From the Desk of Dr. Lasich

Change is in the air! As the leaves start to change, so too will my office location. My new office is located at 900 East Main Street in Grass Valley, CA. New colors, new carpet, and a fresh look bring excitement to my practice. Change can be good sometimes.

Changing your way of thinking about some common problems like Tennis Elbow is on my agenda in this month’s newsletter. Expanding the list of possibilities and imagining the other options can help one avoid problems or persistence of a problem. Take a look at this remarkable case of Tennis Elbow or Is It?

A call for change is also on my mind when examining prescription drug use in America (see Side Line “In the News”). Prescription drug use is escalating here in America and that trend bothers me. Is that what healthcare boils down to? It is no wonder why pharmaceutical commercials refer to healthcare providers as “prescribers”. Funny, “prescriber” is not written on my medical diploma. If all we do, as doctors, is whip out a prescription pad, then our profession will be reduced to a bunch of “prescribers”. I think it is time for a change in direction. I would like doctors to be thought of as health educators and preventers of disease.

Embrace change and enjoy the season’s change.

Tennis Elbow... Or is it?
by Christina Lasich, M.D.

A 36 year old woman sees her doctor about a persistent aching pain in her elbow. She does not recall a particular injury; but, as a mother of two children, she often ignores her own aches and pain until she cannot take it anymore. After a brief examination of her elbow, the doctor determines that she has lateral epicondylitis—tennis elbow. After exhausting conservative treatment for tennis elbow, she undergoes a procedure. Most unfortunately for everyone involved, the procedure goes terribly awry and the patient goes into complete cardiac arrest. After resuscitative efforts, this 36 year old mother is left with an automatic defibrillator implant plus the same old elbow pain.

At this point, this patient is referred to me. My examination reveals no pain to resisted wrist extension. However, the most significant findings are the positive Upper Limb Neurotension signs. My diagnosis is not lateral epicondylits. Rather, my diagnosis is nervous system sensitization of the upper limb quarter causing referred elbow pain.

Whoa! Let’s back this up a bit. What are Upper Limb Neurotension signs? We are accustomed to a popular Lower Limb Neurotension sign—the straight leg raise test. This lower limb test can be done with the patient is lying on her back and raising the straight leg up towards the ceiling. This maneuver creates tension in the lower limb nerves like the Sciatic nerve. If the nerve is sensitive from a disc herniation or stenosis, the angle that the leg can raise to is significantly impeded by pain that radiates along the nerve pathway. This common physical exam technique tests for lower limb nerve sensitization. Well, a nervous system exam can also include a series of Upper Limb Neurotension signs for the median, ulnar, radial, and even the musculocutaneous nerve. Those who wish to learn more are encouraged to read The Sensitive Nervous System and Explain Pain by David Butler. According to David Butler, nervous system generated pain can masquerade not only as tennis elbow, but also a hamstring strain, an ankle sprain, and plantar fasciitis. Sometimes these pains do not resolve because no one addresses the real issue—the nervous system.

After insurance delays and more delays, this 40 year old mother of two finally gets some relief with manual therapy that is concentrating on thoracic spine tractioning and mobilization. She also has a home exercise program centered around David Butler’s concept of nervous system mobilization with “sliders and gliders”. Additionally, the defibrillator, a tremendous source of psychological distress, was removed. Even though the traumatic memories are still fresh and boil just underneath the surface of this 40 year old mother of two, she is now on the right pathway towards healing.

This initial elbow pain might have begun as a simple sensitization of the spinal cord at the cervical/thoracic junction or directly at the C6 nerve root. After the trauma of prolonged resuscitation and chest compression expanded the sensitization to the thoracic spine, her arm pain became bilateral and more widespread. Most people would not recognize the connection between the thoracic spine and upper extremity symptoms. But recent literature has shown the effectiveness of thoracic manipulation for the treatment of cervical radiculopathy/radiculitis symptoms. The integral relationship of the upper thoracic spine with the lower cervical nerve roots is not to be ignored and should be addressed in anyone presenting with sensitization of the upper limb quarter.

Despite this dramatic scenario for a seemingly innocuous problem of tennis elbow, no one is to blame. The current medical system does not foster thorough examinations and complications do happen. This case should serve as a reminder to imagine all the possibilities before jumping to conclusions especially if it is match point.

LIFE Quotes

“If you don’t like something, change it; if you can’t change it, change the way you think about it.”
– Mary Engelbreit

In the News

Apothecary Corner

Tapentadol (Nucynta) is the newest member in the arsenal against nerve pain as both a mu-opioid agonist and a norepinephrine reuptake inhibitor.