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Rapid Responses: Rapid Responses published:
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Tennis Elbow is a whole body response not local!
- Dr A. Breck McKay (1 October 2006)
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tennis elbow
- Michael Snaith (1 October 2006)
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Re: tennis elbow: What is it?
- A. Breck McKay (3 October 2006)
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Applicability in occupational settings
- Alexis Descatha (6 November 2006)
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question
- ara nahabedian (7 November 2006)
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Impact of work exposures
- Jean-Francois Gehanno, Yves Rocquelaure (7 November 2006)
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Tennis Elbow Steroid Injections
- Michael John Hopkins (10 November 2006)
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Corticosteroid not in patient's best interest
- Daniel Pinto (14 November 2006)
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What steroid?
- Tim R Cresswell (17 November 2006)
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Re: Corticosteroid not in patient's best interest
- Dr A Breck McKay (22 November 2006)
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Tennis Elbow is not localised to Extensor Carpi Radiallis Brevis
- S THOMAS, G.H.Broome (Consultant Orthopaedic Surgeon), Cumberland infirmary, Carlisle ,UK (28 November 2006)
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Re: Re: Corticosteroid not in patient's best interest
- TINA AMBURY (28 November 2006)
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An alternative whole body approach to tennis elbow worth considering: Myofascial Release Therapy
- William Rhodenizer, Kenneth C Johnson, Senior Epidemiologist, Public Health Agency of Canada (8 December 2006)
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Dr A. Breck McKay, Family & Musculoskeletal Physician Victoria Point, Brisbane, Qld, Australia 4165
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Dear Editor, I have a major issue with the published article, which appears to ignore whole body function and addresses Tennis Elbow as a single localised condition. While researching Pain and Low Back Pain (1, 2) our group started at the basic questions of 1) Why does a muscle not rip out of its attachments? 2) How Ivan Pavlov’s 1910 Lecture identified the orienting response activating whole body functions to internal and external environmental changes, results in coordinated body activity and not isolated muscle actions. Adding the simple concept that a new born baby is a complete neuromuscular system, responding by orienting to environmental changes; which learns each and every movement by repetition of combined actions, until they pass to unconscious complex conditioned reflexes, (eg, standing to walking to driving and writing, musicianship, craftsmanship, etc). Pain management is similarly learnt, but as a subservient, parallel neural system. (2) Obviously the functional adult body operates as one single unit in Pavlov’s learnt coordinated manner, responding to both internal and external environmental changes. 'Tennis elbow' is a classical example of this as a whole body function. Injury/pain produces internal environment change to the mechanoreceptor and nociceptor inputs from the muscle attachments at the periosteum, which causes afferent dorsal horn stimulation, leading to midbrain activation of the autonomic and sensory-motor systems; resulting in efferent feedback modulation to prevent increased muscle contraction/damage, often before conscious awareness of the injury occurs. Tennis Elbow is an excellent example of this process. We found that after injecting patients with chronic low back pain (2) it often relieved their neck pain, carpal tunnel syndrome and tennis or golfer's elbow. We considered the issue from the above first principles and published(3) our surprising findings with a proposed explanation, supported by over 300 clinical cases. Tennis Elbow must be considered as a whole body response to strain or injury at the lateral epicondyle attachments resulting in secondary activation of the autonomic and other nervous system areas with the efferent result being the clinically perceived syndrome. The published article appears to have considered Tennis Elbow as a localised condition without appreciating the whole body mechanisms and as such must be challenged. References: 1. McKay AB, Wall D, The orienting response and the functional whole human body. Australasian Musculoskeletal Med. November 2003,8(2):86-99. 2. McKay AB, Pain and chronic low back pain: a new model? Part 1 and Part 2 Australasian Musculoskeletal Med. May 2004, 9(1):14-25 3. McKay AB. Tennis Elbow Everywhere, Australasian Musculoskeletal Med. November 2005, 10(2:127-130 These references are available in .pdf if required for assessment. Competing interests: None declared |
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Michael Snaith, consultant rheumatologist Heanor Hospital, Derbyshire DE75 4EA
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Congratulations on your paper: very helpful. I decline to inject tennis elbows even when one is postively requested, unless the patient undertakes to completely discontinue the offending activities for at least 2 weeks. I have found any less rigorous advice results in inevitable recurrence. Since you allowed 'gradual' return to normal activities and also permitted a second injection 2 weeks after the first, I suspect that you did not optimise the response to injection. Just a thought. Michael Snaith Competing interests: None declared |
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A. Breck McKay, Family/Musculoskeletal Physician Brisbane
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Surely we should carefully define what the problem is before we treat/research anything. The references attached to Bisset et al demonstrates a very confused concept with respect to Tennis Elbow aetiology and pathophysiology. 1. Is it a purely local phenomenon and no other part of the body is involved as per reductionist medicine; OR 2. Is it a whole body response to damage via mechanoreceptive/ nociceptive activations passing via dorsal horn amplification to mid-brain and then either/and higher centres for conscious recognition and via autonomic and modulated motor mid-brain efferents back for attempted self repair, resulting in swelling, chemical changes and increased afferent responses again... causing nocioceptive wind-up? This whole body response was originally identifed by Pavlov 1904-1916 in his Lectures, then defined neurophysiologically by de Bono in his Mechanism of Mind 1969 and seemingly forgotten by modern reductionists! Once the 'Tennis Elbow' definition problem is clarified then and only then can we make logically and useful EBM findings and not merely add to the current confused literature. Competing interests: None declared |
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Alexis Descatha, Occupational Physician Occupational Health Department, AP-HP,France/ INSERM U687, HNSM, France
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Dear Colleague, I read with a particular interest your paper about the treatment of lateral epicondylitis. However, I would like to raise two problems: specificity of manual work and associations with other disorders. Although manual works does not seem to be different in the three groups, I think exposure should be detailed (what is manual work?). Actually, some studies have found that manual work were associated with poor prognosis (1;2). No relation was also found between the type of medical treatment given/chosen and prognosis in a randomized control trial where manual work was associated with a poorer outcome (3). My other comment dealt about the frequent association with other upper- limb musculoskeletal disorders in occupational setting (4;5). I wonder if you considered only epicondylitis, you may select your sample. In fact, the exclusion criteria corresponding to other upper-limb disorders represented 25% of the target population (n=123/497, all exclusion criteria, except contraindication). Furthermore, it would be interesting to know if others associated musculoskeletal disorders appeared. In conclusion, this very interesting trial is may be applicable to work- related lateral epicondylitis, but further analyses or studies are needed to extend results for occupational settings. Reference List 1. Lewis M, Hay EM, Paterson SM, Croft P. Effects of manual work on recovery from lateral epicondylitis. Scand.J Work Environ Health 2002;28:109-16. 2. Werner RA, Franzblau A, Gell N, Hartigan A, Ebersole M, Armstrong TJ. Predictors of persistent elbow tendonitis among auto assembly workers. J Occup.Rehabil. 2005;15:393-400. 3. Haahr JP,.Andersen JH. Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Rheumatology.(Oxford) 2003;42:1216-25. 4. Leclerc A, Landre MF, Chastang JF, Niedhammer I, Roquelaure Y. Upper-limb disorders in repetitive work. Scand.J.Work Environ.Health 2001;27:268-78. 5. Descatha A, Leclerc A, Chastang JF, Roquelaure Y. Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors. J.Occup.Environ.Med. 2003;45:993-1001. Competing interests: None declared |
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ara nahabedian, orthopedic surgeon crewe,uk,cw14rn
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Is my understanding of this paper correct, that the study group itself had also other treatments "not in the protocol"? and if it's yes, how can we conclude safe conclusions from the results if they had mixed treatments? unless, the group of "not per protocol" is completly another group of excluded patients, as a "mixed treatment" group. thank you.
Competing interests: None declared |
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Jean-Francois Gehanno, Occupational Physician Rouen University Hospital, Yves Rocquelaure
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Sir, The paper by Bisset et al. provides useful insights for the management of patients with tennis elbow. As the authors pointed out, this disease is common among workers and is in many countries compensated as an occupational disease. The main difference between lateral epicondylitis among workers and in the general population is that workers usually remain exposed to strenuous manual occupations and psychosocial factors, unless they quit their job or get a sick leave. In this study, the aetiology of the disease is not mentioned and we don't know if all groups are comparable in terms of discontinuation of exposure. If they were not, this could bias the results since if exposure to repetitive movements is more important in one group, we can predict a lower improvement in that group. Workers usually want a rapid improvement, in order to go back to work, and corticosteroid injections, which are more efficacious within three to six weeks, could be overused for such patients. Additional data would therefore be welcomed. JF Gehanno, Y Rocquelaure Competing interests: None declared |
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Michael John Hopkins, Medical Osteopath Plymouth PL7 2AU
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This seems to confirm what many already know:- 1. There is nothing better than an accurately placed steroid injection for relief of the pain of tennis elbow, especially if of recent origin. 2. Patients need to know that in the long term steroid injections may delay healing, and the more they are repeated the less likely they are to be curative. 3. 3 hours of physiotherapy may not be everyone's choice for a condition that is going to get better anyway. Competing interests: As one with an interest in musculo/skeletal medicine I give lots of steroid injections. |
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Daniel Pinto, Supervisor of Physical Therapy and Wellness Regional Transportation District
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The choice for best long term patient management of lateral epicondylalgia appears to be 'wait and see' versus 'physiotherapy' based on the findings of Bisset et al's article. A cost analysis needs to be performed to determine whether or not the significant difference in improvement at 6 weeks and 12 weeks found between the physiotherapy group and the wait and see group provides a benefit to society in fewer days of work lost, improved productivity, etc. More research is warranted to find a modality that will improve outcome prior to the six week period, however this treatment should not provide a poorer outcome than wait and see and physiotherapy at one year follow-up. Competing interests: None declared |
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Tim R Cresswell, Orthopaedic Surgeon Derby Hospitals, Derby DE1 2QY
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This paper does not state what type of steroid was used. This is of importance as injectable steroids behave differently due to the degree of water solubility. What type of steroid was used? Competing interests: None declared |
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Dr A Breck McKay, Musculoskeletal/Family Physician Brisbane
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When a patient present with acute Tennis Elbow pain they usually present with four basic statements.(From P Watson Brisbane, Musculoskeletal Physician, also referred to by Bogduk N, McGuirk B,in The Medical Management of Acute and Chronic Low Back Pain, Butterworth, 2002) 1. I hurt! 2. I cannot move my arm! 3. I cannot work! 4. I am scared! Now if these four components are not adequately dealt with the patient will not be fully rehabilitated. Does not matter how long a time period is considered! 1. Corticosteroids/Local anaesthetics give immediate pain relief and restoration of function. BUT THEY DO NEED A REASONABLE EXPLANATION OF TENNIS ELBOW, AS A WHOLE BODY FUNCTION, AS WELL. (1) 2. Being able to immediately use the whole arm again and moving it with loading in all ranges, restores the patient's confidence and they can then be taught the exercises that are necessary to prevent recurrence. 3. With restoration of function they can work again and work place might require modification, if needed, to minimise recurrence and work place encouragement of exercises is essential. The exercises must be simple and easy to do, without any equipment or with readily available items(such as a hand towel or piece of material to twist) 4. The patient is scared because of pain, loss of function, fear of job and fear of family effects of the injury. Do the above and the patient is fully rehabiltitated from the initial presentation! BUT YOU MUST FIRST GET RID OF THE PAIN! That is where steroids and LA are excellent and with correct follow-up and exercises it is possible to prevent all the other problems. The original study used a very rigid corticosteroid injection and exercise protocol with inadequate follow-up, that was not typical of General Practice managements being used in Australia. Reference: McKay AB, 'Tennis Elbow Everywhere', Australasian Musculoskeletal Medicine Journal, November 2005, 10(2):127-130 Competing interests: None declared |
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S THOMAS, Clinical Fellow in Orthopaedics North Tynesdie Hospital,UK, G.H.Broome (Consultant Orthopaedic Surgeon), Cumberland infirmary, Carlisle ,UK
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Dear Editor, It was interesting to note that in this randomised control trial a single dose of corticosteriod was compared to eight seperate sessions of physiotherapy. Tennis elbow is widely believed to be caused by the presence of micro or macro tears of the extensor carpi radiallis brevis. Greenbaum et al has shown that even in the most controlled situations it was not possible to seperate the origin of the ECRB from the common extensor origin which suggest that that this pathology is not localised to a single structure.Hence by giving a single injection to a point cannot address a wider pathology. On the contrary physiotherapy is generaly given to the lateral side to the affected elbow. This along with the placebo effect of seven more treatment sessions just could explain the difference over six weeks. References 1.Greenbaum. B, Itamura. J, Vangsness. C. T, Tibone. J, Atkinson. R[1999]. Extensor carpi radialis brevis: An Anatomical analysis of its origin. J Bone Joint Surg [Br] Volume 81-B (5), September, p 926-929. 2.Bisset.L, Beller.E, Jull.G, Brooks.P, Darnell.R, Vicenzino.B[2006]. Mobilisation with movement and exercise,corticosteroid injection, or wait and see for tennis elbow Competing interests: Authors were involved in a patient satisfaction survey following open release of resistant tennis elbows |
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TINA AMBURY, GP Penwortham, pr1 9bx
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My initial response to the original article as someone who a) administers steroid injections when appropriate for various musculoskeletal problems and, b) someone suffering (++!) and currently being treated for tennis elbow was; am I to put up with this pain and disability for a whole year then? The responses - especially this one - make thought provoking reading. Will I change my current practice? No, because I choose those patients I inject carefully on the basis of the whole picture of their symptoms and their job/lifestyle. WIll I request a change to my own management? Again no. I don't want an injection and will avoid it if I can. I have had steroid injections in the past for other MSK conditions with good response but these injections hurt!! Competing interests: None declared |
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William Rhodenizer, Physiotherapist Fascial North Physiotherapy, Ottawa, Ontario, Canada, K1S 2Z7, Kenneth C Johnson, Senior Epidemiologist, Public Health Agency of Canada
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Recognition of tennis elbow, lateral epicondylitis (LE) as functionally involving the whole body (1) is imperative when considering an efficient, cost-effective, highly successful treatment strategy with lasting long-term benefits for this debilitating lesion. Although local treatments have shown to be effective in the short-term, choosing a wait and see approach (2) facilitates an environment capable of producing a variety of other physical pathologies (3,4) that require more intense, costly treatments compared to treating the LE successfully in the first place. With an injury, the local connective tissue (fascia) becomes restricted.(5) Fascial restrictions are capable of creating abnormal physical strain patterns that crowd or pull the osseous structures out of alignment. This results in compression of joints to produce pain and/or biomechanical dysfunction. Further, neural and vascular structures become entrapped in the restrictions causing neurologic symptoms or ischaemic conditions.(5) Because fascia forms a 3-dimensional, uninterrupted web throughout the body, a restriction in one area over time will cause biomechanical changes to occur in other areas of the body.(6) We have consistently found that an approach incorporating Myofascial Release Techniques to be an effective, efficient treatment strategy to resolve LE for the vast majority of clients after 3-4 treatments over the course of 3-4 weeks. Treatment focuses on first identifying lesions of the facia system through physical examination. Lesions are treated with Myofascial Release Techniques often involving areas of the shoulder, neck, lower back and at the LE site.(4-6) A wait and see approach with LE is host to a variety of other chronic pathologies that require greater time/effort and financial resources to manage. REFERENCES 1. McKay A. B., Tennis Elbow is a whole body response not local!, bmj.com Rapid Responses for Bisset et al 2. Smidt N, AWM van der Windt D., Tennis elbow in primary care, BMJ 2006: 333:927-928 3. Barnes J., Myofascial Release The "Missing Link" in Your Treatment, PT Today; 1995: January 16:1-4 4. Barnes, J,. Myofascial Release-An Introduction for the Patient, Physical Therapy Forum; 1998 5. Barnes, M,. The basic science of myofascial release: morphologic change in connective tissue, Journal of Bodywork and Movement Therapies; 1997: 1(4), 231-238 6. Murphy, J., Myofascial Treatment Proves Beneficial in Acute and Sports Medicine Settings, Advance for Physical Therapists; 1996: September 2. Correspondence:Ken_LCDC_Johnson@phac-aspc.gc.ca Competing interests: None declared |
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