Explore Golfer's and Tennis Elbow, delving into their anatomy, biomechanics, and effective treatment solutions. Using a scientific approach, we present manual therapy (MSR) and exercise strategies to counteract the pain from repetitive elbow strain. Suitable for athletes or anyone seeking relief, this analysis provides an effective route to resolving these conditions.
Article Index
Introduction
Examination & Diagnosis
Treatment
Exercise
Conclusion & References
Introduction
Golfer's Elbow: Medial Epicondylitis
Key Anatomical Components:
Medial Epicondyle: The primary site of pain and inflammation in Golfer's Elbow, acting as an anchor for essential forearm muscles.
Common Flexor Tendon: A fibrous matrix connecting pivotal forearm muscles to the medial epicondyle, experiencing high tension during forceful gripping or wrist flexion.
Palmaris Longus and Pronator Teres Muscles: These muscles are responsible for crucial wrist flexion and forearm rotation, serving as the main drivers of forearm activity.
Vulnerable Structures:
Common Flexor Tendon: Susceptible to strain due to excessive gripping actions.
Palmaris Longus Muscle: Key in wrist flexion and contributes to forearm pronation.
Pronator Teres Muscle: Plays a dynamic role in forearm pronation and flexion.
Common Stressors:
Repetitive Golf Swings: The cyclic nature of the golf swing puts these structures under considerable stress.
Intense, Sustained Grip: Tasks requiring a strong grip can exacerbate symptoms.
Frequent Wrist Flexion: A common motion in various occupational and leisure activities, adding stress to the involved structures."
Tennis Elbow: Lateral Epicondylitis
Key Anatomical Components:
Lateral Epicondyle: The main site for pain and inflammation in Tennis Elbow, serving as an anchorage for muscles involved in wrist extension and supination.
Common Extensor Tendon: A robust tissue that links extensor muscles to the lateral epicondyle, grappling with tension during wrist activities.
Extensor Carpi Radialis Brevis (ECRB): Vital for wrist extension and abduction, aiding in complex wrist maneuvers.
Vulnerable Structures:
Origin of Common Extensor Tendon: Subject to stress from repetitive, strenuous movements.
ECRB Muscle: Prone to overuse in activities requiring continuous wrist extension or supination.
Supinator Muscle and Extensor Carpi Radialis Longus: These muscles assist in forearm rotation and extension and are implicated under specific stress conditions.
Common Stressors:
Tennis Backhand Stroke: A high-impact, repetitive activity that strains the involved structures.Continuous Wrist Extension or Supination: Frequently observed in occupational and everyday tasks.
Intensive Use of Extensor Muscles: Activities requiring persistent use of these muscles can push them to their functional limits.
Kinetic Chain Contributors
For a comprehensive understanding of Golfer's and Tennis Elbow, an in-depth analysis of the kinetic chain - the structurally and functionally interconnected system of musculoskeletal segments from the shoulder to the wrist - is imperative.
Shoulders: The Axis of Muscular Force Distribution
The shoulder girdle, a complex assembly of the scapula, clavicle, and humerus, forms the proximal aspect of the kinetic chain. Its anatomical configuration enables extensive degrees of freedom, permitting a wide array of movement patterns essential for sporting activities.
The rotator cuff, consisting of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, acts as a dynamic stabilizer, balancing movement initiation and joint stability. However, pathological postural adaptations such as anterior shoulder carriage (rounded shoulders) - prevalent in golf and tennis - can lead to musculotendinous strain and dysregulated biomechanics, possibly augmenting elbow stress.
Elbow: The Articulating Force Conveyor
The elbow joint, a sophisticated articulation involving the distal humerus, proximal radius, and ulna, serves as a critical fulcrum in force transmission from the shoulder to the hand. The medial and lateral epicondyles of the humerus - the attachment sites for critical forearm musculature - are the primary structures implicated in Golfer's and Tennis Elbow.
In medial epicondylitis or Golfer's Elbow, repetitive loading of the wrist and finger flexors generates excessive strain at their attachment on the medial epicondyle. Conversely, in lateral epicondylitis or Tennis Elbow, the muscles involved in extending the wrist, fingers, and supinating the forearm excessively load the lateral epicondyle.
Forearm: The Anatomical Orchestra of Fine Movement
The forearm, a dense network of muscles intricately arranged into flexor and extensor compartments, orchestrates the nuanced movements of the wrist and fingers. Encased in fascial compartments, these muscles are prone to developing myofascial adhesions due to overuse, resulting in pain and decreased range of motion.
Wrist: The Nexus of Kinetic Transfer
The wrist joint, a compound articulation where the distal radius, ulna, and the carpal bones meet, signifies the distal culmination of the kinetic chain. This joint plays an integral role in force transmission from the body to the hand, a critical aspect during actions such as gripping a golf club or a tennis racket. Dysfunctional biomechanics and muscular imbalances in the forearm can precipitate wrist discomfort and diminished grip strength, contributing to the complex pathophysiology of Golfer's or Tennis Elbow.
Integrated Approach: The Roadmap to Resolution
A successful treatment plan for these conditions calls for a thorough examination of the entire kinetic chain. By pinpointing and remedying areas of musculotendinous restriction, weakness, and biomechanical imbalance, clinicians can aid in reinstating optimal function and reducing the risk of further injury.
This all-encompassing approach may include advanced manual therapies, evidence-backed strengthening exercises, and targeted mobility work. It extends beyond merely addressing the symptomatic elbow, encompassing the shoulder, forearm, and wrist structures to ensure a thorough recovery.
The Nervous System: A Key Player in Elbow Health
The nervous system's role in elbow health is often overshadowed yet crucial. Besides soft tissue issues, nerve entrapment is a common problem, with Cubital Tunnel Syndrome being a notable example. This syndrome entails the entrapment of the ulnar nerve at the elbow's inner aspect and is a prevalent nerve compression issue in the upper limb.
Interestingly, around 60% of individuals with Golfer's Elbow also experience ulnar nerve compression, often reporting numbness or tingling in their ring and little fingers. Yet, practitioners should also consider cervical spine issues, known as cervical radiculopathy, as a potential source of numbness.
In cases of lateral elbow afflictions, like Tennis Elbow, compression of the radial nerve, termed "Radial Tunnel Syndrome," may occur. Some patients initially diagnosed with Tennis Elbow might actually be facing Radial Nerve Entrapment Syndrome. Thus, a thorough physical examination is crucial to avoid diagnostic missteps and plan an effective treatment strategy in cases of both ulnar and radial nerve entrapment.
Physical Examination
An accurate and thorough diagnosis is the cornerstone of effective treatment. In the case of conditions like Golfer's and Tennis Elbow, this means conducting comprehensive orthopedic, neurological, and vascular assessments.
Orthopedic tests allow us to evaluate the musculoskeletal system, including bones, joints, and soft tissues, to identify any structural issues or restrictions.
Neurological assessments help detect any nerve-related issues, such as nerve compression syndromes, and evaluate the health of the nervous system.
Vascular assessments are essential to examine the blood flow to the area, ensuring that any circulatory issues, which could influence healing and recovery, are addressed.
Together, these assessments provide a holistic understanding of the patient's condition, enabling the creation of a personalized and effective treatment plan.
Elbow Examination - Orthopaedic Testing
This video goes through inspection and observation, palpation, Active and Passive Ranges of motion, and orthopaedic examination of the Elbow.
Upper Limb Neuro Exam
The upper limb neurological examination is part of the overall neurological examination process and is used to assess the motor and sensory neurons which supply the upper limbs. This assessment helps to detect any impairment of the nervous system.
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is a valuable tool used for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video we go over some of the common procedures we perform in daily clinical practice.
Motion Specific Release
The upcoming videos showcase some of the Myofascial Release (MSR) techniques we frequently employ to treat our patients suffering from Golfer's or Tennis Elbow. These techniques encompass a mix of soft-tissue procedures and osseous (bone) manipulation. We firmly believe that effective treatment isn't just about focusing on the area of pain, in this case, the elbow. Instead, we broaden our approach to encompass the larger kinetic chain, when necessary.
This means we also address other interconnected muscles, joints, and fascia that could be contributing to the problem. By integrating the entire body into our therapeutic approach, we aim to not only alleviate symptoms but also address root causes and promote overall musculoskeletal health.
Elbow Release Protocol - Golfer's & Tennis Elbow
Each case of elbow pain should be assessed and treated as a unique dysfunction that is specific to that individual. Certain cases will only involve local structures, while other cases can involve a much larger kinetic chain. The MSR procedures I am demonstrating are very effective at addressing elbow pain.
MSR - Ulnar Nerve Release
As mentioned earlier, up to 60% of patients with Golfer’s Elbow also suffer from Ulnar Nerve Compression. (3) Patients with ulnar nerve compression often complain about sensory changes in the fourth and fifth fingers. They may also complain of trouble when opening jars, or turning doorknobs, or experience weakness when performing work that requires repetitive motion. In this video, we focus on releasing the ulnar nerve by using Motion Specific Release (MSR) procedures.
Exercise
The subsequent videos present a selection of exercises that we commonly recommend to our patients experiencing elbow discomfort. Please note, this is merely a snapshot of the potential exercises we could suggest, and these are shared for illustrative purposes only. These exercises aim to promote strength, flexibility, and overall elbow health for those dealing with conditions like Golfer's and Tennis Elbow.
5 Minute Elbow Pain Relief
Have a sore elbow? Then try our "5 Minute Elbow Pain Relief" routine. Doing this routine several times per day can make a huge difference in eliminating your elbow pain.
Five Great Daily Shoulder Mobilization Exercises
Elbow problems often involve restrictions in the shoulder. For best results, you can perform these exercises throughout your day. These exercises can make a huge difference in your posture, especially when you have been sitting for long periods of time.
Ulnar Nerve Flossing Exercises
If you have Ulnar Nerve Entrapment Syndrome (60% of patients with golfers elbow, then you can use the exercises in this video to floss, mobilize, and release this nerve from its surrounding tissues.
Conclusion
Understanding and addressing conditions like Golfer's and Tennis Elbow requires a comprehensive and nuanced approach. From unraveling the intricacies of the kinetic chain to diagnosing nerve entrapment syndromes, every facet plays a pivotal role in establishing an effective treatment plan. We must not only focus on the site of pain but also consider the entire interconnected system of muscles, joints, and fascia that could be contributing to the problem.
Through thorough orthopedic, neurological, and vascular assessments, along with implementing appropriate manual therapy and exercise regimens, we can offer personalized and effective strategies for our patients. As we navigate the path to recovery together, our goal is not only to alleviate symptoms but also to restore optimal function, promote overall musculoskeletal health, and prevent re-injury. This comprehensive, patient-centric approach is the bedrock of our practice and key to successfully managing conditions like Golfer's and Tennis Elbow.
DR. BRIAN ABELSON DC.
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
Revolutionize Your Practice with Motion Specific Release (MSR)!
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Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.
Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.
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References
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Peterson, M., Butler, S., Eriksson, M., & Svärdsudd, K. (2014). A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Upsala journal of medical sciences, 119(4), 352-359.
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