Tennis Elbow

[alophysio]

Hi rana sh,

I meant no disprespect...

Textbooks are a source of good information - i have recommended many of them.

However, in terms of evidence based medicine, they tend to represent Level 4 evidence (opinion of respected clinicians) unless they present evidence from the body of published research.

Alfredson et al (2000) in the journal acta orthopaedica scandinavia 71(5):475-9 reports that microdialysis of the Ext carpi radialis brevis in 4 tennis elbow patients compared to 4 controls showed high levels of glutamate but no protaglandin E2. In other words, glutamate (a neurotransmitter) was probably mediating the pain and there was not any inflammation.

Here is the abstract for those of you (like me) who can't be bothered to look up references!

We used the microdialysis technique to study concentrations of substances in the extensor carpi radialis brevis (ECRB) tendon in patients with tennis elbow. In 4 patients (mean age 41 years, 3 men) with a long duration of localized pain at the ECRB muscle origin, and in 4 controls (mean age 36 years, 2 men) with no history of elbow pain, a standard microdialysis catheter was inserted into the ECRB tendon under local anesthesia. The local concentrations of the neurotransmitter glutamate and prostaglandin E2 (PGE2) were recorded under resting conditions. Samplings were done every 15 minutes during a 2-hour period. We found higher mean concentrations of glutamate in ECRB tendons from patients with tennis elbow than in tendons from controls (215 vs. 69 micromoL/L, p < 0.001). There were no significant differences in the mean concentrations of PGE2 (74 vs. 86 pg/mL). In conclusion, in situ microdialysis can be used to study certain metabolic events in the ECRB tendon of the elbow. Our findings indicate involvement of the excitatory neurotransmitter glutamate, but no biochemical signs of inflammation (normal PGE2 levels) in ECRB tendons from patients with tennis elbow.

Now he has done the same thing in people with Achilles tendon problems. It is a fairly well known and accepted fact nowadays that Achilles tendinopathy is not an inflammatory problem after the first couple of weeks and there is even some debate as to whether it is present at all!

As for U/S, i consider that electrotherapy but i take your point. The studies on the effectiveness of electrotherapy are equivocal (they go both ways) but one thing to remember from our clinical experience is that what we see as worthwhile and working may not be working for the reasons we think.

For example, asprin is the classic example. The ancients used to think that because inflammation is "hot", they put something cold like willowbark into the system by chewing on it to counter-act the effects of the "heat" of inflammation. Hippocrates mentions it in his writings hundreds of years before Christ but it had been known for thousands of years before that.

But it was only since the 1800s when bayer was able to isolsate the salicin compund that we have asprin in it's form today and we know why it works - it is not because it is "cool".

What i am trying to say is that using ice is great for inflammation. When the cardinal signs of inflammation are present (pain, redness, loss of function, swelling, heat) then you have to treat it as "inflammation".

Pain in itself is not actually a "sign" but a "symptom" so having pain alone is not an indication of inflammation. We also know that pain can be present where there is no inflammation.

Loss of function is often also present wherever pain is present so these 2 on their own aren't good enough for me to be called "inflammation".

I need to see the redness, feel the heat and swelling.

Also, how long does it take for your treatments to "cure" their pain to less than 50% for more than an hour or two??

With the stated procedure above, you can achieve results using manual therapy within minutes that last for more than an hour or two. This may take a little while depending on their chronicity but you can see significant drops in pain and increases in strength, function and satisfaction within one week.

If your treatments take longer than 6 weeks to get better, then could it not just be that natural recovery has run its course?

About shortwave - i consider this electrotherapy as well - i think it is because it requires electricity to make it work!!! (my mistake if this is wrong!).

Is muscle spasm the main problem in epicondylalgia? Because if it is, surely massaging and frictions and releases would be all that is required to make this problem better. Anyone can massage their own arm. Yet we can see that this is not a solution. It cannot simply be sorting out the muscle spasm that is the solution.

I am interested to hear more of what you believe. Obviously i cannot know who you are or what you believe in only a few short posts!

[Dugal]

I'm not gonna jump on a high horse.

I'd check out the Cx spine if I were you.

Read Bill's masterclass - it's illuminating

[alophysio]

You are right, i am sorry.

It is, of course, only an opinion (what i believe that is)