The patient presents with recurrent pain about the outer aspect of the right elbow. He reports that the pain primarily occurs with forceful gripping and occurs with movements of his right upper extremity characterized as repetitive wrist extension and palm upwards rotation of his forearm (supination).

He reports that the symptoms are recurrent, associated primarily with periods of increased racquet sports activity and fitness training. He reports prior use of OTC and prescription NSAIDs, and receiving a number of local steroid injections.

On physical examination his right upper extremity appears normal, without focal redness or swelling. The soft tissue over the lateral epicondyle is mildly swollen and of a softer, fuller texture compared to that on the left. He demonstrates normal active range of motion at the elbow. He reports slight increase in pain over the lateral elbow (epicondyle) with resisted wrist extension and supination, with mildly decreased strength (pain limited) compared to the left.

Assessment

1. Lateral epicondylitis

Considerations

The diagnosis is not particularly challenging or uncommon. Of significance is that the label is only applicable for a limited period. Tendons attaching at the lateral epicondyle that are repeatedly inflamed may degenerate over time, epicondylitis transitioning to epicondylosis. As such, traditional oral anti-inflammatory treatment and local steroid injections will not be effective indefinitely. Moreover, excessive local steroid injections may hasten deterioration of the tissues.

Treatment

1. Educate the patient about the involved musculature, adjacent soft tissue and function.

2. The patient is to attempt to eliminate contributing causal/exacerbating activities as much as is possible.

3. We discussed his workout routine making adjustments to its content.

4. I recommended that he consider purchasing a lighter weight hybrid/composite tennis racquet and decrease backhand stroke frequency.

5. We discussed applying alternating heat, ice, mild friction massage and local electrical stimulation (TENS) to encourage local circulation with limited concurrent analgesic benefit.

6. I recommended twice a day application of a thin layer of topical DMSO overlaid with a balm composed of one or more of the following numerous substances: menthol, aloe, eucalyptus, cayenne, arnica, Emu oil, devil’s claw, c. indica (as allowed in his State); other agents are also applicable.

Presuming that the tissues have not already degenerated significantly and the patient can make appropriate lifestyle changes, I anticipate a positive response to the treatment plan over time. At follow-up we will address additional evaluation and treatment alternatives depending upon case status and how much of the plan he was able to fully engage.

Contact us with questions about this case and other issues of interest.

Memorial Day is experienced reverently and in celebration of the accomplishments of rites of Spring: cleaning, planting, trimming, and sprucing. The sound of steel wool on barbecue grill surfaces, scrubbing up the fire pits, and scaling off the calcium rings in swimming pools will complement the breezes swooshing through new foliage as we prepare for the onset of summer fun, and joy of Memorial Day.

Many of you should likewise prepare your shoulders for the holiday. Its not because the plates of food and the beverages will wear on your musculature, rather you are ill-prepared for water sport fun.

Swimmer’s shoulder is a term used to describe the shoulder symptoms of a competitive swimmer or the overzealous weekend athlete. The pain is similar to that experienced by many athletes playing positions requiring high volume throwing such as pitchers and quarterbacks. While the orientation of the body differs in swimming, the mechanisms of injury are very similar, repetitive wind-up, backward then forwards motions of the shoulder(s) overhead. In swimming, overhead is simply performed in a horizontal position.

Swimming can be even harder on an overzealous weekend sportsman because even between pitches and passes there are periods of rest. Whereas as long as you are moving through the water, your upper extremities, particularly your shoulders are getting a substantial workout. Moreover, swimming requires above average shoulder flexibility and range of motion to be performed well.

The muscle group most frequently injured is commonly referred to as the rotator cuff. The actual component most often offended is the tendon of the supraspinatus muscle as it inserts into the proximal aspect of your arm at the humerus. As such, the injury is known as supraspinatus or rotator cuff tendonitis.

To avoid the injury this spring, start warming up now. Stretching exercises involving reaching your hands forwards, rearwards, away from your sides, up as high as you can reach, “wing-flapping “ motions, and turning circles with your arms along your sides and/or in front of you as you lean forward slightly. There are more muscles, ligaments and cartilage that make up the rotator cuff and complementary elements than just the supraspinatus. You need to prepare all of them for your holiday fun and the summer activities on the way. Stretch your rotator cuff and avoid a Swimmers’ Shoulder injury.

Contact us with questions about this subject or others of interest to you.

Patellofemoral Syndrome is commonly recognized as pain behind the knee. Knee pain frequently does not localize well relative to medial, lateral and  internal source causes.

Generally, age, gender and history of pain are telling factors. Girls 10 to 17 y/o frequently have overly developed thigh abductor muscles (compared to adductors) causing the patella to be pulled laterally, causing retropatellar pain due to patellar tracking problems. Less commonly, tears in the medial petellofemoral ligament cause instability of the patella and similar tracking problem or outright patellar dislocation.

Weak adductors can be conditioned with exercise. Nominal medial patellofibular ligament tears may heal with knee bracing, but more advanced injuries will require surgery. Additionally, prolonged lateral traction on ligaments of the patella may result in compression  of and friction injury to the lateral retropatellar surfaces.

1. Plantar Fasciitis - If identified early more than ninety percent of plantar fasciitis can be adequately addressed by a combination of weight loss and passive plus active ligamentous/muscular stretches of the feet to develop and maintain balanced, normal motion and wearing good shoes.

2. Iliotibial band - Increased iliotibial band stress often occurs with increased impact force during running. IT band micro-injury often precipitates reactive tightening of the band, resulting in lateral torque force on the patella and related soft tissues. To prevent lateral thigh pain, knee pain and plantar foot pain related to the IT band, perform frequent crossed leg sitting stretches and improve the arch support of your shoes.

3. Balance - Walking is a bit difficult without good balance. Tai Chi, a martial art, has as its most important characteristics that it improves balance, endurance and ambulatory skills amongst its practitioners.

Knee pain can be of many origins. This article is not intended to be about knee pain differential diagnosis. Rather, consider that in the absence of arthritis, obesity or effects of specific injuries, many persons experience repetitive strain type injuries to knee structures simply due to loss of flexibility.

 

Particularly, the ilitotibial band (ITB), originating at the lateral pelvic crest extends downward (distally) to the lateral femur and lateral, proximal tibia. It helps stabilize the patella (knee cap) and contributes to hip motion. Repetitive knee bending (alternating flexion/extension) pulls the distal ITB medially (towards the opposite knee), across the distal end of the lateral femur (outer aspect), irritating the distal end of the lateral femur, irritating its insertion if the ITB is tight, resulting in lateral knee pain. It may also cause the patella to be pulled and shifted laterally (outward, away from the other knee) resulting in inflammation of the underside to the patella because of abnormal tracking (motion pattern).

 

If this is your problem, self-care should include a trial of sitting cross-legged, forcing the knees and lateral thighs to the floor slowly, for five minutes, three times per day. Alternatively, perform similar exercises sitting in a chair, one leg at a time with the the leg crossed, the lateral ankle sitting atop your distal thigh.

John Horn at the Los Angeles Times reported that Actress Natasha Richardson dies after skiing accident  The wife of actor Liam Neeson and member of the Redgrave theatrical family was 45.

Natasha Richardson, the luminous British actress from one of the world’s great acting families, died today. She was 45. The wife of “Schindler’s List” actor Liam Neeson and the daughter of actress Vanessa Redgrave and the late film director Tony Richardson died at Lenox Hill Hospital in New York.  Although the official  cause of death was not announced,  she had been hospitalized after suffering a devastating brain injury while skiing Monday.

There are specific legal mandates regarding use of protective headgear in motorcycling, bicycling, and  sports that place the athletes at risk such as football, baseball, softball and lacrosse. However, in spite of the risk of falls and injury, skiers rarely wear helmets.

In a previous posting we noted that numerous investigative resources suggest that we need to reconsider using our head for battering rams, targets in combative sports, or placing them at risk for other injury.  Head-on collisions are now suspected to cause longer-term effects than initially anticipated. A couple of concussions were found to result in slight mental deficits similar to those in Alzheimer patients when studied over time by researchers who recently published in the journal Brain.

Quite unfortunately, this particular sports/pastime activity accident resulted in more than slow degenerative brain disease. We mourn for Mrs. Richardson and her family.  Moreover, we ask all of you to please protect your heads.

The underlying cause of injuries is frequently inflexibility. Many people shy away from yoga either due to misunderstanding its purpose or a belief that its practice requires exquisite flexibility. However, the need for flexibility for preventing injury is one of the best reasons to adopt this activity.

Traditional yoga may be particularly challenging for persons with diagnosed inflammatory joint diseases, due to stretching of the joints and the frequent postural changes typical of a full workout routine. However, numerous introductory programs are sufficiently simple and appropriate for everyone. The following are a few exercises that may be performed in a chair, during your phase of moving from beginner to a full fitness program, and during breaks any time.

Long Torso

Sit up, back upright with arms straightened and overhead. Interlock your fingers, and reach for the ceiling alternating with your palms rotated upwards versus downwards towards you. Inhale and exhale slowly, holding a full breath versus fully exhaled for three second counts.

Crossing Shoulders

Hold a length-wise rolled towel at one end and toss the other end over your back. Reach around at waist height with your other hand, grasping the other end of the towel. While sitting up straight, pull the ends of the towel slowly up and down between the two hands, bending the elbows. Breathe deeply, inhaling and exhaling as you pull the towel ends.

Proud Rooster

Sit upright. Clasp your hands at waist height behind your back. Inhale slowly and deeply, straightening your spine, pulling in your gut, and sticking your chest out. Hold your breath with your chest out for a three count, exhale slowly and repeat the stretch.

Spinal Twists

While sitting upright, reach for, touch and hold the opposite side of the back of your chair. Inhale deeply upon touching the opposite side, hold for a five count, exhale and return to neutral posture. Repeat the maneuver in both the left and rightward rotational directions.

Hamstrings and Calves

Sitting upright in your chair, raise your foot until the leg points straight out in front of you. From that position, inhale deeply, hold your breath, and point your toes back towards you for a ten count. Perform five stretch sequences per leg.

You can perform these few exercises easily during short breaks at a sedentary job. Moreover, those of you who are older or who have not attended well to your conditioning status will find beginner’s yoga to be an easy way to transition to improved mobility. I also encourage those of you engaged at any level of sports and with jobs that are more physical to adopt more vigorous yoga routines to improve your flexibility and prevent injury via improved ligamentous fitness.

For additional information CLICK HERE

[contact-form]

Are you a sports fan or athlete? Numerous investigative resources suggest that we need to reconsider using our head for battering rams, targets in combative sports, etc. Head-on collisions are now suspected to cause longer-term effects than initially anticipated. A couple of concussions were found to result in slight mental deficits similar to those in Alzheimer patients when studied over time by researchers who recently published in the journal Brain. Dr. Maryse of the University of Montreal suggests that the findings are subtle and may not be noticeable unless comparing test performance against the never-brain injured. There appears to be a cumulative effect when considering that those with multiple concussions tend to fare worse than those with fewer injuries. The biopsy of nine-year NFL lineman Tom McHale, who died at age 45 years, demonstrated that he suffered from a severe degenerative brain disease called chronic traumatic encephalopathy, caused by repeated concussions. His biopsy was the sixth of six performed on deceased NFL player who died at ages less than 50 years old, all demonstrating evidence of severe traumatic brain disease. All six men developed severe emotional and behavioral problems after retiring from football, often associated with drug abuse and erratic behavior including suicide attempts. Dr. Anne C. McKee of Boston University reported similar findings in a recently deceased 18 year old who suffered multiple concussions playing high school football. Brain damage in these athletes was found to be similar to that found in boxers who have taken severe head blows, and similar to changes seen in persons with Alzheimer’s disease. These studies suggest that restrictions of certain activities and use of some or improved equipment needs to be considered with our younger athletes (children), and training techniques for soldiers and martial artists that involves blows to the head should be reconsidered. Presently, we have 5 year old athletes learning to make head shots while playing youth soccer. We need our brains functioning at a high level for our lifetime. We need to reconsider how to protect them long-term.