Tennis elbow, also known as lateral epicondylitis is a condition that causes pain over the outer aspect of the elbow. Up to 50% of all tennis players experience some type of elbow pain, and 75–80% of these elbow complaints are attributed to tennis elbow. It most commonly presents in men and women aged between 35 and 54 years.
The muscles of the forearm start at the elbow and end at the finger joints. So, the overuse of muscles at the outer aspects of the elbow leads to wear and tear at their origin. This ultimately leads to pain, swelling, and tenderness over the joint. Activities like turning a doorknob, gripping any heavy object, wringing clothes, etc. are painful.
The natural history of tennis elbow:-
the natural history of LE was between 6 months and 2 years, which has since been widely studied by researchers. In contrast, recent reports have shown that symptoms may persist for many years and recurrence is common. Another common reason explained by researchers states that , people who have a sensitive nervous system tend to develop tennis elbow easily and repetitively.
Risk factors for Tennis elbow:-
Office work, older age, being female,31 previous tobacco use and concurrent rotator cuff pathology are also significantly associated with LE.32Tennis elbow is common in variety of sports like squash, lawn tennis and fitness people like weight-lifters. So, the cause of pain in these players may not just be restricted to the elbow, but, may also originate from the neck or shoulder. Tennis elbow seen in sports players is usually more of a chronic problem which may require screening of the playing technique/ equipment as well.
symptoms of tennis elbow:-
how do we test and confirm tennis elbow at the clinic:-
The most common functional limitation in LE is pain on gripping, and this can be measured as pain-free grip strength, which is a reliable and valid measure that is more sensitive to change than maximal grip strength. With the patient lying supine, the elbow in relaxed extension and the forearm pronated, the patient is asked to grip a dynamometer until the first onset of pain, and the mean of three tests at 1-minute intervals is then calculated.
Elbow, wrist, and forearm range of motion, stress testing of the medial and lateral collateral elbow ligaments, and specific tests for elbow instability (eg, Posterolateral Rotary Drawer Test, and Table Top Relocation Test) are also assessed to aid the differential diagnosis of intra-articular and ligamentous pathology.
Evaluation of the cervical and thoracic spine and neurodynamic testing of the radial nerve are also helpful in identifying spinal contribution to pain.
Management for tennis elbow:-
There are many treatment options for tennis elbow ranging from simply taking medications or steroid injections to a short or long duration of physical therapy to surgery.
The treatment choice depends upon the stage and severity of tennis elbow.
In the initial stage, physiotherapy works to resolve pain and inflammation using either cold therapy or electrotherapy. Gradually, it works on the muscle conditioning to reduce the load on the overworked muscles and to make them work more efficiently.
The Physiotherapy treatment options involve:-
exercise,
manual therapy/manipulation,
orthoses,
laser OR,
Ultrasound OR,
acupuncture OR,
shock wave therapy (SWT).
All of these have been compared to placebo or control by various researches.
The fundamental behind our treatment motto is to resolve the tendinopathy which exists within the elbow ligaments. this is usually done by load management and the machine therapy is mainly aimed at aiding the exercise program. In our experience, a program of eccentric exercises with an elbow orthosis may provide greater global improvement at the end of treatment (around 6 weeks).
Kinesiotaping for Tennis elbowmyo therapy for Tennis elbow
Apart from physiotherapy, external supports can be used to control the pain. Cock-up splint is use when the pain is severe while, a tennis elbow strap can be used for mild to moderate pain.
if you have faced a tennis elbow previously and want to add a prehab to prevent the injury again, try this
Frozen Shoulder is a condition causing severe shoulder pain and difficulty in moving the arm in different directions leading to disability in daily life. The three hallmarks of frozen shoulder are:
1. Gradual shoulder stiffness
2. Severe pain (even at night)
3. Near complete loss of range of movement at the shoulder.
Laboratory tests and x-rays are usually normal.
There are 3 different stages of Frozen Shoulder: Stage 1: The Painful stage
This stage usually lasts for 3 to 9 months. The pain experienced is severe in nature causing difficulty in performing simple movements like reaching the back pocket of trousers or front pocket of a shirt.
Stage 2: stiffening phase
This phase usually lasts for 4-12 months, where the difficulty in moving the arm gets worst. Overhead activities like combing hair and other self-grooming activities like wearing a shirt may be restricted.
Stage 3: thawing phase
This phase lasts for 5-26 months. There is minimal pain but a significantly limited shoulder mobility. In this phase there may be gradual recovery of movements which can be further improved by mobility and stability physio rehab.
The few known causes for frozen shoulder are:
Existing medical problems like diabetes,
hormonal problems eg. post menopause or biochemical changes at the shoulder.
History of repetitive shoulder injuries,
post-surgery,
stroke, or
history of wrist fracture.
How Physio helps with Frozen shoulder?
On the 1st visit based on your symptoms and complains we first identify which stage of frozen shoulder you are in.
We at PhysioCure, we first identify the stage of frozen shoulder and the treatment program is designed as per your goals. You will be counselled about the process and duration required for the treatment program. The rehabilitation focuses on reducing pain and improving overall shoulder mobility. A combination treatment usually involves electrotherapy, manual therapy and/dry needling, taping along with the rehab exercises.
Usually the rehab lasts for 1 month to 6 months depending on the severity and the patient compliance with the programme.
How does diabetes affect frozen shoulder?
Due to increased glucose level in the blood, the soft tissues around the shoulder tend to become stiff leading to worsening of symptoms. It is usually common in both the sexes. A direct correlation is unknown, but controlling blood glucose along with physiotherapy will lead to better recovery.
Is Physio necessary inspite of taking steroid injections?
While steroid injections help to reduce the swelling inside the joint, it does not play an active role to help regain the shoulder mobility. This is where physiotherapy helps. With our customized rehab program you should be able to acknowledge the improvement within 4 weeks.
Chondromalacia patellae is a condition affecting the knee cap (also known as the patella bone) at the knee joint which results because the cartilage of the knee cap softens and undergoes wear and tear.
Pain & crepitus are most often experienced in and around the knee cap. You may experience difficulty in walking, running, climbing or descending stairs due to pain. This condition is seen more commonly in women than in men.
How does chondromalacia patellae occur?
The positional fault of the knee cap
Steroid injection at the knee leading to weakening of the articular cartilage
Osteoarthritis at the knee joint
Trauma
Post-surgical knee immobilization
Obesity
Overuse injuries, usually seen in athletes
symptoms:-
Anterior knee pain is the most common chief complaint of patients with chondromalacia. This pain is usually made worse with activities that increase the stress on the patellofemoral joint, for example, stair climbing, squatting, and running.
What activities must I avoid and for how long?
The best treatment is to avoid activities that compress the knee cap on the joint. This means avoiding going up and down the stairs and hills, deep knee bends(squats), kneeling, step aerobics, and high impact exercises(jumping, sprinting, etc). Do not wear high-heeled shoes. Do not exercise sitting on the edge of the table lifting leg weights (knee extension).
Sports that aggravate chondromalacia patella are:
Volleyball
Basketball
Soccer
Distance running
Raquet-ball
Squash
Weight lifting
Occasionally cycling
How can you prevent it?
In regular individuals or athletes, an exercise program to maintain on the overall leg strength and mobility should help in preventing this problem. In athletes, sports specific activities leading to increased wear and tear of knee cap should be examined and corrected by the appropriate coaches/trainers.
How Physio helps?
A Physiotherapy treatment program is based on correcting the mechanics of the knee and help in reducing pain and disability.
Are pain medications not enough?
Pain medications will certainly help in reducing pain but will not help correct the faulty mechanics at your knee. This may lead to frequent recurrence of the problem. Therefore, physiotherapy becomes an important part of the treatment.
What does the treatment process involve?
The treatment process includes correction of certain lifestyle factors affecting pain (weight, daily activities, footwear and many more). A combination of electrotherapy, Kinesiotaping and soft tissue mobilisation/dry needling is done along with neuromuscular retraining exercises.
What kind of knee support can you use?
Elastic knee cap with a small opening in the front for the knee cap
What immediate treatment can I do to reduce pain/ swelling?
Icing over the front of the knee joint for 10-15 mins helps.
Human anatomy showing wrong postures of using the phone. Wrong angle look at the device screen, causing a problem called “text neck”.
Life has taken a different turn in the year 2020, with the lock down bringing about a change in the workstyle for most people all over the world, the number of neck pain complaints have gone up. My observations are work from home has its side effects in the form of poor sitting posture, uncomfortable working posture, excessive house work all building upto neck pain.
Have u heard of Upper Cross Syndrome?
Well lets explore a physio take on this neck pain problems. in my clinical practice 90% of the clients have something called as “upper cross syndrome“.
these can be people experiencing Neck pain, Shoulder pain or sometimes even wrist pain. The usual routine is getting an x-ray done, being diagnosed as cervical spondylosis by a physician/ an orthopod and then referral for physio treatment. ocassionally clients directly contact me and yes!!! physio can be offered without any medicine referral in cases of neck pain.
How did u get this?
Think about it!! with modern day increased usage of computers/ laptop/mobile phones for work/ leisure and even for that matter for learning skills…… the kind of neck pain you may be suffering ….is all going to fall in the diagnosis of Upper Cross Syndrome
So what is this Upper Cross Syndrome?
Upper cross syndrome occurs when there is an imbalance between the muscles of neck , shoulder and chest as a result of poor posture. It is commonly seen in individuals who have long sitting hours with head pushed forward leading to faulty posture.
This imbalance of the muscles creates a joint dysfunction leading to symptoms like neck stiffness, unilateral headaches, tension and soreness along the slope of the shoulder or the front of shoulder. Ocassionally, it may also cause tingling and numbness along the arms, forearms and fingers as well.
Our routine examination for this problem!!
We first try to understand how the pain developed and what lifestyle factors cause the pain. This is followed by detailed examination of posture & current symptoms as well as identification of the weak and tight muscles around the neck shoulder and chest area. If required, certain specific movement control tests are performed. This process helps with diagnosis and designing a customised rehab program.
Correcting the muscle imbalance via physio treatment and making ergonomic/lifestyle changes usually reduces the symptoms.
An important part of physiocure’s treatment is focused on stretching out the tight muscles and retraining the lengthened muscles.
Rehab plan at Physiocure would include:-
A combination of manual therapy, soft tissue mobilization, neck kinetic control exercises, Kinesiotaping for posture correction along with electrotherapy treatment. if there is an existing shoulder problem then that is adressed as well. it is our obligation to not treat just the problem but help the person holistically
if you are currently facing neck pain and want to do something to help yourslef. then try these simple axercises to recduce neck pain.
Does the neck collar /posture correction brace help in solving this problem?
Neck collar is usually used as an external support to provide rest to the neck muscles. If it is a purely muscular imbalance leading to upper crossed syndrome, neck collar is not required. However, in few individuals, posture correction brace along with exercises has helped improve the outcome.
How long does this problem take to resolve?
Some clients improve in 5 sessions and few clientswho took 6 months over follow ups to improve. there are number of factors influencing number of sessions required; like how serious is the pain, what are the other adjacent problems, are u a complaint client, is your pain chronic. all these decide the numebr of sessions required.
Over the decades, a lot of work has been done in an attempt to reduce the negative impact of low back pain (LBP), and help patients recover and maintain a better quality of life. After the first episode of Low Back Pain, the risk of further episodes is quite high, with one-year recurrences ranging from 24% to 80%. The occurence of back pain is lowest in the youngest individuals, tends to increase between 30 and 60 years of age
What is Low back pain?
There are different definitions of low back pain depending on the source. According to the European Guidelines for prevention of low back pain, low back pain is defined as “pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain”
there are 3 basic different categories of low back pain based on duration:-
Acute:- Episode of low back pain for less than 6 weeks.
Subacute:- Low back pain between 6 and 12 weeks.
Chronic:- Low back pain for 12 weeks or more.
Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for one year after an acute episode.
Understanding Lower back anatomy (Lumbar Spine):-
The lowest part of the spine is called the lumbar spine. This area has five vertebrae. However, sometimes people are born with a sixth vertebra in the lumbar region. The lumbar spine’s shape has what is called a lordotic curve. The lordotic shape is like a backward “C”.
Physiotherapists sometimes look at a spinal segment to understand and explain how the whole spine works. A spinal segment is made up of two vertebrae attached together by ligaments, with a soft disc separating them. Each spinal segment is like a well-tuned part of a machine. All of the parts should work together to allow weight-bearing, movement, and support.
The paraspinal muscles refer to the muscles next to the spine. They support the spine and are the motor for movement of the spine. Your joints allow flexibility and your muscles allow mobility. When you experience a muscle spasm, it is because your muscle tightens up and will not relax. These spasms usually occur as a reflex – meaning that you cannot control the contraction of these muscles. When any part of the spine is injured including a disc, ligaments, bones, or muscles, the muscles automatically go into spasm to reduce the motion around the area. This protective mechanism is designed to protect the injured area.
The nerves of the lumbar spine then reach to your legs, bowel, and bladder. These nerves coordinate and control all the body’s organs and parts, and let you control your muscles. Damage to the nerves themselves can cause pain, tingling, or numbness in the area where the nerve travels.
Causes of Low back pain:-
Depending on various factors like age, gender, lifestyle, nutrition there are numerous causes of LBP:-
Bad posture
Overweight/ obesity
Sedentary lifestyle
Poor general fitness
Stress
Long working hours
Sudden injury/accident/trauma
Back pain in children:-
The impact of LBP on children and adolescents is significant with up to 94% of those with pain experiencing some degree of disability. Furthermore, it has been suggested that LBP experienced during childhood and adolescence increases the risk of LBP in adulthood, possibly through the development of maladaptive beliefs, behaviors, and attitudes related to the earlier pain events.
The spine of a child and adolescent is physiologically different from the adult spine (i.e. ligamentous laxity, bone composition, muscle mass) and therefore potentially responds differently to various interventions, movements, and loading. Although measures like back-related education and promotion programs have been tried other than traditional treatment, research says that they are not effective in reducing LBP prevalence in children.
Low back pain in pregnancy:-
These are known facts that approximately 50% of women experience low back or pelvic girdle pain during pregnancy; 25% continue to experience pain 1 year after delivery. Pelvic girdle pain is associated with a decrease in regular physical activity during pregnancy. But there is a wave of prenatal yoga, exercise programs for prevention and reduction of low back pain during pregnancy. Well here are the research findings
Research says:-
Being physically active during pregnancy did not reduce the odds of developing low back, pelvic, or lumbopelvic pain either during pregnancy or in the postpartum period.
Physical activity performed in various formats during pregnancy decreased the severity of low back, pelvic, and lumbopelvic pain during pregnancy and the early postpartum period.
However, compared with other cost-effective non-pharmacological treatments, such as interdisciplinary rehabilitation, acupuncture, spinal manipulation, or cognitive behavioral therapy, exercise is easily accessible as part of a self-management strategy, can require minimal equipment, and can be performed at home
Conclusion: Exercise appears to reduce the risk of low back pain in pregnant women, and sick leave because of lumbopelvic pain, but there is no clear evidence for an effect on pelvic girdle pain.
Low back pain in athletes:-
There is a relationship between back pain and physical activity. it is essential to prevent back pain but when the amount of physical activity is very high it can be the reason for developing back pain.
Elite athletes have a higher grade of physical activity and thus might have a higher risk of developing back pain. They spend much time in training and competition, which subjects their bodies to a great deal of mechanical strain and, thus, a high level of stress on the musculoskeletal system. Depending on the sports discipline, this stress is exceedingly high especially in the years from adolescence (14 years of age), in which elite competitive sports begin, until peak competitive performance at ages of up to 40 years.
As in the general population, back pain in athletes can lead to high costs of treatment, dropping out of training and competition, decreased quality of life, and limitations to performance. Research says “High physical loads, repetitive mechanical strain, and static or dynamic extreme body positions increase the risk of spinal overload and overuse” are the causative factors of back pain in athletes.”
In some sports disciplines, contact with an opponent and the resulting strain on the spine might be an additional risk factor for back pain. Traumatic spinal injury is more frequent (e.g., gymnastics, wrestling), in sports involving repetitive loading of the spine during motion or load extremes (e.g., gymnastics, cricket, weightlifting, rowing), and in sports in which the spine is subject to high-impact loads with sometimes unpredictable landing forces (e.g., horseback riding, volleyball). Due to the nature of these sports, it is not surprising that the incidence of intervertebral disc or spine abnormal
ties is higher.
A commonly encountered question is, can athletes play through pain? There is no simple answer to this question. For example, an athlete with suspected spondylolysis is generally advised that he or she should not play through pain, while athletes with chronic low back pain from muscular or ligamentous strain may continue to practice, exercise, and compete. However, there is little evidence to support either of these approaches. These athletes should always be monitored for their safety.
Hyperlordosis (lordotic low back pain) is the second most common cause of adolescent low back pain. This condition is related to adolescent growth spurts when the axial skeleton grows faster than the surrounding soft tissue, resulting in muscular pain. Other causes of low back pain unique to children are vertebral endplate fractures and bacterial infection of the vertebral disk.
Examination of Low back pain:-
The main aim of physiotherapy examination is to understand where the symptoms arise from and which movements tend to aggravate the pain. As the client walks into the clinic out examination begins with the observation of the way he/she walked in, he/she able to sit properly, what are the facial expressions.
A detailed history is taken understanding how the back pain started and what all has been done about it. followed by that the client’s movements are examined in standing and lying down and special test if required are carried out.
90% of the clients who walk in have been diagnosed with non-specific low back pain. only a few people fall in the specific diagnosis of low back pain.
Is it important to get an x-ray or MRI done before visiting a physio?
the answer is NO. Evidence confirms that clinicians should refrain from routine, immediate lumbar imaging in primary care patients with nonspecific, acute, or subacute LBP and no indications of underlying serious conditions.
Do you need to go to an orthopedic before visiting a physio?
A physiotherapist will examine your movements as well as your pain and is fully competent in diagnosing your low back pain. It’s ok to contact a physio directly for all your low back pain-related queries.
Management of low back pain:-
There are several treatment options available for back pain. the physiotherapy management is mainly aimed at improving the structures around the low back by treatment and movements and get the clients going back to normalcy. As more and more research goes into movement therapy, older approaches of using machines for low back pain have taken a back seat. there are newer exercise regimes available to cure low back pain.
Individualized physiotherapy has the potential of being more effective for people with LBP. Using the STOPS individualized physiotherapy protocol including manual therapy, directional preference management, postural re-education, motor control training, and graded functional exercise we have been able to treat more than 5000 patients successfully over the past decade. not only there has been a high level of patient satisfaction with this kind of approach but it is cost-effective as well.
The treatment program is customized according to your symptoms, capacity, and goals. It may include a variety of treatment options like electrotherapy, dry needling, manual therapy, Kinesiotaping, or a clinical Pilates-based rehab program targeting your core muscles. Generally, the first session can extend for an hour or more, then onwards as the program is designed the session usually lasts 30- 45 minutes.
try these core exercises for your back strengthening
Exercise therapy for back pain:-
here is what research has to say “Exercise therapy using individualized regimens, supervision, stretching, and strengthening was associated with the best outcomes. The addition of exercise to other noninvasive therapies was associated with small improvements in pain and function.”
A systemic review found segmental stabilizing exercises more effective in reducing the recurrence of pain in acute low back pain; For chronic low back pain, segmental stabilizing exercises were more effective than treatment from general practitioners.
At Physiocure, we teach segmental stabilizing exercises which gradually help to reset the normalcy in the lower back region.
Manual therapy in back pain
There is moderate evidence of short-term pain relief with acute low back pain treated with SMT. Chronic low back pain showed moderate improvement with SMT, which is as effective as NSAIDs and more effective than physical therapy in the long term
Acupuncture and back pain
Acupuncture is often used for LBP. We found moderate evidence of the benefit of acupuncture in patients with NSLBP ((sub)acute and chronic), which was mostly observed post-treatment. Significant effects were demonstrated with respect to pain intensity but not function when compared with sham or placebo acupuncture
Pilates:-
Pilates is a system of exercises widely used in patients with low back pain. The practices based on this method have promoted the restoration of the function of muscles involved in lumbopelvic stabilisation, that is, transversus abdominis, multifidus, diaphragm, and pelvic floor muscles. During each exercise, specific principles of this method should be followed to restore or sustain the motor control of the lumbar spine and proper body posture. no conclusive evidence was found that Pilates is superior to other forms of exercise.
Contraindications comprise unstable fractures, with caution required in unstable spondylolisthesis and radiculopathy. Potential risks can include: increase in low back pain, aggravating pathology, excessive muscle tension, or even self-injury during exercises.
Pilates exercises should be administered more than two to three times a week, with a session lasting a minimum of 60 min, within at least 20 sessions (20 hours).
Bracing/Lumbar Supports
Braces are not effective in preventing back pain. However, there is conflicting evidence about whether braces are effective supplements to other preventive interventions. Bracing, in combination with activity restriction, is effective in the treatment of spondylolysis in adolescents. A meta-analysis of 15 observational spondylolysis and grade 1 spondylolisthesis treatment studies did not find a significant improvement in rates of healing with bracing when compared with conservative treatment without bracing. Most experts recommend surgical consultation for spondylolisthesis with 50% slippage or more (grade 3 and higher).
References:-
Zaina F, Balagué F, Battié M, Karppinen J, Negrini S. Low back pain rehabilitation in 2020: new frontiers and old limits of our understanding. Eur J Phys Rehabil Med. 2020 Apr;56(2):212-219. doi: 10.23736/S1973-9087.20.06257-7. Epub 2020 Mar 25. PMID: 32214063.
Eliks M, Zgorzalewicz-Stachowiak M, Zeńczak-Praga K
