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Two Common Sports Injuries

Course Authors

Andrew Turtel, M.D.

This activity is made possible by an unrestricted educational grant from the Novartis Foundation for Gerontology.

Dr. Turtel reports no commercial conflict of interest.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 
Learning Objectives

Upon completion of this Cyberounds®, you should be able to:

  • List the differential diagnoses of tennis elbow

  • Discuss the treatment and management of tennis elbow

  • Discuss the treatment and management options for heel pain.

 

The popularity of fitness programs and active recreational lifestyles requires that medical professionals, more than ever, will need to diagnose and treat sports-related injuries. In this Cyberounds® Special Features, distinguished orthopedic surgeon and sports medicine physician, Dr. Andrew Turtel, brings you up-to-date on tennis elbow and heel pain. Currently, the team physician for the Metrostars, a Major League Soccer team, Andrew was, formerly, team physician for The New Jersey Nets of the National Basketball Association.

-- The Editors.

Elbow Pain -- Lateral Epicondylitis - "Tennis Elbow"

Lateral epicondylitis is a condition that causes pain primarily at the outer or lateral aspect of the elbow in the area of the lateral epicondyle. The moniker "tennis elbow" dates from a letter written in The Lancet in 1882 by Henry J. Morris, when he first described a condition seen in lawn tennis players. Though there are many other etiologic causes of lateral elbow pain, the term tennis elbow has become quite familiar to the lay public. The characteristic pain can extend down the forearm and can be quite significant, affecting almost all upper extremity activity, compromising even simple chores such as picking up a coffee cup.

The site of pathology is the lateral epicondyle of the humerus, which is the origin of a number of muscles that are involved in extension of the wrist and fingers. In tennis elbow, the origin of the Extensor carpi radialis brevis and,, to a lesser extent, the origin of the Extensor carpi radialis longus are injured. Overuse of these muscles, during activities such as tennis, use of hand tools, or any situation of constant hand use can cause degeneration of the tendon origin. In EMG studies done in tennis players, the Extensor carpi radialis brevis was shown to be the most active muscle of all extensor muscles during groundstrokes.(1)

Epidemiology

Tennis elbow, usually, will occur in the fourth and fifth decades of life and most typically affects the dominant arm.(2) Women and men are equally afflicted. It is estimated that 10 to 15 percent of tennis players will suffer some degree of elbow pain secondary to this condition. Certainly, in this patient population, specific mechanical factors such as grip size, poor stroke mechanics, or racket string tension can have major impact as an etiologic cause.

Pathology

Current consensus is that microtears of the Extensor carpi radialis brevis tendon are the main cause of the symptoms of tennis elbow. The tears, as well as granulation tissue that is formed in the reparative process, are inflammatory. Nirschl has shown gross pathology and tendon degeneration in 97 percent of his surgically treated patients. Thirty-five percent of these specimens had gross tendon rupture.(2)

Presentation

Lateral epicondylitis usually presents with pain over the lateral aspect of the elbow specifically originating at the lateral epicondyle. The pain is most often a couple of millimeters distal to the actual bony epicondyle at the site of the tendon origin and often radiates into the forearm. The patient gives a history of insidious onset, rather than a specific or acute event that they remember. The pain can be quite severe, although many patients may practice "trick maneuvers" in order to reduce their symptoms by altering otherwise coordinated activities of the shoulder and wrist (i.e., changing the mechanics of tennis serve or baseball throw). These modifications may put additional stress on areas remote from the elbow, causing secondary pain.

In addition to pain, there is usually severe tenderness at the tendon origin and at the lateral epicondyle. The tenderness can extend down the forearm and may be mistakenly construed as a muscular problem of the forearm itself. Resisted finger and wrist extension will often elicit or intensify the pain. Range of motion of both the elbow and wrist is usually unaffected. Although wrist extension may be weakened, the gross neurologic exam, including sensory testing, should be intact.

X-rays are, generally, of little help, although on occasion one might see radiographic evidence of calcifications in the tendon. A complete examination of the upper extremity, as well as the cervical spine, should be done in order to rule out any other condition or pathology.

Treatment

The initial treatment of lateral epicondylitis is usually nonoperative. Much evidence supports conservative measures(3),(4) -- reduction of the local repetitive trauma and relief of the inflammation. Both strategies are followed with a rehabilitation program.(3)

Cessation of the offending activity often brings inflammatory relief. Casting or splinting is usually not necessary, except in the most stubborn cases. Minimizing muscular atrophy during this time may help in the ultimate rehabilitation that will follow. Ice and oral anti-inflammatory medications can be used to initially reduce the inflammation. Physical therapy, such as ultrasound treatment and range of motion exercise with strengthening of the surrounding musculature, can be successful but there are no long-term studies that demonstrate whether or not they are beneficial.

If these simple measures do not bring relief to the patient, steroid injection can be entertained.(5) It is important to place the injection anterior and deep to the Extensor carpi radialis brevis. Direct injection into the tendon may cause premature degeneration, while subcutaneous injection may result in skin discoloration and atrophy of the soft tissues. Overall, the literature supports pain relief in 55 percent to 89 percent of patients with a recurrence between 18 percent and 54 percent, encompassing all nonsurgical conservative measures.(6)

Prevention and Management

If this course of treatment is successful, management must include continued protection against the initial-offending agents. Any unusual technique during a sporting event or other repetitive motion activity needs to be recognized and corrected. In the case of tennis, for example, proper body and arm mechanics and equipment need to be reviewed, possibly with a professional instructor.

Surgical Treatment

The majority of patients should respond to this course of treatment and only a small minority will need to undergo surgical correction. Recurrences can be expected and approximately 10 percent of patients who originally do well following conservative treatment will have a recurrence of symptoms. Patients who have repeated recurrence or pain lasting six to 12 months are candidates for surgical treatment. The reader is referred to more specific texts with regard to this treatment and the rehabilitation following surgical procedure.(7)

Heel Pain -- Plantar Fasciitis

One of the more common injuries that is seen in relation to the foot and ankle, especially in the very active population, is plantar fasciitis, a condition that causes heel pain. Although not the only cause of heel pain, it is probably the most frustrating because it has a relatively high incidence and is often difficult to treat. This site of pathology is at the origin of the plantar fascia, where it originates from the calcaneus. Presently, it is believed that there is a degeneration of the fascia from the take off site at the calcaneus. The pain can be quite debilitating, and it is difficult for many patients to stay off their feet in order to relieve the inflammation and repetitive trauma to the area, making this a frustrating clinical problem.(8),(9),(10),(11)

Pathology

The plantar fascia originates at the two tuberosities of the calcaneus and extends to the plantar surface of the MTP (metatarsal phalangeal) joints of the toes. When the foot is placed on the ground during the gait cycle, it tends to flatten out because of the body's weight. When this occurs, the fascia tightens secondarily, creating tension at its origin and insertion. This tension is increased when the rollover/toe off phase of gait occurs. The tension created in the relatively inelastic plantar fascia stabilizes the arch of the foot but also places great tensile force at the fascia - periosteal origin at the calcaneus. The tensile forces are maximal at the medial calcaneal tuberosity, which is the site most often symptomatic in this condition.(12)

Wood first described "plantar fasciitis" in 1812.(12) Recently, pathologic studies of surgical specimens showing microtears of the fascia and angiofibroblastic hyperplasia have been identified.(13) This is consistent with the chronic degeneration and inflammation involved with repetitive stress. Bone scans in chronic situations are often positive, again giving evidence to the suggestion that plantar fasciitis is secondary to a chronic stress situation.

Differential Diagnosis

There are many reasons for chronic heel pain and the examiner must be aware of the various systemic inflammatory arthropathies, tumors, infections and calcaneal stress fractures that may be the cause of such pain. It is important to distinguish between all of these possibilities. In addition, neuropathies secondary to diabetes and alcoholism may also be associated with this type of pain.

Because of the proximity of the medial calcaneal nerve and the lateral plantar nerve, several authors propose that the origin of the pain is due to impingement and compression of either one of these nerves.(14),(15),(16) For this reason, it is important to attempt to locate the exact site of the patient's pain. Knowledge of the distribution of these nerves will allow the examiner to determine if either nerve is involved.

Diagnosis

Even with the imposing list of differential diagnoses, straightforward plantar fasciitis should be easily diagnosed. Patients will complain about pain after arising from bed or after a period of rest. Usually the pain will subside after a relatively brief period of ambulation and/or stretching. The pain can be quite severe and occur the morning following excessive exercise the previous day. The pain is unmistakably located about the area of the medial tubercle of the calcaneus. Direct palpation of this area will elicit pain, which may be exacerbated by dorsiflexion of the toes.

One of the most controversial and confusing issues relates to the association of the heel pain and radiographic visualization of a calcaneal bone spur. Although the association of heel pain with the bone spurs is recognized, the spur is probably not a primary cause of the pain, but rather a secondary traction spur that is the result of the chronic condition.(17)

Treatment

There is no single treatment that stands out as the most efficacious, although it is well accepted that, most of the time, conservative measures are usually successful. Physical therapy modalities with ice and heat have been tried with some success. Stretching exercises, both during the day and evening, utilizing splints, are quite successful since they stretch the plantar fascia as well as the Achilles tendon.(10) Nonsteroidal anti-inflammatory medications have also been successful, although there are significant populations of patients who do not improve on NSAIDs. Various heel cups and heel pads have been used but studies disagree as to the outcomes achieved.(18)

Injections of corticosteroids, limited to two per heel, have been used to reduce symptoms. However, plantar fascia ruptures, secondary to these injections, have been reported and can be quite debilitating.(18)

If none of these treatments is successful, patients should undergo a regimen of casting in order to reduce pressure on the area as well as the irritation from daily pressure. Casting is generally not used as an initial treatment because patients do not like to be so inconvenienced by a treatment for a situation they consider relatively minor. In addition, casting produces significant atrophy, further compounding the problem. Casting may need to be done over many months and the particular patient population, such as runners, poorly tolerates this length of immobility.

Although beyond the scope of this discussion, surgery is a final option and the reader is urged to research this further.(19)


Footnotes

1Morris M, Jobe FW, Perry J et al: Electromyographic analysis of elbow function in tennis players. AJSM 1989; 17:241-247.
2Nirschl RP, Pettrone FA: Tennis Elbow: The surgical treatment of lateral epicondylitis. JBJS 1979; 81:832-839.
3Cicotti MG, Lombardo SJ: Medial and lateral epicondylitis in Jobe FW (ed) Upper Extremity Injuries in Sports. C.V. Mosby 1995.
4Leach RE, Miller JK: Lateral and medial epicondylitis of the elbow. Clin Sports Med 1987; 6:259-272.
5Price R, Sinclair H, Heinreich I et al: Local injection treatment of tennis elbow: hydrocortisone, triamcinolone and lidocaine compared. BrJRheum 1991; 30:39-44.
6Kaplan EB: Treatment of tennis elbow by denervation. JBJS 1959 41:147-151.
7Jobe F, Ciccottti M: Lateral and medial epicondylitis of the elbow. Journal of the American Academy of Ortho Surgeons; 1994 Vol.2 No.1, 1-8.
8Blockley NJ: The painful heel: A controlled trial of the value of hydrocortisone. BMJ 1956 1:1277-1278.
9Campbell JW, Inman VT: Treatment of plantar fasciitis and calcaneal spurs with the UC-BL shoe insert. Clin Orthop 1974; 103:57-62.
10Wapner KL, Sharkey PF: The use of night splints for treatment of recalcitrant plantar fasciitis. Foot Ankle 1991; 12:135-137.
11Lapidus PW, Guidotti FP: Painful heel report of 323 patients and 364 painful heels. Clin Orthop 1965; 39:178-186.
12Leach RE, Seavey MS, Salter DK: Results of surgery in athletes with plantar fasciitis. Foot Ankle 1986; 7:156-161.
13Schon LC: Plantar fasciitis/heel pain in Pfeffer GB, Frey CC, Anderson RB (eds) Current Practice in Foot and Ankle Surgery, New York McGraw Hill 1993; 243-261.
14Bordelon RL: Heel pain, in Mann RA, Coughlin MJ (eds) Surgery of the Foot and Ankle, 6th Edition. St. Louis Mosby Year Book Vol. 2, 837-857.
15Kenzora, JE: The painful heel syndrome: an entrapment neuropathy. Bul Hosp JT Dis Orthop Inst 1987; 47:178-189.
16Savastano, AA: Surgical neurectomy for the treatment of resistant painful heel. Rhode Island Med J 1985;68:371-372.
17Graham CE, Painful heel syndrome rationale of diagnosis and treatment. Foot Ankle 1983;3:261-267.
18Gill LH, Kiebzak GM: Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int 1972; 82:163-168.
19Daly PJ, Kitaoka HB, Chao EYS: Plantar fasciotomy for intractable plantar fasciitis: Clinical results and biomechanical evaluation. Foot Ankle 1992; 13:188-195.