Monthly Blog

Lateral Epicondylopathy AKA Tennis Elbow

Tennis elbow, also known as lateral epicondylitis, is a condition that causes pain and inflammation in the tendons on the outside of the elbow. Initially it may start as a tendonitis (First six weeks of inflammation). For many it progresses to a tendinosis, where the tendon actually becomes thickened and relatively avascular.

Tennis elbow is usually caused by activities involving repeated gripping and wrist extension, like playing tennis, but also from other manual tasks like painting, using a screwdriver, or typing on a computer, where the forearm muscles are constantly engaged and can become inflamed over time; even though not all people with tennis elbow play tennis.

Up to 50% of all tennis players develop symptoms due to various factors including poor swing technique, the use of a heavy racquet, or poor proximal/shoulder stability and strength.

  • Common postural findings: anteriorly tilted/protracted shoulder girdle, scapular winging, internally rotated humerus/upper arm bone.

  • Common ROM findings: limited neck and shoulder mobility, decreased thoracic rotation, painfully limited elbow and wrist motions 

Notably the combination of elbow extension and pronation with wrist flexion > the tennis serve

  • Common strength findings: poor Scapular strength/stability, rotator cuff weakness, and decreased grip strength.  

What about Pickleball Elbow?

  • Lateral epicondylopathy is actually quite common in pickleball players

  • Pickleball is often branded to people as “easier tennis” therefore many are trying a new sport for the first time without any experience in playing racquet sports

  • Style of play is more similar to table tennis, however you have a much larger paddle therefore more torque on the elbow

Treatments:

Cortisone injections

  • can temporarily relieve pain from tennis elbow in the short term

  • Some studies have shown in the long term that cortisone can increase the risk of continued pain or relapse one year later. Other studies found that people who received cortisone injections had more pain after a few months than those who didn’t receive any injections

  • Covered by many insurance plans

    PRP- Platelet rich Plasma

  • A medical professional removes a small amount of blood from the patient's arm, spins it in a centrifuge to separate the blood components, and then injects the platelet-rich plasma into the injured area. The plasma contains growth factors that help stimulate healing and tissue regeneration

  • A single PRP treatment typically costs $500 - $2500, and repeat treatments may be required. 

  • Few insurance plans cover the cost

  • While PRP injections are a well-studied treatment for tennis elbow, randomized controlled trials have reported inconsistent results.

    Stem Cells

  • Uses patients own stem cells to help the body heal damaged tissues 

  • Doctor draws blood from the patient to extract bone marrow from the hip

  • Accelerates healing: Stem cells help the body's natural healing process, which can lead to faster recovery.

  • Reduces pain and inflammation: Stem cell therapy can help reduce pain and inflammation in the elbow.

  • Stimulates collagen production: The process of stem cell therapy stimulates collagen production, which helps keep connective tissue strong.

  • The cost of stem cell therapy can range from $5,000 to $50,000, not covered by insurance

Shockwave Therapy/ Radial Pressure Wave

  • A handheld device sends low-energy sound waves into the injured area,

    which increases blood flow and stimulates healing. 

  • Shockwave therapy can relieve pain and improve grip strength. It's non-invasive,

    doesn't require surgery or injections, and can lead to long-term relief.

  • A course of 4-6 treatments is usually recommended, with each session lasting

    a few minutes and occurring once a week

  • Not covered by insurance, $80-$300/ session 

  • Based on the existing clinical evidence, extracorporeal shock wave therapy can effectively

    relieve the pain and functional impairment (loss of grip strength) caused by tennis elbow,

    with better overall safety than several other methods- 

  • -Meta-Analysis Yao Et Al, 2020 Mar 18:2020:2064781. doi: 10.1155/2020/2064781. eCollection 2020.

How does it work?

  • Acoustic sound waves penetrate up to 2 inches into the target tissue. 

  • Creates a biochemical response to help with cell proliferation

  • Nitric oxide releases and promotes vasodilation and neovascularization 

  • Helps to regulate the immune and inflammatory response 

  • Cavitation creates energy release imposing a stress on the cells to stimulate tissue regeneration and promotes the body’s ability to heal itself

  • Analgesic- decreases substance P levels and reduces c-fiber number in the target tissue to decrease substance P synthesis at the dorsal root ganglion (substance P is a neuropeptide that is involved in transmitting pain signals)

    What does it do to the tissue?

  • Reduces fibrotic tissue 

  • Scar tissue remodeling

  • Tenocyte proliferation- tendon regeneration/ remodeling

  • The energy in RPW creates microscopic trauma and stimulates the development in new blood vessels and collagen production in the area

  • Side effects: redness, bruising, local discomfort

  • Best when combined with stretches and exercise

  • NO KNOWN ADVERSE EFFECTS 

None of the above will be good long term solutions and you’ll waste A TON of MONEY if you do not CORRECT why you developed lateral epicondylopathy in the first place… 

Comprehensive full body assessment of your individual motion starting from your neck down to your toes

We look at posture, range of motion, strength and stability with consideration of individual ADL's, occupational activities, and recreational/professional athletic goals.

Toe Awareness and foot strengthening

Foot and toe strength- why is it important? Toe weakness is actually the SINGLE biggest predictor of falls as we age. Toe weakness is also a risk factor for developing plantar fasciitis. At age 50, it takes 20% more pressure to simulate the proprioceptors in your feet. By age 85, there is a 75% decrease in sensitivity to these proprioceptors. If you exercise your feet, you increase circulation to your sensory nerves which decreases pain and increases sensation/ joint proprioception. The important muscles to focus on here:

  • Abductor Hallucis- this muscle helps to straighten the big toe. If your big toe is starting to deviate away from midline (bunion) this muscle is SUPER important. This muscle runs along the medial arch of your foot

  • Flexor digitorum brevis-runs parallel to the plantar fascia. This muscle aides in deceleration of toe extension when we walk. This is important because this is the muscle that SLOWS DOWN PRONATION. Pronation of the foot is normal and helps with shock absorption, but can be problematic if it is happening too quickly or excessively. Good gait mechanics is all about CONTROL and SLOWING DOWN the movement.

  • Transverse metatarsal ligament: When your toe is able to splay while you walk, it triggers receptors in the deep transverse metatarsal ligament to give you stability through your plantar fascia. Forefoot splay helps the whole foot get ready to get strong and stable. Using toe spacers daily and having footwear with a wide toe box to allow forefoot splay is crucial for foot function. This is particularly important when choosing kids shoes. I have a link to the toe spacers and shoes on my recommended products page.

Video 1: Toe Yoga is a great way to find the general awareness of your foot and start to develop some dissociation and control.

Video 2: Progression of strengthening- think 40-50 reps, we want ENDURANCE for walking, hiking and running!


Thoracic Spine

If you spend a significant amount of time at a desk or looking at your phone, this is a great way to keep your thoracic spine moving. One major takeaway from learning and practicing the SFMA for the last two years is how important your thoracic spine range of motion is. Having poor thoracic range of motion can cause excessive strain at your neck, loss of scapular stability leading to shoulder pain and low back pain to name a few. This is a great stretch utilizing your lungs and diaphragm to help mobilize your mid back. For the step by step written instructions please visit my YouTube channel @mobilitycollectiveco

Foot Pain

One of the most common sources of foot and heel pain is a condition many of us are familiar with called Plantar Fasciitis. There are three main factors that predispose someone to getting plantar fasciitis. The first risk factor is overuse- too much, too soon with too little training which creates inflammation and pain, especially that first step out of bed in the morning. The second risk factor is limitations in dorsiflexion, which is the ability to translate your tibia (shin bone) over your foot. The third risk factor is weight gain therefore this can be very common in pregnancy. Typically, plantar fasciitis starts as an inflammatory condition which progresses to a fasciopathy and can persist, on average, for 9-12 months.

Treatment should including having your dorsiflexion assessed- both with and without taking the gastrocnemius muscle into consideration. Is the muscle restricted, or is the joint restricted. Is it talus on tibia or tibia on talus, or another bone at fault. Orthotics can be used in some instances, however if you take an ankle that already doesn’t move and slap an orthotic on, you create a greater loss of movement which can transfer up the chain and create compensation at the knee joint. The quickest way to treat plantar fasciopathy is to use shockwave treatments to expedite healing and improve blood flow if the condition has persisted more than 6-8 weeks. This should be accompanied by stretching usually of the heel cord, dorsiflexion mobilization and foot strengthening exercises. If your condition was from overuse, another great remedy is to decrease the amount of weight bearing activity you are doing. So if you’re a runner, try cycling instead for a while to allow the structures to heal. Follow along in the next blog for videos of exercises given to support the plantar fascia.

Pickleball & Injury Prevention

Pickleball has taken the world by storm. In the United States, Pickleball is the fastest growing sport for the third year in a row. The only problem is, pickleball is described as a less aggressive form of tennis therefore it attracts people who may have never played a racquet sport, whether newly retired or just out having fun. It is critical to perform a dynamic warm up prior to playing to reduce injury risk. My best advice is to arrive at the court 30 minutes prior to playing. Walk or jog two laps around the courts and do a series of dynamic movements (as in the video below) prior to playing.

Top 5 injuries from Pickleball:

1: Ankle sprain. Make sure you are wearing court shoes and not shoes have tall soles. Don’t get me wrong, I love me some Hokas, however these may substantially increase your likelihood of sustaining an inversion type injury.

2. Achilles tendonitis and/or rupture. There is where a dynamic warm up is particularly helpful. Statistically speaking, men in their 40s who make a sudden movement without properly warming up are at higher risk for an achilles rupture.

3. Hamstring or quadriceps strain. Often happens from lunging to make a shot. Again, take a few laps around the court and do a dynamic warm up to avoid straining your muscles through quick movements.

4. Shoulder impingement/ rotator cuff tear. Some people may have never played the sport and being playing without proper scapular control/ shoulder stability. This can lead to creating excessive strain to the shoulder as well as lateral elbow pain. For the sake of this article we’ll call it pickleball elbow, though not sure that’s actually a thing.

5. Wrist fractures from a LOB, or as well call it in therapy land, loss of balance. Warming up and performing quick motions will prepare you to avoiding losing your balance for those shots that are high and may require quick backward movements.