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Tennis elbow: the new disease of the non-tennis player!

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One complaint that is becoming more common is the tennis elbow.  More correctly, we should call it the “Non-Tennis Elbow”.  Far more people sit at keyboards than swing racquets, and these are the ones we are seeing in epidemic proportions.  To be sure, there are other tasks that can create a painful elbow, such as gardening, or tinkering with tools around the house.   But by far the most common causes of tennis elbow lie far from the fields of activity, and reside right in front of our desks: the keyboard.  

Let's take a look at office ergonomics. 

 

 

Even with good desk ergonomics, the forearm waits nervously to pounce on the mouse, or hit the keys in a spasm of typing.  Away from the desk, the cell phone can command the full attention of powerful hand and arm muscles for endless texts, emails or games. Even on the drive home from work, the forearm muscles clench the steering wheel or stick shift with a white-knuckle ferocity.  It all comes down to a massive muscular group pulling on a tiny, bony  knob on the lateral side of the elbow.

What is a SPORT DISEASE?  A TENNIS elbow is just a name for a painful outer knob at the elbow; the inner knob, when painful, is called a GOLF elbow.  Neither require tennis or golf in their genesis. But then even a non-athlete can get “ATHLETE’S foot”.

 

 

For those who do play the actual game of tennis, the eponymous elbow injury can indeed be explained.  Peter Burwash, one of the great experts in the teaching of tennis, writes brilliantly in his classic book: “Tennis For Life”.  He points out five ways to GIVE yourself tennis elbow.

 

These include mal-positioning the thumb up the grip on backhands, straightening the arm on the forehand, serving with a straight arm and a stiff wrist, a whipping topspin, and lazy feet.  The latter causes the player to get to the ball after it is already past, forcing the wrist to flick backhand shots at a horrible mechanical disadvantage.  All fixable by a good tennis pro.  An additional help could come from an equipment expert, who might to correct a racket fit with the wrong string tension, stiffness, or grip size.

In any event, how do we fix this pain in the arm?  Most hand surgeons agree; they don’t have any really good answers.  Once they cut through the skin, they can all see the inflamed tissues, but then what?  They really don’t have much  to offer.  Perhaps cortisone shots, but not many, as they can lead to permanent thinning of the tissues.  In our clinic, we have found good results with medical acupuncture, as well as with physiotherapy, massage, and chiropractic treatments, in selective cases. 

In the end, it is easier to fix the cause of the problem than to fix the result.  Take a look at your ergonomics, and take a look at your timing.  Shake off your hand stiffness every fifteen minutes at the desk.  In a tennis game loosen your death grip on the handle between shots.  Remember, if we can invent a whole new way of working, we need to also invent whole new strategies to tame our new stresses.  This also goes for our mental stresses!

For more reading on this subject:

http://www.medicinenet.com/script/main/art.asp?articlekey=47974

For those who actually got their tennis elbow from tennis, read this:

http://www.pbitennis.com/

For a good review of treatment options:

 

 

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Injury prevention: a bit of a stretch? Not so fast!

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 Stretching: the Truth!

When people are under a lot of stress during a sedentary desk career, a natural outlet is sports.  Which is ideal, as long as you don't hurt yourself.  But while stress relief is only a jog or a bike ride away, it is good to prepare for the possibility of injuries.  People who don't often end up in sports clinics like mine.  One of the most common injuries in weekend athletes is to their “soft” tissues.    In other words, injuries to muscles, tendons and ligaments.  In most cases a simple routine of prevention would go a long way to avoiding these.

First, let us define terms here.  In medicine, the suffix “itis” is simply “inflammation”, and it is at the cellular root of all diseases or injuries.  This completely demystifies medical jargon; consider dermatitis (inflammation of skin), pharyngitis (throat), bronchitis (bronchial tubes), arthritis (joints), and so on.  

So if you tell your doctor that you have “inflamed your hamstrings”, and your doctor tells you that you have a case of “tendonitis”, then all that has been accomplished is to translate an English complaint into a Latin diagnosis.   Once a treatment plan is in place, then it would be most helpful to see how to prevent such injuries in the first place.

POSTURE:

Soft tissues, as the name implies, are pliable, and they usually have a good memory.  So if we sit all day at a desk, with our legs folded up like a card table, then the muscles learn to stay in this position.  This means the hamstrings for example will “learn” to stay in their shortest length, and thus to become very likely to suffer when asked to perform long strides in running.   Same point for the calf muscles, and the Achilles tendons.  If these muscles are used to being not-used, they retract into their shortest length, until asked to push off in whatever weekend sport is being asked of them. 

A classic response for these cases has been to have a pre-exercise “stretch” routine.  Every morning I see joggers out in their short pants pushing against the side of their house with their hands, while stretching one leg out behind them.   Then they bounce as they try to touch their toes, and, for a grand finale, yank their heel up to touch their buttock for a few seconds per side. 

The problem here is this cold-stretch is a real injury producer, and should be completely revisited.

THE TURKEY MODEL: We all know that a turkey leg is easy to move when served hot on a festive platter.  That’s because warm tissues have natural elasticity.  However, served cold the next day, the ligaments and muscles all stiffen up dramatically.  Therefore, consider the cardinal rule of human soft tissues to be “Never stretch (or exercise) COLD tissues”. ( So much for the weekend-athlete leaving four skid marks in the parking lot as they race in to the gym or golf course).   

THE HEAT MODEL:  The soft tissues can be heated by gentle exercise, like the skipping motion that boxers do before their fight.  Or, one could do as many coaches are now advising, and save the  stretches til the END of the exercise, not at the beginning.   If you have access to full facilities, consider taking a whirlpool before you start exercise, then use your warm-up pants as their name implies, until you are fully sweating in your chosen exercise.  One example of this was a squash court I used to belong to in Canada, where there was no heat overnight.  In the winter the air was so cold the ball would behave like a bean-bag, and not bounce at all.  In frustration we solved the problem by taking the ball with us into the sauna, where we sat, fully clothed in our warm up gear, waiting for the ball to become bounce-able.  Once the ball was ready, so were our muscles! 

For further reading, take a look at this link: skip-the-stretch-before-running.

For a more comprehensive look at specific muscle stretches:  http://www.sportsinjuryclinic.net/cybertherapist/stretching/allstretches.php

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When stress gets out of hand: Carpal Tunnel tips

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Carpal Tunnel: it’s all in the wrists.

One of the more common complaints I see in my office is carpal tunnel syndrome.  It is three times more common in women than men, and more likely in assembly line workers and those who operate power tools (think jack-hammer, for example).  However, it is now becoming more common in office workers and students  who type or text for protracted periods.

The syndrome refers to numbness at the wrist, usually because of a compromised median nerve that runs in a bundle of tendons to the fingers. What compromises this nerve is puffiness, usually of the tendons that flex the fingers.  While other causes include pregnancy, rheumatoid arthritis, hypothyroidism, diabetes, and obesity.   

The results of this condition are numbness and tingling in the finger tips, usually thumb, index and mid fingers, along with half of the ring finger.  If protracted, the condition will lead to muscle atrophy of the hand muscles, especially on the palm, over the “heel” of the thumb.  (aka the “thenar” muscles).

The ultimate test is an EMG, which confirms that the median nerve is being interrupted at the wrist, as opposed to other causes of finger numbness that are actually from nerve impingement higher in the arm or even neck.

The ultimate cure of an advanced case is surgery, to snip the fibrous band that holds the bundle of tendons, vessels and nerves into such tight quarters.  For less advanced cases, medical acupuncture,(see our post here), wrist braces (especially at night), and physical therapy can all have a role in treatment.

However, there are a couple of considerations to prevent carpal tunnel:

1.       BEWARE THE WRIST REST: If you type, watch your ergonomics.  The wrist rest was intended to rest your wrists when your hands were relaxed over the keyboard. (In fact it was made necessary in lap-tops by the need to house the components and still have space for the keyboard to be next to the screen; then it was marketed as a "benefit").   However, the rest encourages users to keep the wrists pressed against it, while the wrists extend to allow the fingers to keep typing.  This means the bundle of tendons at the wrist have to work around a corner, and these tendons over time will develop “rope burn” from the unnecessary friction.  Action item: consider a tack attack!  As demonstrated by my old typing teacher in school on her typewriter at the front of the class, the wrists can be held in neutral alignment if a row of thumb tacks is inserted into the sticky side of a piece of tape,  this barbed tape was applied to the wrist wrest area.  All we had to do was look at it, and the lesson was immediately processed (although she kept an open offer to apply this tacky-tape solution to any of us who needed reminders!).  No chance of letting those wrists rest now! Note that great piano players can perform from childhood into late age with hours of repetitive movements, never getting carpal tunnel problems.  The reason is their forearms and hands are all in the same alignment; if the piano stool was six inches too short, and the player had to bend the wrists to let the fingers reach the keys, then carpal tunnel would soon follow.

 

2.       WATCH THE TIME: Try to limit typing to periods of 15 minutes at a time.  Even if you need to do long hours at the computer, set up your screen (or simple kitchen timer etc) to alert you every quarter hour.  Simply drop your hands to your sides, let them relax as you shake them a bit, do a couple of neck and shoulder rolls, and then plunge back to work.  Doesn’t need to take more than a few seconds, and it will save a lot of aggravation later on.

3.       WATCH THE SIZE: In general, small keyboards are fine for small jobs.  But if you spend more than a couple of hours a day on one, you should consider getting a full sized wireless keyboard linked to your laptop.  If you text a lot on your cell phone, take breaks more often.

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Low Back Pain: Some Simple Strategies

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Back pain has become more common in the computer age than it was in the agricultural age. This may appear puzzling, because we are no longer working the land, we are now working the hand. Or at least both hands, at a keyboard. So how does the modern worker contract back pain while literally lifting nothing more than a finger at a time? Let's take a look...

Lower back pain is more common today that it was a few generations ago

The human body was designed (and evolved) for movement. Hunting, gathering, hacking and hewing. The daily activities of work in the old days kept our core muscles toned, and kept our legs in top shape to support us. Most back pains were muscular in nature, and would heal with a bit of rest.

The daily activities of modern work, by contrast, keep our core muscles slackened,, and our legs folded underneath us like a card-table. As a consequence, we are now seeing a significant rise in the number of cases of back pain associated with desk jobs. Even in young people.

To be sure, we can hurt our backs with too much lifting or twisting, such as clearing a heavy snowfall from your driveway. But most of the pains we now see are from too little movement, and need a whole new strategy.

Take a look at the ergonomics of your work area. If, like most people and you are sitting at a desk, then make sure the height of your computer screen is high enough so your eyes can look at just below the horizon when you are sitting upright. Then, make sure your hands are at the right altitude so you can type without bending your wrists. In other words, don't use your laptop for more than short time periods. If you have the keyboard down at a comfortable lap-level, then you have to look sharply down with your head. If your head and neck are comfortable with a higher screen placement, then your wrists are bent acutely to let your fingers reach the keys. I usually rig up a wireless keyboard along with a separate screen, and run both via my laptop.

Take a look at the time. We need to move, and a timer can be a huge help. Every fifteen minutes, set a timer (or a feature on your computer) to alert you. Give your arms a shake, roll your shoulders, and, if you can, try to stand and pace or twist for a few moments. At the very least, try to flex and extend your legs while you are still at your desk. Otherwise the computer can be a time-hog, and hours can pass without you moving any major muscles at all.

 

Take a look at the chair. On most chairs, you can fall asleep. That's because you need no muscle tone to stay sitting. That's why the legs get weaker, and the core muscles around the spine and trunk get more atrophic. Try a Pilates ball instead of a chair. First get the right size, so when you are sitting you will be able to bend your knees to 90 degrees and still have your thighs parallel to the ground. Take your first try with the ball almost against the corner, to protect you if you roll away. Build up your tolerance, starting with five or ten minutes an hour. Once you get the hang of it, you will be impressed that you cannot slouch or even doze. Muscles are used from the toes to the knees, the inner and outer thighs, the hip flexors, abdominals, and the remainder of the core muscles. Your head will naturally be in line, like a Dressage rider.

Now that we have invented the modern workplace, we need to be inventive in our strategies. If you have pains in your back, or if you simply want to prevent them from starting, take a look at your ergonomics and your time. You can be "on the ball" in more than one sense of the word!

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The Big Three in the Devil's Kitchen

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Medicine is supposed to be a precise science.  One set of symptoms means one disease, usually with one treatment.  At least in the text books.  In the real world, all bets are off.  Just because a patient has one disease does not mean they couldn't have another, and another.  When patients complain of fatigue, general achiness, stomach cramps, headaches, and lack of focus, Doctors are often baffled.  They are basically flipping through one chapter after another in their mental database, trying to find one disease that will expain all.  A hundred years ago, we just made up a word, and called it "liverishness".    Nice way of ducking the question.  Now, with patients quick onto Google, that bluff answer won't work for long.

So what can we do about these multi-system complaints?  After a routine physical examination, and tests to rule out hidden dangers, I often consider a therapeutic trial of diets.  The patient needs a pencil and paper, to record daily diet intake, as well as symptoms.  

We now turn our attention to the most common offenders in today's diet: The Big Three in the Devil's Kitchen:

1. "White Death"  

Otherwise known as white sugar.  White flour also turns to sugar in minutes.

Because neither comes with its original equipment of whole fibers, then both are instantly absorbed and cause inflammatory results right away.  As inflammation is the basis of all disease, this means that virtually all symptoms can be flared up, from hyperactivity and depression to muscle aches and colitis.  In their whole form, sugars and starches that are still encased in their fruit or grain bodies are fine.  They come with lots of fiber to fill the stomach, and slow the rate of absorption.  Once all the fiber is "refined" away, then the body is vulnerable.  As a simple illustration, our stomach can probably only hold three apples and a glass of water.  But if we remove the fiber from the apples, and boil off the liquid from the juice, we get a sugar-filled concentrate, or eventually a powder.  Now we could fill up the stomach with the sugar of fifty apples, and still have room for more!

Action Item: Because "white death" is junk food, it doesn't need replacement in our grocery carts.  Just removal.

 

2. Dairy 

Brilliantly marketed as "Nature's Perfect Food", milk is only perfect if you are a three-hundred pound heifer.  One should note that even cattle are smart enough to quit milk once they grow up; it is only humans who persist after they become adults.  And we drink the milk of a different species.  Dairy products taste great, and in many cases cause no immediate or obvious side effects.  But in the case of "liverishness" symptoms, it is one of the likely offenders, causing unnatural challenges to the human imune system.  Remember, there is twelve pounds of milk in a pound of cheese, so that means trying your pizza with "extra-no cheese".  Also note that singers never drink milk between songs, as the mucous thickens immediately in the throat; so avoid all dairy the next time you have a cold, cough, or earache.

Action Item: If you are having vague symptoms, try excluding all dairy for four weeks.  Then try and introduce it for an occasional meal; take a look at your records to see if there is a connection.  If your symptoms are connected, then leave the dairy alone; otherwise bon apetit!

 

3. Gluten 

 Now this one is tricky, as it is found in lots of excellent foods, like whole grain pastas and breads.  But there is a significant number of people (quoted as high as 40%) that can have some reaction to it.  It may be as simple as a bit of gassy bloating after a meal, but for many it can mean abdominal pains, muscle aches, headaches, and insomnia just for a start. 

Action Item: Once you have spent a month on your "dairy diary", you may already have your answer.  If your symptoms are still present, however, you can elect to go back to the milk products, and move on to the exclusion of gluten for the next month.  This requires some persistence, but you can find "gluten-free" labels on pizza crusts, sandwich wraps, breads, pastas and even pastries.  When in doubt, just stick to fish, eggs and green vegetables as a mainstay.  At the end of the month, see if your record shows any improvements.  If not, then you can return to full diet.  For more info on gluten, see http://en.wikipedia.org/wiki/Gluten

 

 

Note that the above is simply an adjunct to the process of investigation.  If symptoms persist, and your record shows food intake is irrelevant, then your doctor can escalate the investigations as needed.  Better to solve your symptoms back at the grocery store, before needing to involve the hospital! 

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Headache relief without drugs!

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If you are suffering from headaches, especially the tension headaches we associate with stress, don't assume you will always need to take a prescription drug, or otherwise be doomed to enduring the pain.

 

Stress headaches are caused by muscle tension.  Muscles are built to flex and extend as we move, and get all their circulation between movement.  That's when the blood supply brings in food and oxygen, and carries away the products of metabolism. 

During sleep this takes place naturally, but during the day our modern workplace gets in the way.  We have invented the cubicle to replace the spear and rake.  Now we hunt and peck, instead of hunting and gathering.  But by the end of several hours, our large muscles have not moved, except to draw our shoulders forward, to raise our shouldertips up to our ears, and to crane our necks downwards toward the screen.  While the small muscles of the hand may be moving, the large muscles are screaming for fuel and oxygen!

The result is pain.  In just the same way, two suitcases held at arms length can become extremely painful.  Even if the suitcases are empty, and the arms are muscular, the muscles cannot withstand permanent tension, which is why this technique has infamously been used as torture.

So if you feel like you are being tortured with headaches while you are working at a stressful job, here are some simple steps to try before resorting to a prescription drug:

1. Set a timer.  Every fifteen minutes, have a kitchen timer or an Outlook reminder sound the alarm.  Then straighten up your posture, pull back your shoulder blades so they almost touch, and roll your neck and shouldertips around in slow cirles.  Just a short break, then back into the task you go. 

2. Take a breath.  Most of us breath very shallow cycles unless we are huffing in full sprint.  With desk work, this means the lungs never properly fill or empty, and carbon dioxide builds up in our blood.  This makes our pH acidic, and further adds to the pain in our muscles, already painful by their buildup of lactic acid from contracting.  During your fifteen minute mini-break, take a moment to exhale through your mouth.  Blow it all out, then blow out even more.  You will be surprised how much extra air you were holding back!  Now take a slow breath in through your nose, until you can't inhale any more.  Pause for several seconds, then blow it all out again.  Repeat a few times, then return to your task.

3. Take a drink. 

 Most people are "down a quart" in water, just like our cars are often short of motor oil.  Rehydration with water will improve sludged circulation to those tense muscle cells.  Hot water or cold, it doesn't matter. 

4. Try a massage.  First, your own fingers can help if you press firmly over the temples.  Clench and unclench your teeth, and feel the scalp muscles on each side of the head as they engage.  If there are tender spots here, apply your own fingerpressure firmly for a few seconds, in a slow circular motion.  If the headache is still bad, pair off with a co-worker; have him or her stand behind you as you sit, and place one thumb over each of your shoulder tips.  The exact target is the half-way point between the spinal nob at the base of your neck and the edge of the shoulder, where the seam of the arm meets the body of the shirt.  The Chinese Acupuncturists know this as "Gall Bladder 21", and MD Pain specialists know this as a classic "trigger point" to inject with freezing.  But without needles, it is still a powerful point to prevent tension pains.

Press with the thumbs firmly, and visualize descending a four story elevator.  The muscles will start to ease under the thumbs, then add more pressure to go down to the third floor.  The thumbnails will be white with the pressure, and you will soon feel the release of the underlying shoulder muscles again.  Repeat until down to the "lobby".  Do NOT start at the surface and then press all the way to the basement!!

If the above doesn't work, then try a non-prescription drug.  If still no luck, see your doctor for a full assessment, diagnosis, and then a treatment plan.

 

 

 

 

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