Tennis Elbow (Lateral Epicondylitis)
Tennis elbow is a form of tendonitis and you don´t have to go anywhere a tennis court to get it! Tendons are largely made of collagen which has a very high tensile strength. They connect muscles or muscle group to their boney attachment and do not have a great blood supply which is why once you have it – it is difficult to get rid of. If the tendons were pitted with the fine capillaries which bring the blood supply then the tendons would not be as strong as they are.
The muscle groups involved in Tennis Elbow are those that bring about grip with some extension to the wrist and attach to the outer knobbly bit of your elbow. A good topspin backhand will do well to bring on TE but so will repetitive gripping activities and carrying a heavy load.
In the yachting world we see this a lot among the engineers lifting heavy tool boxes in confined spaces as well as tight grips with the tools themselves, sanding, painting and carpentry work are all good examples of the kind of repetitive activities which can bring on TE. If you consider that the average tool box or suitcase will weigh in at 30 kilos plus,it is a lot of pull on very small area.
The symptoms of Tennis Elbow include pain and tenderness in the bony knob on the outside of your elbow and difficulty locking it in full extension. The pain may radiate up or down the arm and there may also be some swelling or redness of the skin.
Simple activities will bring on pain and a weakened grip such as opening a door, trying to pour your glass of wine or reaching something out of the fridge.
So what can you do about it?
Complete rest would be ideal but unfortunately most of us can´t do this so protecting the tendon from repeated stress is the first thing to consider. There are many TE supports on the market from expensive rigid supports attaching at the elbow and wrist to a more humble neoprene and velcro band. Our patients often find these cumbersome and awkward at work as they can catch on clothing. An alternative is to use cohesive bandaging. This form of bandage sticks to itself and not the skin and can be loosened and tightened easily as required during your day. 3 turns around the widest part of the forearm is sufficient and you should find that the pain is diminished when you grip.
Ice at any opportunity during the day for a good 15 minutes each time until the area is red. Don´t be too stingey, it is important that the whole elbow is cooled not just the knobbly epicondyle.
Anti-inflammatory gels and creams will also help and can be purchased at the pharmacy without prescription.
If there is no improvement then it is time to call your physio. They will use techniques such as frictions, passive stretching, interferential diathermy and ultra-sound to encourage healing and repair.
If the problem is being particularly stubborn then oral non-steroidal anti-inflammatories may be prescribed.
In some cases, particularly if your elbow is a repeat offender, your physio may refer you to an Orthopaedic surgeon for infiltration of steroids into the area. This injection quickly reduces pain and combined with physiotherapy produces good results however the infiltration on its own may not necessarily be a definitive cure.
Knee Cartilage (Meniscal) Tears
The knee is the biggest joint in the body and it has to put up with a lot of impact and torsion. It is comprised of 3 bones, the thigh (femur) shin bone (tibia) and the kneecap (patella). Unlike the hip and shoulder ball and socket joints, the knee does not have a lot of inherent stability and relies heavily on the quadracep and hamstring muscle groups for support.
The femoral end of the articulation has 2 rounded surfaces called condyles, the inner condyle is slightly longer that the outer and this gives the knee its ability to twist slightly. It also means that the inner cartilage is the more vulnerable. The tibial end of the knee joint has only 2 shallow recesses which on their own offer very little stability. This is where the cartilages or menisci come in to play.
A meniscus is a ¾ moon shaped piece of cartilage with a thicker outer rim than it´s centre. This shape enhances the concavity and so gives the knee joint that bit more stability. There are two, one for the inner and one for the outer compartments and they also serve as sacrificials, bearing the brunt of the knees hard labours.
Over time these cartilages can wear depending upon your activities.
The cartilages (menisci) are particularly susceptible to twisting on a bent knee. This is why footballers frequently suffer meniscal tears. When they go for a kick their full weight is on the supporting leg which is bent and rotates as the kick is followed through.
Other sports prone to this are squash and snow-boarding to name a few.
The menisci cannot really be seen on an X Ray but any narrowing in the gap of the inner and outer joint spaces between the femur and the tibia is a good indication that there may be damage. The only way to establish a meniscal tear is with a Magnetic Resonance Scan (MRI). There are many different types of tears of the meniscus and their names tell us where they are in the knee joint eg. Posterior Tag Tear, Transverse or Longitudinal Tear. If the results of your scan read Foreign Body, don´t panic! nothing has actually entered your knee as this is the description given when a piece of cartilage has broken off and is floating freely around in the knee joint.
Many of us probably have existing tears and foreign bodies and not even know it as they are not producing any adverse symptoms. As I mentioned, the menisci are sacrificials and tiny slivers may shave off over our lifetime. It is only when these slivers or tears get caught in the mechanics of the joint that the symptoms begin.
These symptoms include pain after exercise accompanied by swelling and/or locking of knee usually when standing from sitting or the knee may give way which is particularly noticeable when going downhill or descending stairs.
If these problems persist physiotherapy can help the symptoms and frequently gentle manipulation of the knee can free up the mechanism. I have had patients who have had few if any problems since the original diagnosis and subsequent treatment.
The menisci, like a broken finger nail cannot repair themselves as they have no blood supply. If symptoms persist the best solution is surgery.
Your surgeon will likely choose to perform an Arthroscopy which is keyhole. There are normally two small incisions, one for the camera and one for the tools. The surgeon will take away the tag tear and generally “hoover up” the foreign bodies in the joint space.
There is usually an overnight stay in hospital although it can be done as day surgery.
The patient will wake up to a think compression bandage from mid thigh to calf which is applied to help any post operative swelling. This is removed before discharge from hospital. Crutches will be necessary for walking as it is not advisable to fully weight bear during the first week as any irritation will only delay recovery. At this stage you should attend for physiotherapy straight away for treatment to speed up the healing process and to assess when you can increase the weight bearing walking through to running again.
Arthroscopic surgery is a very successful solution for cartilage tears. Any post-operative complications and delayed recovery are often caused by the patient weight bearing too early so do check with your physio before dropping the crutches.
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