbow pain exert pressure and tension force on damaged cells, creating capillary micro-tears that promote new localized circulation and metabolism through the release of special enzymes known as “growth factors.” This results in the formation of new blood vessels that improve blood supply and oxygenation, accelerating the healing process in the elbow and relieving both unilateral and bilateral elbow pain. Moreover, by modulating tissue plasticity, shockwave treatment for elbow pain remodels damaged tissues and breaks down deposits of calcium in the soft tissues, allowing a reabsorption of the calcium. Because excess calcium deposits in the soft tissue the root of many types of musculoskeletal pain, by breaking up these calcium deposits the pressurized waves relieve elbow pains and increase range of motion.

6. On top of all this, shockwave therapy for elbow pain stimulates bone cells that are responsible for healing and new bone growth, while simultaneously diminishing pain by stimulating the so-called “gait control mechanism.” The release of acoustic waves through the surface of the skin stimulates the healing process, effectively bringing elbow pain relief. Elbow Pain Treatment in New York The elbow is a complex hinge joint that assists in arm flexion and wrist rotation. However, it is also especially susceptible to tendinitis, sprains, strains, and medial and lateral epicondylitis. Fortunately, physician-approved programs of exercise for elbow pain and elbow pain support can help the injured patient recover strength and range of motion in the injured area and resume a normal life. Elbow Pain Diagnosis The first step in treating elbow pain relief is determining its origins. There are several closely related conditions with painful symptoms that result from injury or degeneration of the elbow. Tennis elbow, or lateral epicondylitis, is an inflammation of the lateral epicondyle, a small protrusion in the humerus just above the elbow joint to which are attached four muscles that help extend the wrists and fingers—the supinator, the supraspinatus, the triceps brachii, and the brachiordialis—and a muscle that extends the elbow, the anconeus. When the lateral epicondyle is damaged as a result of tennis elbow pain and swelling, it can seriously impair the ability of the muscles to flex and extend the lower extremities. Tennis elbow pains result from damage to the extensor carpi radialis brevis (ECRB), a muscle in the forearm that stabilizes the wrist. The ECRB can be damaged from overuse through constant backhanded-stroking during tennis (hence the name of the injury), which places strain on the tendinous muscles, causing micro-trauma at the tendon’s source of origin in the lateral epicondyle. As micro-trauma accumulates, the patient experiences severe elbow pains and

7. inflammation. This is not limited to athletes who play tennis, but may afflict anyone who repeatedly overloads the muscles in their arms or shoulders. In order to obtain a proper elbow pain diagnosis, a patient should be able to pinpoint the exact area where the pain is emanating. Individuals suffering from tennis elbow will report pain above their elbow when gripping or flexing, and in other areas of the elbow and forearm. Tennis elbow typically only affects one arm, the arm that is used most prominently in high-intensity sporting events. Closely related to tennis elbow is a condition called “computer elbow” or “mouse elbow” that affects many of the same muscles of the wrist and forearm. Computer elbow typically results from repetitive or forceful movements of the fingers, wrist, and arm, and can develop because of too much force applied over a prolonged period of time. Specific movements that may place an individual at risk of developing computer elbow are sudden throwing motions, stressful gripping in combination with inward or outward movement of the forearm, and attempting to bend the wrist and rotate the forearm simultaneously. Symptoms may include extreme tenderness on the outer side of the elbow, tenderness when bending the wrist while strengthening the elbow, and burning elbow pain that can become chronic if not soon treated. Because the symptoms of tennis elbow and computer elbow are so similar, a physician may be needed to make a proper elbow pain diagnosis. Radial head subluxation, or “nursemaid’s elbow,” refers to a condition in which two of the three bones that comprise the elbow joint are torn out of alignment. This typically affects children between the ages of one and four whose bones have not fully developed, though it may occasionally be found in older children as well. Frequently the immediate cause of injury is excessive pull on the arms; this may occur when a child is being swung by the arms or dragged along by one arm at a hurried pace. Olecranon bursitis is one of the more common causes of bilateral elbow pain, or pain in both elbows. A bursa is a fluid-filled sac situated between

8. bones and soft tissues providing a lubricant that prevents excessive friction between tissues during movement. The olecranon bursa is located at the tip of the elbow, and while in most cases it remains flat, it may become swollen or inflamed when a patient is suffering from bursitis. Causes of bursitis include sudden, traumatic injury and repetitive, prolonged pressure on the tip of the elbow. Symptoms include elbow pain and swelling, bilateral elbow pain, and limited range of motion in the elbow joint. Exercises for Elbow Pain Elbow pain exercises for tennis elbow include what are called the “super 7,” seven basic exercises for elbow pain that are designed to strengthen the muscles in the forearm and increase flexibility. For patients suffering with straightforward symptoms, these exercises are designed to bring complete elbow pain relief within four to six weeks. In the first exercise, the patient stretches the muscles that extend the wrist. He or she should straighten the arm and push the palm of the hand down until a stretch is felt across the top of the forearm. Like the first of the seven exercises for elbow pain, the second is designed to stretch the flexor muscles. However, its method of operation is an exact inversion of the first. The patient straightens her arms but keeps her palms facing the ceiling. She then pushes the palm downward until it faces the opposite direction from her. When performing this exercise the patient may sit in a chair. Once she has become accustomed to it, she may use a light weight such as a book or a hammer. This should be done five times per session, three times a day. In the third exercise for elbow pain, the patient holds a weight in his hand with the palm facing the floor. Then, slowly extending the wrists upwards till the palm faces the opposite direction, he holds this position for between two to five seconds and releases. As with the previous exercise, this one should be done up to fifteen times a day.

9. In the fourth exercise, as in the third one, the patient holds a weight in his hand. However, this time he turns the palm up towards the ceiling. Then, pulling the wrist towards his body, he holds the position for five seconds and lowers slowly. The fifth exercise is an exercise for strengthening the deviator muscles, the muscles that move the wrists from side to side. Holding a weight or small pipe in her hands, the patient points the thumb upwards. She then moves the wrist up and down as though preparing to hammer a nail in place. In order for this exercise to be effective, the patient should be careful only to move the muscles of the wrist. In the sixth exercise, the patient strengthens the pronator and supinator muscles that twist the wrist by holding the pipe in her hand with the thumb pointing up and then turning the wrist inward as far as possible (eversion) and then outward as far as possible. Lastly, in the seventh tennis elbow pain exercise, the patient performs a massage over the area of soreness by applying firm pressure on the injured area. Elbow braces, or tennis elbow supports, are especially designed for the treatment of tennis elbow and golfer’s elbow. Typically elbow supports are plastic and U-shaped, designed to fit the upper forearm for the purpose of applying pressure to the extensor tendons or flexor tendons, protecting the tendon while reducing the pressures placed on them when the wrist is in use. When pressure is applied to the muscles, the tendons are less susceptible to sudden shocks and injuries. The brace can be adapted to different uses depending on whether the patient suffers from tennis or golf elbow. Wearing it under the forearm with the larger end applying pressure to the lateral elbow treats tennis elbow, while turning it around the other way so that it’s worn over the front of the elbow will treat golfer’s elbow. Occasionally a physician may instead recommend the use of an epicondylitis brace, a neoprene

10. support with a strap around the upper forearm that can treat both conditions. How Do We Treat Burning Elbow Pain? For patients suffering from tennis elbow, computer elbow, and bilateral elbow pain, the New York DNR can provide assistance. We offer elbow pain support by guiding patients in moderating their activity according to the demands of recovery, drawing up a program of exercise for elbow pain designed to repair tendon and muscle dysfunction. A patient suffering the early stages of elbow pain and swelling should seek help as soon as possible, because conventional and home treatments lose their efficacy as time passes without treatment and injuries may become chronic. Dynamic neuromuscular stabilization helps rehabilitate the elbow and surrounding tissues on inflamed nerves and restoring motion in the joints. We use DNS and manual myofascial manipulation to improve motor control in areas causing nerve impingement, lengthening the myofascial tissue to provide more freedom for the nerves. In more severe cases, such as pain in both elbows, our physicians may recommend biological treatments such as extracorporeal shockwave therapy (ESWT), an advanced regenerative treatment that does not require a sub-cutaneous incision and is therefore less invasive than surgery. A set of pressure waves is used to stimulate metabolism and enhance blood circulation, regenerating and restoring damaged tissue to accelerate the healing process. TENNIS ELBOW OR LATERAL EPICONDYLITIS Lateral epicondylitis is a painful condition at the outer forearm, just where forearm meets the arm. This condition is also known as tennis elbow. Lately due to new evidence this condition has been brought under the umbrella of OOS (Occupational Overuse Syndromes also known as repetitive strain injury (RSI) syndromes.

11. SYMPTOMS Tennis elbow pain is most often connected to the activity of the arm or a wrist such as opening a jar or a door. Pain could also be quite intense with burning quality. ETIOLOGY (Cause) Latest studies have revealed a widespread mechanical hypersensitivity in patients suffering with lateral epicondylitis. Studies show that the brains perception of mechanical input such as occurs with normal activities of daily living is heightened. Patients with tennis elbow have significantly higher pain levels to pressure or cold applied over the muscles of the forearm. This evidence supports a role of peripheral sensitization mechanisms in the initiation of this syndrome. ● In patients younger then 45 years old the cause is repetitive strain (overuse) ● Sensitization phenomenon (also occurring in younger population) ● In patients older then 50 years old with presence of degenerative joint disease in the cervical spine (neck

12. arthritis) the cause is secondary to the degenerative disease disrupting neck arm nerve connection. TYPES OF LATERAL EPICONDYLITIS There are three types of lateral epicondylitis: ● Osteogenic – the pain is in the bony prominence of the lateral epicondyle ● Myofascial – the muscles attaching to the lateral epicondyle are either hypotonic (weak and flaccid) or hypertonic (too tense) ● Tendinosis – there is a degenerative process occurring in common extensor tendon (the tendons originating in the lateral epicondyle which primary function is to extend the wrist) ● Arthrogenic – facilitated hyperactivity of elbow musculature secondary to secondary to the degenerative disease of the cervical spine ● DIFFERENTIAL DIAGNOSIS Following conditions could mimic tennis elbow: ● Radial nerve impingement ● Posterior interosseous nerve impingement ● Elbow arthritis ● Fracture of lateral epicondyle (trauma must be present) ● Cervical radiculopathy https://nydnrehab.com/what-we-treat/tennis-elbow-lateral-epicondylitis/