Today’s blog entry is a little bit of a mismash of several topics which are loosely related through the game of tennis, a game which I love, and many of my friends and colleagues do as well. (Too bad I was just terrible at it while I was growing up!)
First of all, today, I want to veer away from diet and nutrition for a moment, and go back to my “roots” as a hand surgeon and talk about a very common condition that I see quite frequently which is called lateral epicondylitis, otherwise known as tennis elbow.
Tennis elbow, very simply put, is tendinitis, or swelling and inflammation, of the tendons of the elbow. The classic presentation of lateral epicondylitis is pain over the elbow with extension of the wrist, and this typically happens in tennis players who are hitting the backhand.
One of tennis’ greatest players: Roger Federer. When you hit a tennis ball on your backhead, much of the force of contact is transmitted directly to the elbow: specifically at the lateral epicondyle.
When a backhand is hit, stress is placed on the insertion of the extensor muscles at the elbow at the lateral epicondyle. Subsquently, tears and inflammation at that point can occur and result in swelling and pain.
There is also an associated condition with this which is very important to appreciate and diagnose if it is present which is also called radial tunnel syndrome or what can also be known as posterior interosseous syndrome. This is a very different condition that Lateral epicondylitis, or tennis elbow, and is treated differently as a result.
Basically, radial tunnel syndrome is a pinched nerve in the area of the forearm where the radial nerve passes by the lateral epicondyle and goes underneath the supinator muscle in the forearm. This is all very complex anatomy, but what it is important to know here is that the radial tunnel can be a problem along with lateral epicondylitis, and sometimes we have to treat both conditions in order to relieve pain effectively for patients.
How is lateral epicondylitis diagnosed?
This is a clinical diagnosis, meaning the doctor has to examine you and perform a series of provocative tests that reproduce the pain you are having. Sometimes, an MRI is necessary to do this, but not always. Radial Tunnel is also a clinical diagnosis, although a nerve test can sometimes help diagnose radial tunnel. Often though, the nerve test will be negative, and show no pinch of the radial nerve, even though symptoms consistent with the diagnosis are still present.
What are the modalities of treatment for lateral epicondylitis?
- Change your technique: When I started playing tennis, a lot of time was spent with the technique of the upper body as it relates to hitting a backhand. Turning your body sideways, using your foot work to place you correctly to hit the ball, and the proper backstroke and follow-thru. That was in the says of wooden rackets as well, and the new graphite racquets were just being introduced. It has taken about 20 years or so, the philosophy has changed due to the likes of players like Federer, Nadal, and Djokovic, who with their enormous physical talent and the technology of lighter, faster, bigger, and more powerful racquets have totally changed the game. Technique is taught in a totally different way, and one the keypoints in this new philosophy is the use of a shorter backswing and follow-through. This also lessens the strain on the the lateral epicondyle, and perhaps may let you win a few more points as well! Here is a link to the technique. Please note: I know of this only through my wife who is the big tennis player, and I had a chance to read about it, and have her share her experience with me. It seems to me like it’s worth a try. I can’t promise relief from tennis elbow with adoption of this technique, but as they say, it can’t hurt to try!
- Rest and immobilization. Many times people use a forearm air splint, which I do not recommend because I think it puts too much pressure on the radial nerve when it is not worn properly )and often people do not wear this splint properly). The better option is using a forearm splint, the kind that you would wear for carpal tunnel syndrome to prevent extension and flexion of the wrist and this will rest the origin of the extensor muscle thereby not allowing it to tear and cause pain and inflammation.
- The splint pictured above can put undue pressure on the lateral epicondyle making symptoms worse. I prefer the regular wrist cock-up, or carpal tunnel splint for treatment of lateral epicondylitis .The second line of treatment is usually physical therapy, which involves massage, stretching, rest, and a modality-based treatment protocol which involves things like ultrasound and iontophoresis which is transcutaneous application of steroids.
- The third line of treatment is a steroid injection. Steroid injections are generally not as painful as they are in the hands or the wrists and they can be very effective.
- However, when all these fail, sometimes you need to perform surgery if you want relief of your symptoms. and the surgery though it is not complicated, it is not as successful as let us say carpal tunnel syndrome which is a 90% to 95% rate of cure. It is important to note that lateral epicondyle surgery is very safe but for complete pain relief, the literature suggests that is about 60% to 80%. In my experience, most patients have either a significant or moderate amount of pain relief but it is not always alleviated through the surgery. That is why we reserve it for as a last step.
Now, on to the fun talk about tennis!
As you know, the three best tennis players in the world at this current time are Rafael Nadal, Roger Federer, and Novak Djokovic. Novak Djokovic (the Djoker!) Novak has been on an absolute tear this past year. He has gone 64-2 and won three major titles (French Open, Wimbledon, and the US Open). How did he get so good? How did his game improve so dramatically? Commentators were amazed at not only the technical prowess of his game, but the fact that he simply does not get tired. His energy, speed, accuracy, technique and his form is the same in the 1st set when he is fresh, as it is when he is playing in the 5th set. Why the improvement? Well, Djokovic credits his adoption of a gluten free diet as one of the major keys to his success. As you know, I am passionate about health and nutrition so I could not let this one slide by without some commentary.
- Novak “Nole” Djokovic: World’s #1 Tennis player in 2011
Recently, there has been a wonderful book published called Wheat Belly by Dr. William Davis, which I have quoted many times in my blog and there are also many blog reviews of it as well. It is on a New York Times bestseller list and it is an excellent book, which makes the case that wheat is very toxic to us, not only because it is toxic by its nature with the , but it has been genetically modified for mass production in such a way it makes it even more toxic for us than it usually would.
As I’ve stated, Novak Djokovic started with a gluten-free diet a while ago before he started on this amazing tear and everybody has noticed that he has had more energy, he has strength at the end of the games, his service and motion does not weaken with time, and he just simply dominated Rafael Nadal in the finals of the US Open. He also beat Federer in an amazing 5 set victory in the semifinals.
Now is the gluten-free diet responsible? Maybe. Is that just a placebo effect? Perhaps. It is silly to assume that a causal relationship can be established in any meaningful way here. But that being said, Djokovic had a lot of energy throughout the match and and it seemed to give him the edge over Rafael Nadal and Roger Federer. The ultimate point is: a gluten free diet is very easy to try, and the fact is, a lot of people are wheat sensitive. This has a lot to do with (1) the gluten in wheat (2) the fact that wheat is GMO. It’s something we are going to have to deal with as obesity, type II diabetes, and celiac disease are all on the rise, and all the fingers point to gluten-grains as a major contributor.
But whether it will make your tennis game better is uncertain. Nadal, Federer, and Djokovic are all excellent tennis players, and there are a ton of reasons each player is great in their own right–one of which is that they are competitors and bring out the best in each other.
I had the pleasure to watch their Wimbledon final a few years ago between Federer and Nadal and I thought it was one of the most amazing tennis matches I had ever seen. I was not alone of course, as people called this the greatest tennis match ever played.
- Federer and Nadal: A great rivalry. The Magic vs. Larry of Tennis, for sure…in perhaps the greatest tennis match ever played: Wimbledon 2006
Nadal is certainly no stiff. From a hand surgery prospective, Nadal is very interesting because his coach, his uncle, taught him how to play left-handed. He is actually not a natural lefty, but he started at an early age to play lefty, which is a perceived advantage in many sports and tennis is one, baseball is another, and basketball is another as well. I think it is also interesting that several of our last presidents have also been left-handed, but that is another story in and of itself.
And Roger Federer is an equally amazing tennis player, as well as a class-act (So, is Nadal by the way). He is now a legend in his own right, and he is a subject to be of an excellent article which I want to share with you if you do not know much about tennis or if you love tennis; it is called Roger Federer as Religious Experience.
It was written by David Foster Wallace who was an amazing author. Unfortunately, he battled depression for much of his life and eventually took his own life at the age of 47, which is sad because he wrote some really, really wonderful books that I enjoyed reading to this day and re-reading some of the articles.
He had very good insights into tennis and this article is simply fun to read as a casual tennis observer like I am or a true fan. So I share that with you today.
As I have said, this is a kind of a disjointed blog entry today that talks about several things, but I hope you enjoyed it and I hope to share more of my nonlinear thought process with you in the future.