Elbow Pain - Tennis Elbow

Most of us had random jobs growing up, and for me it was building tennis courts for my uncle's company out in the Berkshires (if you only vacation on the Cape, the Berkshires is that green part of the map 2 hours west of boston and a beautiful part of our state).  Piretti Tennis was a great place to work and, for the few of you who have never actually built a tennis court, it's actually pretty difficult.  And it's amazing how many people can afford their own private tennis court!  It didn't matter if we were in Lenox or up in Dalton, people just loved to have their own courts... it always amazed me... But that's not really relevant here now is it...so lets try to stay focused :)

Building these courts was not only grueling work that caused me to go home with random aches and pains, but it was also a good place to learn about something called tennis elbow.  Since I was around tennis players from time to time (and since my uncle was a coach) I learned a lot about elbow injuries.  So let's talk a little bit about what tennis elbow is, and how to prevent this nagging injury.

If you turn your hand over, palm facing the ceiling, and look down at your elbow you'll see a bump on the inside that sticks out a bit.  That bump is called the medial epicondeyle of the elbow and on the opposite side of that bump is another smaller bump called the lateral epicondyle.  Both spots are attachment points of the forearm muscles.  The medial epicondyle is where the flexor muscles attach (the ones that flex your wrist in a "come here" motion) and the lateral epicondyle is the attachment point for the extensor muscles of the wrist (which would pull your wrist back if you suddenly touched a hot stove).  Both areas can cause pain, but Tennis elbow is referring to the Lateral Epicondyle of the elbow.

Photo Credit: http://prpstopspain.com/tennis-a-golfers-elbow-a-painful-elbow-tendonitis/

It's referred to as tennis elbow because of a one-handed backhand.  Now I'm not an expert when it comes to tennis but when you hit a one-handed backhand you're using the extensors of your wrist.  Not only that, but when you  hit a forearm you have to use your extensors to pull the racket back before you hit the forehand.  Overuse of these muscles, as seen in tennis, can cause inflammation at the point where these muscles attach to the bone... the lateral epicondyle.  But it's not just seen in tennis.  It can be seen after typing too much, using a mouse too much, using a hammer, twisting a screw driver, basically anything that is a repetative motion can cause "tennis elbow."

The question is why does it effect one person and not another?  You can take two carpenters and one may have tennis elbow and one may not.  The primary reason is that one person probably has a tightness in the extensor muscles which pulls the muscles too tight, and then they pull at the point where they attach to the bone.  Another reason is simply overusing the muscle and not resting.  If you bang a hammer day in and day out, and your extensor muscles are too tight, you'll probably develop some elbow pain.  A third reason is just doing too much too fast, as seen with a "weekend warrior" tennis player who wakes up, after a day playing tennis, with elbow pain.  But the main issue is usually a tightness of the extensor muscles that predisposes people to this problem.

To prevent tennis elbow you have to make sure the extensor muscles are nice and loose, through self massage, stretching, or actually getting a massage.  Second, make sure the muscles are strong by using some form of weight training.  Third, don't do too much too soon, take it slow and give the muscles time to build strength and hopefully stay loose at the same time.

If you already experience tennis elbow you've got a bunch of options for treatment.  First is rest, ice and anti-inflammatories.  This is the first line treatment because tennis elbow is an inflammatory condition, just like any tendonitis.  So anything that gets rid of the inflammation will get rid of the pain.  If that doesn't work some people get a cortisone injection, this is like crumpling up a bunch of advil and shooting it directly into the elbow (not the most accurate analogy but it's close enough).  These typically help, but don't come without risks.  Cortisone, since it's a type of steroid, can decrease bone density and may decrease tendon strength... so they aren't the best option although they do usually work.

The best treatment option is to first have someone evaluate the extensor muscles of the forearm for tightness and weakness.  If you figure out why the elbow is actually hurting then you can fix the problem and prevent the elbow from hurting in the future.  A good massage therapist or physical therapist will be able to evaluate the forearm and work out any tight or spastic muscles, thus decreasing the pressure on the elbow and decreasing pain.  Then they will give exercises and stretches to do at home so that it doesn't come back.

So if you've got elbow pain there are a few options, but there's really only one good option, and that's to have it truly fixed.  You can pop advil and ice it but the pain will probably come back and become a chronic issue.  It's not something that anyone should have to live with, and if you find someone who knows how to treat this problem it may be a quick fix.

Doctors Note:

1. Tennis elbow can be seen in any form of repetitive work, not just tennis, and is caused by tight or weak muscles in the forearm that pull on where they attach to the elbow, which causes inflammation.

2. Anti-inflammatories and cortisone injections, although effective, won't cure the underlying problem and the pain may return later in life

3.  A good Chiropractor, massage therapist or physical therapist should be able to loosen the tight muscles, and strengthen the weakened muscles, which will decrease the elbow pain and provide permanent relief.

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Can Changing Your Brain Change Your Pain?

I'm always getting asked about "other things" people can do to decrease their pain, when they can't make it into the office.  Luckily, in my former life I was a personal trainer so I've always got certain exercises or stretches that can help some of the time.  A few people need weight loss, some people need muscle strength, and others need a different way of thinking.  This blog is dedicated to one of those patients, who opened my own eyes to a different way of thinking.

Recently I finished a book called Finding Flow: the psychology of engagement with everyday life by Mihaly Csikszentmihalyi.  It wasn't the easiest read, I wish I could recommend the cliffs notes, but it was fascinating.  I picked up this book a few weeks ago because of a patient I see every month who has a horrible back.  A back that I wouldn't wish upon anyone, but amazingly this guy is always up beat, and happy.  He lives in pain, and we try to give him some relief, which he is always grateful for.  But last time I saw him I was particulary stressed, about who knows what, and I had to ask him how he stayed so positive, so relaxed... so happy.  And he referred me to this book he read years ago called Finding Flow, and what follows is my own journey to find flow.

Flow is often times referred to as "the zone" and athletes around the world can relate to this feeling.  But it doesn't just relate to athletes, it can be seen anywhere.  Basically it's those times in life when all of the sudden you wake up and say "wow, I was just (doing something) for the past hour and it felt like 5 minutes."  It can be seen when new couples are out to dinner and they notice nothing about their surroundings, not the time, not what they ate, not anything but each other.  Or when a mother holds her newborn baby for 8 hours straight and realizes she hasn't even eaten breakfast.  Or when you workout intensely and forget about all the stress in your life.  It's a time where intense focus for the present event completely drowns out your surroundings.  Whether it's during intense exercise, intense work, or intense connection with another person, flow is when our brains are the most happy.

The author believes that the happiest people on the planet live most of their lives in flow.  No matter what they do, whether they're athletes, teachers, or carpenters, they all find a way to live in flow.  He thinks that when the brain blocks out all other stimuli it can function at a high level and what comes from this is happiness.  The book delves into many examples and he makes some great points about how focusing intensely on whatever we're doing will eventually train our brains to enjoy that activity.  It's a very interesting premise.

Now for me, and maybe you as well, finding flow is not as easy as it sounds.  I once had flow... playing sports years ago.  That cingular focus, where nothing else enters your brain other than what you have to do at the moment.  It's the exact opposite of multitasking.   As a business owner and just as a person in general, finding flow is much more difficult.  You can probably relate.  What bills do I have to pay?  What new supplies do I need? Have I payed my quarterly taxes? Does this tie match? What am I eating for dinner, etc. etc. etc.  When I allow my brain to think about everything I must do during a single day I am scattered and nowhere near my flow.  I'm sure you can find times in your life when you're looking at a task in front of you, and ten minutes into the task you realize that you're searching the web, checking your phone, checking the weather, planning the weekend, or texting a joke to a friend.  Even when we walk down the street enjoying the weather our brains lose focus.  We start thinking about our jobs, our appearance, the appearance of someone walking by us, what we have to do this weekend. We all do it, but is it the best way to live?

Back to the patient we talked about earlier.  He explained to me that he never allows his brain to multi-task.  He writes out what he has to do for that day, and he focuses on each act separately, as intensely as possible.  It enables his brain to stay focused, allows him to finish every task he starts, and his days just fly by.  He says that he used to allow his brain to focus on what was wrong with his back or what was wrong with his life, but once he trained his brain to start focusing on the right things a lot of his pain went away.  Now he goes from activity to activity with focus and passion, no matter if it's closing a deal or washing the dishes, he uses focus to keep him on point.  When he gets home and talks to his wife, he actually talks to her, he doesn't stress about anything that happened at work, cause he knows he needs to focus on what he's doing at that very moment.  He said after a few weeks of practice it became second nature and now he's happier than ever before.

After reading "Finding Flow" I started to take a look at how much of my day was spent out of flow.  How many times do I listen to someone talk but not hear what they're saying?  How often do I check my phone, facebook, twitter, email, etc for no apparent reason other than to pass time?  How many days have I gone to the gym and been bored by doing the same routine over and over again?  When was the last time I felt that feeling of complete focus without letting other thoughts creep into my head?  Let me tell you, this exercise was not easy.  It made me realize that most of my day is spent multitasking but not really getting much done.  I realized that most of my productivity can be boiled down to just a few hours of intense focus, and the rest is just fluff.

So I started to think about how I could get some flow back in my life.  I asked my patient how he found his own flow, and he told me he started with exercise, in his case it was yoga but he said it could be anything.  This I liked.  Like many others, I am drawn to exercise and it's the one area where I used to feel that flow feeling, as many people probably do.  I can remember when I used to play basketball and got into the "flow" of the game and how it was impossible to think about anything else.  As time has gone by my workouts have been filled with thoughts about what's for dinner, how the work day went, do I have to pick up my dry cleaning?  These are all flow stoppers.  So in an instant, I stopped all that, and joined a boxing gym.

If you follow us on facebook, which apparently is a big flow stopper :), you know that a few weeks ago I started doing fighter training classes over at Peter Welch's gym in southie.  It's a 50 minute workout that is constantly moving... and intense.  You're doing different movements throughout the class, all of which are pretty difficult.  If you go full throttle the entire time you'd probably pass out, unless you're in great shape.  The first time I went I had to stop because I was going to throw up, but I  got through the class.  And you know what I realized?  It was the first time in a long time that I'd gone an hour without thinking about... well anything.  Not once did I want to search the internet, or check my phone, or worry about any ache or pain I normally feel... not once did I think about anything other than the task in front of me.  I was focused, for one hour, on just getting through the class.  And you know what?  That feeling of focus lasted the whole day.  Even when I got to work, I wasn't worrying about every little detail, I wasn't wondering what was going to happen tomorrow, or what happened yesterday.  For that day, I was relaxed, and focused... I was in flow.

And that's how it happens, according to my new Yoda (or Miyagi if you prefer a karate kid reference).  Once your brain feels that flow experience the results last for hours.  Day after day, as flow enters your life again, you supposedly go longer and longer feeling like you're in flow.  This is how my patient trained himself to go throughout each and every day.  He started with something intense that could keep his focus, and he built from there.  Now he focuses on the present moment and doesn't allow his brain to stress out about his pain.  His foundation was Yoga, mine apparently is boxing.  And after a few weeks I am a convert, I believe in finding flow.   Have you found yours?

Doctors Note:
1. Read Finding Flow: the psychology of engagement with everyday life by Mihaly Csikszentmihalyi
2. Take an inventory of your own life.  How often do you lose focus, check email, etc when it's not really necessary.
3.  Find something that enables you to intensely focus, whether it's athletics or art or building something.  Just find it.  And start doing it for an hour each day.  That focus will eventually spill over into everything you do.
4.  Do what Timothy Ferris (the author of The Four Hour Work Week) does.  He checks his email twice a day(if that), and looks at his phone twice as well.  How many times have you checked your phone today???  He says constantly looking at these things causes you to lose focus, and I think I agree.
5.  If you're in chronic pain this may help you focus your brain on something other than the pain.  It may allow your nervous system to reset itself and enable you to live your life in less pain.  It's worth a shot.
6.  Just try it... I'm in no way an expert on flow, I just started paying attention to it.  But I think everyone could use a little more flow in their lives... because honestly, do we really care what that person we met, that one time, and are now friends with on Facebook, had for dinner last night?  Are we really that bored? :)

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Disc Injuries

A long-time friend of mine is a great personal trainer down in Miami.  He travels from Miami to the Bahamas on occasion to work with private clients on their private island... sounds nice right? But from time to time he'll call me with a medical questions that he's a bit unsure of.  Most of the time it's an injury that isn't responding to exercise.  Since his background is in exercise he usually thinks that if you exercise more the pain will go away.  He (as most of us do) sometimes falls prey to that old saying... if you were a hammer everything would look like a nail... meaning since he's a personal trainer everyone should respond well to exercise.  But to his credit, when things aren't responding he looks for answers elsewhere, which every health provider should do.  This post is dedicated to one of his questions... and of course the names and locations have all been changed to protect the innocent :)

Question:
"I'm working with this woman who is complaining of tingling and pain down the back of her gluteal muscle that sometimes goes into the front of her thigh, but not all the time.  We've been doing core exercises and back stabilizing exercises to strengthen the low back.  But after 1 month of exercise she's not getting any better.  And she heats the area every night, takes Advil, even takes some stronger stuff too.  But nothing is changing. Oh and it started when she bent down to pick up her baby one day, who is obviously tiny, but she could hardly stand after it happened.  What do you think?"

Let's delve into this case.  First off, whenever I hear tingling, pain, or numbness going down the back of someones leg or into the thigh I put that into a more sever category.  It's in a category called "disc or pinched nerve."  Which means that this could very possibly be a disc problem or a pinched nerve problem.  Then we think about how the original injury happened... bending forward to pick up her child... this puts her in another category... "hurt bending forward."  Which means that it's more likely to be a disc or nerve impingement problem as opposed to a muscle or joint problem.  Of course, these are just generalizations, but it's how most health providers go through the thought process.

I follow up with a few more questions:

1. Does the pain get worse with sitting?
2. Does the pain get worse with sneezing?
3. Does heat seem to help for a few minutes, but does the pain then come back soon after?


The answer to all 3 questions was "yes."  Before we go over why the "yes" answer is important we have to discuss the basics of a disc in the back.

In between each vertebrae of the spine are shock absorbers called discs.  They are like large pads of cartilage that prevent each bone from rubbing against each other.  Similar to how a knee has cartilage to keep it moving, the spine has discs to keep it moving.  I like to think of a disc as a jelly doughnut because each disc has an outer layer which is stronger, and an inner layer that is more fluid.  Similar to a jelly doughnut.  When someone bends forward the jelly in the middle of the disc will naturally be pushed towards the back of the doughnut, and when someone bends backward the jelly will move a bit forward, it's normal physics.  Similar to  how when you pinch one side of a jelly doughnut the jelly will move away from your hands.

A problem arises when the outer part of the jelly doughnut (disc) becomes weak from inactivity, obesity, trauma, sitting too much, old age, etc.  When the outer part becomes weak the jelly can push out towards the edge, like when you push down on one side of a jelly doughnut and the other side bulges outward.  This is what's called a bulging disc.  This causes inflammation, pain, and sometimes causes a pinched nerve since the nerves are very close to the disc itself.  If the outer part of the doughnut becomes weak enough the jelly may leak out of the doughnut (disc) which is a big problem.  The jelly then irritates and pinches off nerves near the spine causing extreme pain and dysfunction. Luckily most problems are simply bulging or irritated discs, and not the kind where the jelly actually breaks through the disc wall.

So lets go over the questions.

1. does sitting make it worse?  Yes... this is important because when we sit the pressure on the disc increases by 50% because now the legs don't take any of the force.  Also, when in a sitting position our  bodies are actually flexed forward... and thus the jelly in the disc will naturally flow toward the back or our bodies.  For someone with a disc problem this will cause an increase in pain.

2.  Does the pain get worse with sneezing?  Another important disc irritation question.  When we sneeze the internal pressure increases dramatically.  For someone with a disc problem this can cause more pain.  As the pressure inside increases it will push on any areas of weakness.  With a disc problem this means that the weaker outer crust of the disc will be pushed upon buy the jelly inside and thus make the disc bulge a bit worse, and the pain worse as well.

3.  Does heat seem to help for a few minutes, and then come back soon after?  This question is not really specific to a disc problem, but I see this problem so often that I thought I'd throw it in here.  Heat is the #1 most deceiving healing modality on the planet.  On a daily, literally daily, basis I have a new patient walk into the office with a disc problem or a nerve problem and they say this... "My doctor said use heat and it helps me for a little while but then I wake up in pain again."  Here's the issue with heat, and the reason why many doctors and therapists use it so much.  Heat increases blood flow and decreases muscle tension so that people feel better right away.  If you have a party to go to and your back hurts, heating it will help for a little while.  Similar to how you can get in a bath and your pain will most of the time get better.  This is also why many people say "oh just heat it" and they sound like they know what they're talking about... if it gets immediate results most people think it helps.  So by the time I see someone they are pretty well convinced that using heat is the way to go.

Any injury, any injury at all, causes swelling.  It's just how the body works.  If an area is damaged the body sends out more blood flow with healing blood cells to start in the healing process.  The redness we see around a simple scratch is a form of swelling.  It's a vital part of healing, but when the swelling gets too great it irritates nerves and causes pain.  We've all sprained an ankle, seen the swelling and felt the pain.  The same thing happens in the back, but unfortunately it doesn't swell up like an ankle, so most of us can't see the swelling.  The back normally swells deeper than an ankle would, and since there are larger nerves in the back that deep swelling causes a lot of pain.

When you heat the back it improves blood flow and decreases muscle tension, but it also increases swelling.  This causes a feeling of improvement for an hour, maybe a couple hours, and then the symptoms come right back.  Many therapists and doctors use heat in an office setting because it makes the patient relax and feel better while they're in the office, and makes them "feel" like coming to the office is helping... but usually it's not helping the problem.  It sets up a vicious cycle of heating, feeling better, going to bed, waking up with pain again.  So unless the problem is arthritis or truly just a muscle tightness issue, do not heat an injury... ICE IT!!!!  But I digress...


Since I didn't have a chance to examine my friends client there was nothing else we could use to come up with a diagnosis.  Most of the time I can use reflex tests, orthopedic tests, spinal palpation and even an MRI to make a proper diagnosis.  But many cases can be solved just by hearing the history of the problem.  In this case, we came to the conclusion that a disc in her lower back had probably become irritated, perhaps bulged, when she bent down to pick up her baby.  The exercise wasn't helping because it was increasing swelling, and the problem wasn't that she had a weak back, the problem was that she had an irritated nerve.  She was also keeping herself injured by heating every day and sitting too much.  After my friend listened to my thoughts on disc injuries he decided to have the woman rest and ice the back for the next 2 weeks and within a week she was not experiencing the neurological symptoms any more.  Within a  month she was back working out with her trainer.  Sometimes it just takes an understanding of spinal anatomy and a couple small lifestyle changes to see a dramatic effect.

Doctors Note:

1. Do not heat an injury!  It may help your pain momentarily but it's deceiving!  Ice should be used!
2. Do not try to exercise through a back or neck injury... although injuries may occur because of a weakness in the back, they very rarely get better by exercising more.  Most people need to get the inflammation down, perhaps seek some treatment, and then after the pain has decreased start to exercise again.
3. Avoid anything that flexes your body.  Examples: sitting, bending forward, biking, stair climbing, etc.  These all push the jelly of the disc back towards the nerves that cause pain.
4. Disc issues are hardly ever surgical cases, unless the "jelly" has really gotten out of the "doughnut." Most cases respond to small adjustments in the spine to get some pressure off the discs and allow the inflammation to go down.

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