Happy New Year to all of our BSEMS patients, staff and friends.

We hope that 2011 proves successful in maintaining health and fitness. If you are struggling than feel very welcome to come and see one of our specialists- at BSEMS there is someone who can help get you back on track.

Welcome to Dr Thomas Gan

In mid January Dr Tom Gan will be commencing sessions at BSEMS. Tom is a senior registrar, meaning he is nearing completion of his Sport and Exercise Medicine specialty training. Tom has worked as a team physician for various elite sporting teams and has also been medical director for world class sporting events such as the Brisbane International Tennis tournament.

He has many professional interests including lower limb stress fractures, tennis injuries, cricket injuries, and trigger-point acupuncture.  He is available to provide consultations for a variety of paediatric and adult sports medicine conditions.

Tom will be working Tuesday mornings between 8am-12pm in the BSEMS rooms.

This year we are aiming to include a fact sheet from one of our practitioners to each blog. The fact sheets will be catalogued in our “Patient Info” webpage, under appropriately enough “Factsheets”.

For January we have provided an information sheet for patients and referrers regarding the appropriate preparation needed before a compartment pressure test is performed. This can help ensure that the test is performed correctly the first time and to reduce the chance of a false negative investigation.

Compartment Pressure Testing

Pre-test Preparation

Chronic exertional compartment syndrome is a cause for leg pain with exercise. The usual pattern is a gradual increase in pain during continuous exercise to a point when the athlete has to stop. Pain then takes between minutes to hours to go. Patients describe a feeling of hardness or fullness in their legs, and occasionally will notice lumps in the muscles. The condition is diagnosed by performing a compartment pressure test (CPT).

During a CPT the patient must be able to reproduce their leg pain as bad as they can get it. This means that in the days to weeks before the test is done, the patient should perform moderate level exercise (and not rest) so that they can reliably reproduce their symptoms on the day of the test. The patient will also guide the Sport and Exercise Medicine (SEM) Physician as to which compartments need testing, and they must pay attention to where they develop their pain (i.e. front of the leg, side, behind the shin bone, or more than one area).

The CPT involves injecting a small amount of local anaesthetic into the skin at the sites where the pressures will be tested. The patient will then jog/run/whatever needs to be done to bring on their symptoms, usually for 10-15 minutes. They then return to the room, and the SEM Physician performs the test, which involves inserting pressure manometer needles into the relevant muscles. One special needle has a catheter inside it, and this remains in the leg while the patient does specific exercises, whilst the pressure in the leg is monitored.

The test is very safe, but complications can occur- listed below. The test takes one hour. Typically the patient can drive or fly after the test is completed.

The SEM Physician always prefers to see the patient before arranging a time for the test, to ensure the test is done correctly right the first time, reducing the risk of getting a false negative result. If the diagnosis is confirmed, then the only real treatment is surgery (a procedure called fasciotomy, performed by an orthopaedic surgeon).

Complications

Compartment pressure testing is a relatively safe procedure, but is an invasive intervention, and some complications may result including (but not limited to):

Infection

Bleeding and bruising at the puncture sights

Possible (permanent) damage to underlying blood vessels

Possible (permanent) damage to underlying nerves, resulting in sensory or motor disturbance

Failure of the procedure

Risk of development of acute compartment syndrome requiring and urgent operation

Risk of development of a complex regional pain syndrome

Please feel free to discuss any questions or concerns you may have with the BSEMS staff and specialists.

New Year and New faces.

The staff at BSEMS trust everyone had a safe Christmas break, and enjoyable New Year celebrations. As everyone returns to work, and gets back to their normal routine, rest assured that all of the practitioners at BSEMS are ready and raring to help you stay fit and active.

We are happy to welcome a few new faces to our staff this year including Joel Simpson, Exercise Physiologist, and Dr Thomas Hilton, who replaces Dr Thomas Gan as our senior Sports Medicine Registrar. Dr Hilton’s profile will be up soon, but please contact our staff if you have any queries. To start the year off we have included the topic of tennis elbow to our fact sheets, a very common problem that probably affects more non-players than not!

All the best for a safe 2012, and happy exercising.

Tennis Elbow

AKA Extensor Tendinopathy/ Lateral Epicondylosis

Aetiology:

The primary pathological process is thought to be degeneration of the extensor carpi radialis brevis tendon, usually within 1-2cm of its attachment. There is an invasion of fibroblasts and vascular granulation tissue rich in nociceptive nerve endings. There is often continued or repetitive use of wrist extension. The grip on the racquet may be too small or poor technique is present. ECRB crosses 2 joints and works eccentrically at both ends during certain manoeuvres, and may be compressed by the radial head.

History/Examination:

There are 2 distinct presentations: The most common is insidious onset of pain 24-72 hours after performing an unaccustomed activity involving wrist extension. The other presentation is a sudden onset of lateral elbow pain associated with a single instance of exertion involving the wrist extensors.

Examination shows maximal area of tenderness 1-2cm distal to the lateral epicondyle. The pain is typically reproduced with resisted wrist extension (particularly when the wrist is pronated and radially deviated (Mills’ test) and with resisted extension of the middle finger. There may be neural tension on the upper limb tension test and there may be decreased ROM in the neck particularly around the C5/6 apophyseal joint.

Predisposing factors should be treated (e.g. bad technique, wrong grip size) and biomechanical deficits corrected (assess the wrist, shoulder, scapula, neck and back).

Common faults in tennis include:

• “leading elbow”
• early wrist flexion with abrupt extension on impact
• exaggerated wrist pronation
• ball impact in the lower portion of the racquet.

Racquet size and stiffness have been postulated as causative factors, although neither has been definitively shown.  A stiffer racquet transmits more vibration to the arm.  Higher string tension will transmit more force through to the arm.  Vibration-damping devices placed between the strings have been shown to decrease string vibration but with no benefit to the arm. A larger grip size has been shown to produce lower muscle activity in the forearm extensors.

Treatment:

Control pain with rest, ice and NSAIDs. Modalities, stretching and massage may be used. Dry needling may help with trigger points.

Counterforce bracing can be used during the rehab.

Corticosteroid injection and iontophoresis may be used (although benefits are controversial), other adjunctive treatment may be considered (PRP, GTN patches, shockwave and/or sclerosant injection) with surgery as a last resort.

To improve wrist flexion mobility place the wrist extensors on passive stretch with the elbows extended. As flexibility starts to approach normal, strengthening should commence with isometric contraction and progress to concentric and then eccentric exercises. A progressive resistance programme is incorporated which may include free weights or a Theraband. Use a weighted rod to strengthen the muscles of pronation and supination. This should follow with a graduated return to activity.