Epicondylitis lateralis

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Epicondylitis lateralis

Postby Roka » Sat Jul 07, 2012 9:18 am

I've just got it. Any experience how to train your arms after the treatment ?
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Re: Epicondylitis lateralis

Postby Mike » Sat Jul 07, 2012 2:22 pm

Which treatment did you get?

I had it twice, and each time acupuncture did the trick for me.

And after a period of resting, I began to practice conga, type and write
with less force, use screwdrivers etc. in a relaxed but not altogether flabby or wobbly way.
This helped me. For really hard physical work (which I am not used to) I bought some bandages
for my elbow joint which have a pressure point on the part of the bone where the sinew starts.

I hope there is a solution for you too. Good luck!
Peace & drum
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Re: Epicondylitis lateralis

Postby jorge » Sat Jul 07, 2012 2:43 pm

Epicondylitis lateralis or lateral epicondylitis is also known as tennis elbow because around 10% of tennis players have it (generally from improper technique playing tennis), but there are many other causes as well. It is a muscle and tendon injury of the muscles that attach across the elbow to the bony prominence of the humerus (upper arm) on the outside (lateral) side. The first question for you, assuming your doctor's diagnosis is correct, is why you have it.
Risk factors for lateral epicondylitis include repetitive activities for more than 2 hours a day and forceful activity, including lifting or managing heavy loads. Smoking and obesity are sometimes additional contributing factors. Playing congas is potentially a cause, and I have seen lateral epicondylitis in conga players, but other activities are much more common causes in most countries outside Cuba. Do you do any other repetitive forceful hand activities besides playing congas? Some occupations involve such activities, as well as some sports besides tennis.
Recommended treatments include rest, stretching and strengthening, appropriate use of a splint, and, probably most important, modification of the repetitive and/or forceful forearm activities that have caused and aggravated the lateral epicondylitis.

Your question about training after treatment is the central question. I would expand on this by saying:
1) The first and most important step is to confidently identify the repetitive and/or forceful hand and forearm movements you do frequently that are likely causing or aggravating your condition.
2) If playing congas, bongo, bata or other hand percussion instruments is high on the list, the main issue you need to explore is your playing TECHNIQUE.
3) Since the anatomy and biomechanics are somewhat complicated, and most doctors are not knowledgeable in the details of hand drum technique, you need to find real experts. In my view (as a physician) the experts you want to consult are older hand percussionists who have played the instruments you play every day for their entire lives and have no tendinopathy problems. These are the guys that have developed hand techniques that are not self-injurious as evidenced by their freedom from injury, but they are not easy to find. I have found that learning hand technique from older Cuban rumberos and bataleros has been the best. They generally don't know the anatomy or biomechanics, but they do know how to get the best sound without hurting your hands. They can watch you play and critique your playing technique so you can work on correcting it. Watching great younger players play can help, but some of the best players I have talked with have serious hand pain and a few have lateral epicondylitis. You want to find the older very experienced guys who don't have lateral epicondylitis. Probably the best way, if you speak Spanish, is to go to Cuba a few times, find a few teachers and ask them, among other things, about hand and arm pain. The guy I learned from was Regalao from Afrocuba de Matanzas, but he is now retired and not playing anymore. Learn your rhythms and playing from the best players, but learn your hitting technique from the few guys who you know play a lot, play competently, and don't have hand and arm pain. A fun but not easy assignment!

You may wind up having to learn by trial and error like most rumberos have learned, which is a slow process since tendinopathies like lateral epicondylitis can take months to heal. Start by learning hand technique from great players and from carefully practicing your sounds and hand technique every day. Aim for clear, loud slaps and tones with minimal force, which takes years to master and apply to your playing. If you play with amplified or loud bands, get and learn how to use a good mic, and insist on using it whenever sound levels are loud. Here is some medical information from a reliable source (UpToDate) about lateral epicondylitis. The prevention section is not written for conga players so may not be that useful. Almost all the recommended prevention techniques involve reduction of work activities with the hands, which is not practical if you are a musician and playing music is causing your problem. Hence the more difficult focus on proper hand technique.

_____________________________________________________________________
Below is a topic taken from UpToDate that I thought you might find interesting.

UpToDate is a clinical information service that has thousands of topics such as this one, designed to give immediate answers to clinical questions. Visit them on the web at http://www.uptodate.com.


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©2012 UpToDate ®
Official topic from UpToDate®, the clinical information service on the web and mobile devices. To subscribe to UpToDate®, visit us online at http://www.uptodate.com/store.


The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2012 UpToDate, Inc.


Patient information: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)

Author
Neeru Jayanthi, MD Section Editor
Karl B Fields, MD Deputy Editor
Jonathan Grayzel, MD, FAAEM

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2012. | This topic last updated: Oct 11, 2011.


INTRODUCTION — Tendons are tough bands of tissue that connect muscles to bones. There are several types of tendon problems (called tendinopathies):


Repetitive activities and sudden trauma can injure tendons and lead to inflammation, pain, and difficulty using the joint. This is called tendinitis.
As people age, tendons can break down (degenerate) or even tear; this is called tendinosis. Symptoms of tendinosis usually last more than a few weeks.
Less commonly, tendon problems can be caused by other conditions, including rheumatic diseases.

Tendinopathies are common problems. The risk of having a tendinopathy increases with age and is greater in people who routinely perform activities that require repetitive movement that increases stress on susceptible tendons.

Treatment of tendinopathy focuses on resting and protecting the injured tendon so that it can heal, inflammation can resolve, and muscle strength can improve. In most people, tendinopathy resolves with little or no treatment.

Tendinopathy can affect many different tendons in the body. Separate articles discuss other types of tendon problems. (See "Patient information: Biceps tendinitis or tendinopathy (Beyond the Basics)" and "Patient information: Rotator cuff tendinitis and tear (Beyond the Basics)".) More detailed information about elbow tendinitis is available by subscription. (See "Epicondylitis (tennis and golf elbow)".)

WHAT IS ELBOW TENDINOPATHY? — Tendinopathy (tendinitis or tendinosis) is the most common condition affecting the elbow.


It is called "tennis elbow" or lateral epicondylitis when there is an injury to the outer elbow tendon
It is called "golfer's elbow" or medial epicondylitis when there is an injury to the inner elbow tendon

However, elbow tendinopathy can be caused by sports other than golf and tennis, as well as work-related activities that involve heavy use of the wrist and forearm muscles.

ELBOW TENDINOPATHY SYMPTOMS — Elbow tendinopathy most often affects the dominant arm (ie, the right arm in people who are right-handed, etc.). Symptoms include:


Pain in the elbow that spreads into the upper arm or down to the forearm
Weakness of the forearm
Pain can begin suddenly or can develop gradually over time
You might have a harder time with activities that require arm strength, including sports that require you to hit backhand or throw a ball

ELBOW TENDINOPATHY DIAGNOSIS — Elbow tendinopathy is usually diagnosed based on an exam and your description of pain.

ELBOW TENDINOPATHY TREATMENT

Pain relief — If needed, you can take a pain medicine, such as acetaminophen (sold as Tylenol® and other brands), ibuprofen (sold as Advil®, Motrin®), or naproxen (sold as Aleve®). (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".) You should not take more than 4000 mg of acetaminophen per day. If you have liver disease or drink alcohol regularly, you should speak with your doctor or nurse before taking acetaminophen.

Arm brace — A tennis elbow brace or strap applies pressure to the muscles of the forearm, reducing pressure on the injured tendon in the elbow. You can use the brace or strap while working or playing sports. Apply the brace so that the cushion is resting on your forearm muscles, about 3 to 4 inches (10 cm) from the tip of the elbow bone. You may need to wear the brace for up to six weeks. Avoid wearing a wrist splint (which prevents your forearm from moving).

Flexibility exercises — Flexibility exercises can help to improve your arm's strength and ability to move.

Tennis elbow — While standing or sitting upright, hold your injured arm straight out in front of you and point your fingers down toward the ground. With the hand of the uninjured arm, grasp the hand of the injured arm, thumb pressing on the palm, and try to bend the wrist further (picture 1). Hold for 30 seconds; repeat three times. Perform this stretch daily.

Golfer's elbow — Stand at arm's length away from a wall, with the affected arm closest to the wall. Place the palm against the wall with the fingers pointing down. Apply gentle pressure to the hand. Hold for 30 seconds; repeat three times. Perform this stretch daily.

Strengthening exercises — A special type of strengthening exercise is used to treat elbow tendinopathy. You can start these exercises once your flexibility has improved and you have little or no pain with the strengthening exercises.

Tennis elbow — People with tennis elbow should perform eccentric extension exercises (figure 1). You should expect to feel some mild discomfort with these exercises. If the pain becomes sharp or is more than moderate, stop the exercise and rest for two to three days. Restart with fewer repetitions.

Golfer's elbow — Golfer's elbow is treated with eccentric flexion exercises. You should expect to feel some mild discomfort with these exercises. If the pain becomes sharp or is more than moderate, stop the exercise and rest for two to three days. Restart with a lighter weight or fewer repetitions.

Sit with your arm supported (on a table) at shoulder height. The back of your hand should face the floor, and your hand should hang off the table. Start with your elbow bent, which is less painful, then progress to keeping your elbow straight. Hold a 1 pound weight in the hand. Using the unaffected hand, lift the hand with the weight toward the body (keep the arm flat against the table).

Move the unaffected hand away, and slowly allow the affected hand (with the weight) to drop. Repeat 15 times, then rest one minute. Repeat two more times. Perform five times per week.

After one week, try to lift the hand with the weight without assistance. Increase the weight by 1 to 2 pounds per week. Do not increase the weight unless you can complete 15 lifts.

Kinetic chain — If you play a sport that requires arm strength (such as tennis or golf), hold a 1 to 2 pound weight in your hand and reproduce the wrist and elbow motions of your sport. At the same time, brace your lower body and core (back and abdomen) muscles.

Then, replace the weight with a golf club or tennis racket and practice your swing (without the ball). If you do the exercises incorrectly, you may feel more pain. If you have pain with strengthening exercises, consider seeing a rehabilitation specialist, such as a physical therapist or athletic trainer, to help supervise your recovery.

When will I feel better? — Most people respond well to treatment. You might have some pain during work or sports for up to 6 to 12 weeks. Some people will need formal rehabilitation with a physical therapist.

If your pain persists, an injection into the painful tendon might help to relieve pain. In addition, there are many new treatments being developed to promote tendon healing, such as using blood products, shock wave therapy, acupuncture, and nitroglycerin patches. Surgery is not usually needed unless symptoms have not improved after six or more months of treatment. (See "Epicondylitis (tennis and golf elbow)".)

ELBOW TENDINOPATHY PREVENTION — A healthy elbow requires a healthy shoulder and wrist joint and strong muscles around the scapula (shoulder blades) and arms to decrease the load on the smaller forearm muscles.

To prevent overuse and strain in the elbow and forearm:


Take frequent breaks from activities that require extensive hand/wrist motions.
Reduce or avoid lifting objects with the arm extended.
Reduce repetitive gripping and grasping with the hand and wrist. Decrease the overall tension of gripping.
Avoid the extremes of bending and full extension.
Work or weight-train with the elbow in a partially bent position. Use wrist supports when weight-training.
When using tools, increase the gripping surface by wearing gloves or adding padding. Use a hammer with extra padding to reduce tension and impact. Hold heavy tools with two hands.
Use a two-handed backhand in tennis. When hitting a tennis stroke, use your entire lower body, hip, pelvis, and back, and use less of your elbow. Using the proper technique in tennis can help reduce symptoms. Reevaluate the size of your grip, string tension, type of string, new strokes, and new grips for new strokes, which can all contribute to problems.

Some suggest lowering string tension, finding the heaviest racket that does not affect your swing speed, finding the largest grip that is comfortable, and using softer strings.
Apply grip tape or an oversized grip on golf clubs.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (http://www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Bursitis (The Basics)
Patient information: Biceps tendinopathy (The Basics)
Patient information: Elbow tendinopathy (tennis and golf elbow) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Biceps tendinitis or tendinopathy (Beyond the Basics)
Patient information: Rotator cuff tendinitis and tear (Beyond the Basics)
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)


Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Elbow injuries in the young athlete
Epicondylitis (tennis and golf elbow)
Evaluation of elbow pain in adults

The following organizations also provide reliable health information.


National Library of Medicine

(http://www.nlm.nih.gov/medlineplus/healthtopics.html)


American Academy of Orthopaedic Surgeons

(http://orthoinfo.aaos.org/main.cfm)

[1-3]



Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1 De Smedt T, de Jong A, Van Leemput W, et al. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. Br J Sports Med 2007; 41:816.
2 Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006; 333:939.
3 Smidt N, Assendelft WJ, Arola H, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med 2003; 35:51.

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Re: Epicondylitis lateralis

Postby JohnnyConga » Sat Jul 07, 2012 4:33 pm

I have been playing for 49 years and have never had any of these problems while playing..YES technique is everything, but also sitting at the right height, breathing and relaxing the body, NO TENSION, FROM THE ARMS OR CHEST AREA,while 'stroking" the drum..NO PUSHING into the drum, that will affect your elbows and shoulders, thru the 'shock' of pushing the arms into the drum rather than-"hitting"/stroking" from the wrist rather than from the elbow or shoulders..Changuito says separate the wrist from the elbow from the shoulder..relax, relax, relax...control your body..recognize HOW it reacts to your physical playing and make adjustments...and Im sure this 'tennis elbow' syndrome will not happen to you..if it is/does, then chek out all the things your doing and make the adjustments to minimize any 'shock' to your elbow and shoulders...just my experience...
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Re: Epicondylitis lateralis

Postby vxla » Sat Jul 07, 2012 7:41 pm

What Johnny said! I see so many videos of people playing congas at the height of their chest, with bad wrist position. I think the best investment could be a stool that achieves the perfect height for a player!
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Re: Epicondylitis lateralis

Postby Roka » Sat Jul 07, 2012 9:12 pm

Mike wrote:Which treatment did you get?

I've got the injection into my elbow and my arm is in gypsum for a 4 weeks in order
to get fingers not moving.
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Re: Epicondylitis lateralis

Postby Mike » Sat Jul 07, 2012 9:36 pm

Roka wrote:
Mike wrote:Which treatment did you get?

I've got the injection into my elbow and my arm is in gypsum for a 4 weeks in order
to get fingers not moving.

I am sorry to say this, but arresting the arm in a bandage is the worst thing you can actually do.
It is merely a sign of the doctor´s helplessness!
You should look into another doctor, or better a decent physical therapist.

Besides, like many illnesses, epicondylitis has its psychological origins.
So stress relief is a bigger help than any medication...
Peace & drum
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Re: Epicondylitis lateralis

Postby Derbeno » Sat Jul 07, 2012 10:23 pm

To state it's all due to bad technique is a gross generalization.

I used to play Squash at a high level and suffered from time to time. As a coach I got my swing analyzed by other professionals and there was not much wrong with it or my grip for that matter.

Whenever it got severe this "Bandit" strap allowed me to play. I am lucky not to be effected playing Congas but it's worth a shot since Squash exhorted more stress on the joints and tendons than Congas ever will.

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Re: Epicondylitis lateralis

Postby jorge » Sun Jul 08, 2012 3:03 am

Four weeks in a plaster cast is not the state of the art of treatment for lateral epicondylitis. The adverse effects of complete immobilization can be very substantial. I would strongly urge you to read the UpToDate patient information I copied in my post. That is a good summary of the state of the art of medical treatment of lateral epicondylitis. It is worth the 20 minutes it may take to read it carefully. UpToDate is a state of the art medical textbook used by more physicians than any other medical textbook. There are several different approaches to treatment that may depend on your particular case and on your doctor's experience, but complete immobilization for four weeks is not one of the recommended approaches.
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Re: Epicondylitis lateralis

Postby Roka » Sun Jul 08, 2012 7:05 am

And what about the injection of Platelet rich plasma ?
I've been suggeted to do this also.
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Re: Epicondylitis lateralis

Postby jorge » Sun Jul 08, 2012 10:41 am

Injection of platelet rich plasma for overuse tendinopathies is still considered investigational. Adequate clinical trials have not yet been done. For Achilles tendinitis, in a randomized trial of 54 patients, PRP did not add any additional benefit beyond that of a program of physical therapy emphasizing eccentric strengthening exercises. This small trial was not a definitive result for Achilles tendinitis. For lateral epicondylitis, two randomized trials among patients also receiving a program of eccentric strengthening exercises showed better results for the PRP groups compared with the steroid treated groups. These results are not definitive, and one was supported in part by a company that manufactures centrifuges used to make the PRP. Major adverse effects were not reported, however the trials were too small and short to adequately study possible uncommon or long term side effects. Immobilization for a few days after the PRP injections may be recommended, but full immobilization in a cast for 4 weeks is not generally recommended. My interpretation is that the jury is still out, PRP may work for some types of overuse tendinopathies, and probably does not cause common major side effects, but still needs to be studied more to confirm that it works and does not cause harm.

Eccentric strengthening exercises involve application of a load while a muscle is lengthening (rather than shortening, the usual way to do strengthening exercises). Carefully designed and executed programs of eccentric strengthening exercises have been shown effective in multiple clinical trials for overuse tendinopathies in different anatomic sites. A systematic review of 23 randomized trials of various modalities of physical therapy for lateral epicondlyitis did not find adequate studies to conclude there is a benefit of eccentric strengthening exercises. Enough well executed studies just have not been done yet. Some of the studies have conflicting results, maybe due to different populations or methodologies. My opinion is that it probably works and probably does not cause common major adverse effects, but evidence is not conclusive.

Regarding playing congas and other hand percussion instruments, if that is the main cause of your lateral epicondylitis, then prevention of future tendinitis by proper technique, posture, ergonomics, and the other factors (thanks JC) is probably the best way to go. My own belief is that if reasonable methods of prevention are available, the preventive approach is better than treatment after the fact. In your case, I recommend you ask your doctor about starting physical therapy with eccentric strengthening exercises as soon as you can and try to get him or her to take the cast off as soon as possible. If you got the PRP injections already, probably no harm done and it might help. If not, I would look into physical therapy using eccentric strengthening exercises first. On the internet and without knowing you, I can't recommend one treatment over another, I can only give you general advice about what to discuss with your own doctor. I don't know anything about medical care in Lithuania, but a second opinion from another orthopedist (preferably one who uses physical therapy liberally) would be helpful if you can get it.
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