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Published: 15 January 2021

• elbow
• pain
• tennis elbow
• lateral epicondylitis
• tendonopathy
• tendonitis

Though there are MANY causes of elbow pain, the most common cause of pain to the elbow is lateral epicondylitis, commonly known as Tennis elbow. Tennis elbow effects about 1-3% of the general population, and 15-30% of the workforce. 80% of those effected recover within one year. Based on its name, a high percentage of tennis players are effected by this condition (40-50%). However, it is actually more common in amateur golfers than golfer’s elbow. And hey, now that the greens are covered with snow, it’s time to talk about getting a plan in place for next season and living pain-free. ^{1,2,3,4,5,6,8,12.}

Those who develop this condition will experience symptoms that include pain over the bony prominence at the outside of the elbow, known as the lateral epicondyle, and/or pain to the surrounding tissue. Pain can radiate into the forearm. This area may also be tender to touch. Pain is often exacerbated or made worse by gripping, twisting, lifting, or repetitive activities such as the use of tools or typing.

Lateral epicondylitis is the result of repetitive activity or overuse of the extensor tendons of the forearm, which attach their associated muscle to the outside of the elbow (at the lateral epicondyle of the humerus).

Tendons normally adapt and become more resilient when an optimal amount of tension or stress is applied to them. When the tension applied to a tendon exceeds it’s tolerance, often due to repetitive loading, micro tears occurs. These cumulative micro tears lead to tendinosis, which is essentially a symptomatic degenerative process to the tendon.

These degenerative changes to the tendon can occur over time from repetitive gripping, extending of the wrist, rotating the wrist and forearm, or from activities such as using tools/manual work, prolonged typing, playing an instrument, or from sports such as golf or tennis which require gripping with a stable wrist position. Generally, individuals with painful lateral elbow symptoms tend to underuse or rest their painful arm, which can result in further weakening of the tendon, making it more susceptible to injury, and lowering the threshold for tendon micro tears to occur. ^7,11,12,13

There are many other contributing factors that can make you more susceptible to experiencing this condition, including poor posture, poor scapular stability, rotator cuff pathology, nerve impingement, history of smoking, a labour type job, and obesity. ^1,8,12

So now what? A few helpful tips for success:

Modify your activity but stay active! Initially, take aggravating activities out of your daily routine, or modify the way you perform a task to keep them pain-free. This may include: taking breaks from typing throughout your work day, adjusting your work station, golfing less days per week or less holes per round, wearing a counterforce brace to offload your elbow, or even simple activities such as lifting a milk jugs with your other hand. ^{7, 12}

Posture, posture, posture: Have you ever heard the phrase “Sh$t flows downhill? Well this is VERY true for not only sh$t but also for pain in your elbow. Working on your posture and your postural and scapular endurance/stability can help offload the elbow during aggravating activities. Don’t slouch. By mindful of your posture throughout the day, and change positions often. Ensure you have good desk ergonomics if you work at a computer. Your wrists should be supported on a pad (or rolled up towel), and placed in a neutral position versus extended. ^7,12

Counterforce brace: The use of a counterforce brace (tennis elbow brace) which when worn correctly applies compression just below the tender area of your forearm, can reduce the load to the tendons that attach at your elbow, therefore reducing pain during aggravating activities. ^7,12,13

Physiotherapy: A physiotherapist will perform an examination, help determine a correct diagnosis (remember, MANY causes of elbow pain, and not just local to the elbow), and guide you through the proper rehabilitation process specific to you, your lifestyle, and your goals. Treatment should include a gradual and progressive exercise program, education and strategies for self-management, activity modifications, and may also include dry needling/acupuncture to change muscle tension, manual therapy, and taping to offload the painful area.

A gradual progressive home exercise program to build up strength in your forearm muscles, and making their associated tendons more resilient, as prescribed by your physiotherapist is a KEY component to treating this condition. Working on posture, core, and scapular stability is also as important part of the process. ^{7, 8,9,11,12,13.}

Injections: Research has shown that PRP and prolotherapy injections may to beneficial in treating lateral epicondylitis in addition to a good progressive exercise rehabilitation program. One study showed that physiotherapy and physiotherapy plus prolotherapy are optimal over prolotherapy alone at 12 weeks. Cortisone injections, although good for relieving pain in the short term, are actually worse for pain at 3 months and beyond compared to physiotherapy and a wait and see approach. ^{7, 8,9,10,11}

Final thoughts:

This topic is SO complex, and this is just a small generalized glimpse into this common condition without mucking the waters. Remember, this is just one of the many conditions that causes lateral (outside) elbow pain. If you are experiencing any pain with life, please see a health professional, such as a physiotherapist, to better assess and help guide your care. The above is just a starting place.

Stay healthy, Stay active, Stay kind.

Regards,

Kayla Eagle, PT, MScPT, Bkin

References

1. Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006 Dec 1;164(11):1065-74. doi: 10.1093/aje/kwj325. Epub 2006 Sep 12. PMID: 16968862.

2. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum. 2004 Aug 15;51(4):642-51. doi: 10.1002/art.20535. PMID: 15334439.

3. Ranney D, Wells R, Moore A. Upper limb musculoskeletal disorders in highly repetitive industries: precise anatomical physical findings. Ergonomics. 1995 Jul;38(7):1408-23. doi: 10.1080/00140139508925198. PMID: 7635130.

4. Stockard AR. Elbow injuries in golf. J Am Osteopath Assoc. 2001 Sep;101(9):509-16. PMID: 11575037.

5. McCarroll JR. The frequency of golf injuries. Clin Sports Med. 1996 Jan;15(1):1-7. PMID: 8903705.

6. Gosheger G, Liem D, Ludwig K, Greshake O, Winkelmann W. Injuries and overuse syndromes in golf. Am J Sports Med. 2003 May-Jun;31(3):438-43. doi: 10.1177/03635465030310031901. PMID: 12750140.

7. Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev 2016;1:391- 397. DOI: 10.1302/2058-5241.1.000049.

8. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Nov 4;333(7575):939. doi: 10.1136/bmj.38961.584653.AE. Epub 2006 Sep 29. PMID: 17012266; PMCID: PMC1633771.

9. Bot SD, van der Waal JM, Terwee CB, van der Windt DA, Bouter LM, Dekker J. Course and prognosis of elbow complaints: a cohort study in general practice. Ann Rheum Dis. 2005 Sep;64(9):1331-6. doi: 10.1136/ard.2004.030320. Epub 2005 Feb 11. PMID: 15708885; PMCID: PMC1755654.

10.Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013 Feb 6;309(5):461-9. doi: 10.1001/jama.2013.129. PMID: 23385272.

11.Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. J Physiother. 2015 Oct;61(4):174-81. doi: 10.1016/j.jphys.2015.07.015. Epub 2015 Sep 8. PMID: 26361816.

12.Cutts S, Gangoo S, Modi N, Pasapula C. Tennis elbow: A clinical review article. J Orthop. 2019 Aug 10;17:203-207. doi: 10.1016/j.jor.2019.08.005. PMID: 31889742; PMCID: PMC6926298.

13.Ma KL, Wang HQ. Management of Lateral Epicondylitis: A Narrative Literature Review. Pain Res Manag. 2020 May 5;2020:6965381. doi: 10.1155/2020/6965381. PMID: 32454922; PMCID: PMC7222600.

Details

Published: 02 June 2020

Meet our newest friendly face, Dr. Nicole Barry DC! Dr. Nicole is an experienced chiropractor who can be found at both our south (Acadia/Willowpark) and north (Evanston) Calgary locations. Learn more and book an appointment with her here:  https://energizehealth.ca/book-online.html

Hi! I'm Dr. Nicole! As a chiropractor, I believe the key to a happy and healthy life starts with motion. The way you move can not only affect how you perform activities, but also the perception of how your body feels. Our bodies were designed to move and I am passionate about helping people function at their best.

This is a principle I have grown to respect in both my professional and personal life, and the reason I became a chiropractor.

I graduated from Western University with a Bachelor of Arts in Kinesiology before completing my Doctor of Chiropractic in 2013 at Canadian Memorial Chiropractic College in Toronto, Ontario. For the last seven years I have practiced in a variety of clinical settings and gained experience treating a wide scope of injuries. Whether you are a recreational runner, a busy mother, or working from home with a less than ideal set up, I strive to understand what your goals are and help you reach your full potential.

I am a big proponent that different bodies require different treatments. While most people associate chiropractic care with adjustments, this is just one of the tools in my toolbox. I like to use a combination of soft tissue therapies, adjustments, mobilizations, kinesiology taping, custom orthotics and rehabilitative exercises.

Many people traditionally seek my services for neck and low back pain, but I am also well trained to diagnose and treat other areas of the body such as shoulders, elbows, wrists, hips, knees and feet.

Details

Published: 11 May 2020

CURRENT AS OF OCTOBER 23, 2020

Our doors are open but it is anything but business as usual at Energize Health.

You may be wondering what changes have been made to our clinics since the government announcements that health care professionals may resume services. Here is a list of FAQs we hope you will find helpful.

Please note that the information below is subject to change as this is a constantly evolving situation. In the event of a discrepancy between this information and the directives of the provincial public health authorities, the directives of the provincial public health authorities take precedent.

Are you open?

Yes. Our clinics are open and we are accepting appointments for all services: chiropractic, physiotherapy, massage therapy, manual osteopathy, acupuncture and psychology.

What measures is Energize Health taking to screen people for COVID-19?

As part of our new processes, we are required to pre-screen individuals for symptoms of COVID-19 a minimum of two times: once at the time of booking appointments or when reminding people of their appointments, and again upon their arrival to the clinic. If an appointment is booked in advance, we conduct a third additional screening closer to the appointment date.

Our staff is also required to pre-screen themselves for symptoms prior to arriving to work and upon arrival to work.

People with symptoms of COVID-19 are recommended to self-isolate and contact 811, and follow the Isolation Requirements set forth by the Government of Alberta and our Chief Medical Officer of Health (CMOH).

People with symptoms of COVID-19 are not able to attend the clinic while symptomatic, even if they have tested negative for the virus. It is important for symptomatic individuals to stay home until their symptoms resolve so they do not infect others.

Energize Health continues to waive our late cancellation fee in the event of illness when someone advises us they are unwell and thus unable to attend treatment. We ask that you provide as much notice as possible if you are ill, to allow us the opportunity to rebook your appointment time with another patient, but we understand symptoms can have a sudden onset. Any notice is better than no notice!

Am I required to wear a mask to my appointment?

As of August 1st, 2020 The City of Calgary introduced a mask requirement for indoor spaces in Calgary (Bylaw 26M2020). We ask that everyone entering our clinics wears a mask for the duration of their visit, including during treatment, whenever possible. If you do not have a mask, you may purchase one from our front desk for $1

Will my clinician wear a mask?

Yes, your clinician will be wearing a medical mask for the entire duration of your visit. A condition of returning to practice is the proper use of PPE for all staff and clinicians and this includes continuous masking of our clinicians while providing services.  

What about hand hygiene?

You will be required to sanitize your hands upon arrival, using hand sanitizer at our front desk.

You will also be required to sanitize your hands prior to touching our payment system at the end of your appointment. In the interest of reducing the need to touch the payment system, tap is the preferred method of payment, whenever possible. We are also able to securely keep your credit card on file and can process payment that way.

You will be encouraged to sanitize your hands prior to leaving the clinic.

Can I bring someone to my appointment?

To reduce the number of people in the clinic at one time, we are asking patients to attend their appointments alone, if possible. If a patient needs or wants to have someone attend their appointment with them (a parent, guardian, caregiver etc) that person will be asked COVID-19 screening questions, will be asked to provide their name and contact information, and will be required to sanitize their hands.

What time should I arrive to my appointment?

In the interest of reducing the number of unnecessary close interactions, we ask that you please remain in your vehicle or outside the clinic until a couple minutes before the scheduled start time of your appointment. We will be doing our absolute best to run right on schedule, just as we always have.

What other changes can I expect in the clinics?

Our reception areas look quite different. We have:

• Plexi-glass barriers on the desks
• Removed many of the high touch surfaces and items including reception furniture, brochures, literature, and children’s toys. A clean chair will be made readily available to those who are uncomfortable standing however there will be minimal wait time as we do our absolute best to run right on schedule.
• All surfaces people touch are disinfected with medical grade disinfectant several times throughout the day, minimum. Many surfaces and items are disinfected after each use including all treatment surfaces, equipment, pens and payment systems.

Additionally:

• Our staff will be wearing PPE including masks
• Our regular disinfection procedures for treatment surfaces and equipment remain essentially unchanged as we have always thoroughly sanitized these items with medical grade disinfectant between each and every use. Our thorough sanitizing procedures reduce the risk of any transfer of illness from an a-symptomatic or pre-symptomatic person to other individuals. 

Your safety and the safety of our team is our top priority. Things will look and be a bit different at our clinics for the foreseeable future but we look forward to continuing to help you achieve your health goals during these unusual and challenging times.

If you have any additional questions please contact us – we are always happy to help. If you would like to access treatment but are high risk for severe outcomes from illness, or have any other concerns, please contact us. We are happy to make additional accommodations to further ensure the safety and comfort of our patients.

Details

Published: 03 March 2020

Acupuncture therapy has been a well-known part of Traditional Chinese Medicine (TCM) since ancient times dating back at least 3000 yrs. However, for anyone new to the realm of holistic medicine, this practice can seem quite the mystery. How can inserting needles into the skin possibly make a person feel better and where's the proof?

In short, acupuncture is a safe, minimally invasive technique that stimulates nerve-rich areas of the skin surface in order to influence organs, tissues, glands and various functions of the body. In a world where people are searching in earnest for safe alternatives to prescription drugs, acupuncture, well-known for its minimal side-effects, is a very compelling therapy to consider...and the evidence that it actually works is piling up.

Over the past 20 years, there have been over 13,000 studies conducted across the globe in 60 countries, including hundreds of meta-analyses summarizing the results of thousands of human and animal studies.1 The clinical areas that have been studied include pain, cancer, pregnancy, stroke, mood disorders, sleep disorders and inflammation, among many others. In 2014 the entire literature base was summarized by the Australian Department of Veteran Affairs).2 This was followed by a landmark review in 2017 called The Acupuncture Evidence Project which determined that acupuncture demonstrates moderate to strong evidence of effectiveness in the treatment of 46 conditions and is considered safe in the hands of properly trained practitioners. 3  In this review the strongest evidence was shown for migraine prophylaxis, headache, chronic low back pain, allergic rhinitis, knee osteoarthritis, chemotherapy-induced nausea and vomiting, post-operative nausea and vomiting and post-operative pain.

• 2013 meta-analysis comparing treatments for osteoarthritis of the knee found that acupuncture out-performed exercise, sham acupuncture, and weight-loss. 4 
•  2015 meta-analysis comparing treatments for shoulder impingement syndrome (all along with exercise) found that acupuncture outperformed 17 interventions such as steroid injection, NSAIDs, and ultrasound therapy. 5 
• 2016 comparison of 20 treatments for sciatica concluded that acupuncture was 2nd most effective after the use of biological agents, outperforming epidurals, disc surgery, manipulation, opioids, exercise, and a procedure called radio-frequency denervation. 6
• 2018 meta-analysis concluded that acupuncture was more effective than drugs for treatment of chronic constipation, with fewer side-effects. 7 

 Concerning acupuncture for chronic pain, the Archives of Internal Medicine published a meta-analysis which reviewed 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain, and concluded that "acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option". 8  Additionally, a review published in Current Opinion in Anaesthesiology summarized acupuncture as being "effective, safe, and cost-effective for treating several chronic pain conditions when performed by well-trained healthcare professionals. 9

Many of my clients ask what acupuncture is good for, and the list is long!  Naturally the first thing that comes to mind is pain, but there is so much more...

The NCCIH (National Center for Complementary and Integrative Health) 10, notes that acupuncture  has been proven to help in cases of:

• low back pain
• neck pain
• osteoarthritis
• knee pain
• headache and migraine

In 2003, the World Health Organization (WHO) listed a number of conditions in which they say acupuncture has been proven effective. 11 These include:

• high and low blood pressure
• chemotherapy-induced nausea and vomiting
• some gastric conditions, including peptic ulcer
• painful periods
• dysentery
• allergic rhinitis
• facial pain
• morning sickness
• rheumatoid arthritis
• sprains
• tennis elbow
• sciatica
• dental pain
• reducing the risk of stroke
• inducing labor
• depression

Other conditions for which the WHO say that acupuncture may help but more evidence is needed include:

• fibromyalgia
• neuralgia
• post-operative convalescence
• substance, tobacco and alcohol dependence
• spine pain
• stiff neck
• vascular dementia
• whooping cough, or pertussis
• Tourette's syndrome
• insomnia
• may help treat a number of infections, including some urinary tract infections and epidemic hemorrhagic fever.

 (For a more extensive list of the WHO recommendations pls refer to : 12  )

It is important to note, however, that the WHO points out that “only national health authorities can determine the diseases, symptoms, and conditions for which acupuncture treatment can be recommended.” Equally important is that the NCCIH advise people not to use acupuncture instead of seeing a conventional health care provider, and this is sage advice all around that I always encourage in my practice.

All together, this strong scientific support and global endorsement is impressive and helpful for patients in the context of a healthcare system where many treatments lack evidence for their use. Acupuncture is also considered cost-effective for a number of conditions where evidence is available and carries minimal side-effects. Patients and medical professionals alike can be confident that the recommendation of acupuncture for many patients is a safe, cost-effective, and evidence-based recommendation.

  - Dr. Joan Boux, MD (ret.) R.Ac - 

1. Ma Y, Dong M, Zhou K, et al. Publication Trends in Acupuncture Research: A 20-Year Bibliometric Analysis Based on PubMed. PLoS ONE 2016;11
2. Hempel S, Taylor SL, Solloway MR, et al. Evidence Map of Acupuncture. Washington (DC): : Department of Veterans Affairs  2014
3. The Acupuncture Evidence Project – A Comparative Literature Review 2017 – Acupuncture.org.au. 2017;1–81. 

4. Corbett MS, Rice SJC, Madurasinghe V, et al. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis and Cartilage  2013;21:1290–8. 

5. Dong W, Goost H, Lin X-B, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine (Baltimore) 2015;94

6. Lewis R, FLCOM NHWPF, PhD AJS, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal 2015;15:1461–77. 

7. Zhu L, Ma Y, Deng X. Comparison of acupuncture and other drugs for chronic constipation: A network meta-analysis. PLoS ONE 2018;13

8. Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E., et al. (2012). Acupuncture for Chronic Pain. Archives of Internal Medicine, 172(19), 1444. 
9. Yin, C., Buchheit, T. E., & Park, J. J. (2017). Acupuncture for chronic pain: an update and critical overview. Current Opinion in Anaesthesiology

10. Acupuncture: In depth. (2017, February 21)

https://nccih.nih.gov/health/acupuncture/introduction

11. Chmielnicki, B. (2003). Evidence-based acupuncture WHO official position

https://www.evidencebasedacupuncture.org/who-official-position/

12. https://3pacupuncture.com/faq/conditions-treated-acupuncture/who-report/