• Got A Little Arm Pain? - By : Bert Berrong
• Oh My Aching Elbow - By : Jeffrey Granger
• A Physical Therapist's View - By : Todd Reiff

By : Bert Berrong

Bert Berrong, of Brighton, Colorado, flies his Rebel 300 in the Unlimited category of competition.

1. It has nothing to do with getting old. The problem is spread uniformly across aerobatic pilots ages 25 to 70.
2. It has everything to do with calling upon the muscle-tendon-bursa materials to support stress which is beyond the "then current" capability. The result is distributed "micro-tear damage". Throttle and stick arms are both involved. The combination of high g-loads, rapid arm movements (accelerations), and odd wrist positions is thus the prime causal suspect.
3. It takes a minimum of three months for such tissue to heal. Six months is more like it before you again try the task which caused the injury in the first place.
4. You get temporary pain relief using Motrin or other anti-inflammatory drugs. This treatment does NOTHING to speed or help the healing process. The common dosage for ibuprofen is 800mgs three times a day on a full stomach, or regret it! (This is a report of what is common, not me giving medical advice.)
5. Two methods of muscle-tendon strength building were suggested as repair and prevention systems:
   • The first comes from IAC member Jim Houston, who reports that this problem is common among body builders and is often caused by executing reverse curls. His suggested exercise is to tie one end of a string to a tolerablesized weight and the other end to the middle of a 1.5 inch diameter dowel. Use both hands to roll up the weight. Do it with palms up and palms down. Do it with forearms straight down and with forearms horizontal in front of you.
   • The second method comes from Fred DeLacerda. There are three small rubber "eggs" available with graded stiffness. Squeeze them with the small end towards the thumb to work the forearm muscle-tendon-bursa materials. Use every conceivable forearm and wrist combination of positions.

   Overuse injuries are the result of three contributing factors: awkward positions and/or sustained postures, repetitive motion and excessive force. Injuries usually occur when two or more of these factors are combined over a period of time. The common signs and symptoms of lateral epicondylitis include: Pain over the outside aspect of the elbow. Decreased grip strength. Gradual onset of pain. Arm and elbow painless at rest. In severe cases, pain at rest occurs along with varying decreases of motion at the extremes of flexion and extension.

   
   
   

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   Oh My Aching Elbow

   By : Jeffrey Granger

   
   

   Dr Granger, is an orthopedic surgeon practicing in Logansport, Indiana.

      Lateral epicondylitis of the elbow - also known as "tennis elbow" - is one of the more common conditions presenting to the general orthopedist. It was first reported in 1882 in association with lawn tennis and since then has been linked to a variety of occupations such as meat cutting, plumbing and carpentry as well as to other racquet sports, golf, baseball, etc. It classically occurs in the 30's and 40's, but can happen at any age. The majority of tennis players will experience some symptoms during their career.
   
      The common feature is microscopic tearing within the origin of the extensor tendons on the lateral aspect of the elbow. Vascular healing tissue invades this area and develops an acute or chronic inflammatory component. Diagnosis is based on tenderness over the lateral bony prominence of the elbow and pain with resisted extension of the wrist. Nonsurgical treatment is the mainstay. First, oral medication or occasionally steroid injections to relieve the local inflammation, then rehabilitative exercise. Then, exercise should be brought in gradually so as not to result in an early relapse of the syndrome.
   
      Modification of the activity is critical. If the patient uses some aberrant technique in sports or occupation, it should be identified and corrected. For the tennis player a low vibration or less tightly strung racket is often helpful. Counter force bracing with a strap a few inches below the elbow or wrist splinting is frequently helpful. Surgery is only rarely done and only after a minimum of 6-12 months of conservative treatment with no response.
   
      I have not encountered this my Skybolt flying, but my once-a-week practice schedule during the summer is much less intensive then what the competitor describes in preparation for the Nationals. I don't see enough aerobatic pilots in my AME practice to judge the incidence in that population, but it may be a common under-reported problem. I would encourage the pilot who encounters pain in the lateral elbow to cut back on the practice schedule, apply ice, take an over-the-counter anti-inflammatory medication and consult the local orthopedic surgeon or sports clinic if there is not improvement in week or two.
   
   

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   A Physical Therapist's View

   By : Todd Reiff

   
   

   The author, Todd Reiff, is Director of Physical Therapy at North Central Indiana Sports Medicine Center in Logansport, Indiana.

      Lateral epicondylitis, "tennis elbow", is one of the more common overuse injuries encountered in the physical therapy profession. It is also one of the more frustrating conditions we treat, due to the length of time it can take to resolve the problem.
   
      Self-treatment for lateral epicondylitis can aid in the recovery precess. The following sequence of activities has been used with success. The first concern is to relieve pain. To relieve pain on a home basis, cold therapy can be instituted. The first procedure is a method known as ice massage in which a small paper or Styrofoam cup is filled with water and frozen. When frozen, remove approximately 1/2 inch of paper from the top of the cup, then rub the ice directly on the skin which overlies the painful site. This should be performed for five to ten minutes until the area is numb. Sensations you will feel include: 1 Cold 2. Burning 3. Aching 4. Numbness.
   
      An alternative is use of an ice pack. Place a bag of ice over the painful area for 10-20 minutes. A wet towel may be placed between the skin and bag to increase tolerance. The use of cold therapy is especially beneficial in the acute (Early) phases of the problem, or at later times when activity has re-aggravated the condition. A world of warning about cold therapy - be sure you do not fall asleep with the ice pack on your elbow as prolonged exposure to the ice may lead to further problems.
   
      The next step in the sequence is the use of splints and/or braces. The more common brace used is the "counter-force armband." It is believed that the "armband" disperses stress away from the lesion. There are many types of armbands available from the simple strap type brace to armbands with air pouches built into them. A word of caution - avoid tightening the band so it cuts off circulation. Another brace which is beneficial is known as the wrist cock-up splint. This splint holds the wrist in a slight degree of extension (movement away from the palm), thereby resting the extensor mechanism.
   
      Another consideration in the sequence is tissue healing. It is important not to overuse the arm during the early healing phase. Try to avoid activities that aggravate the symptoms. However, complete immobilization is not recommended since controlled stress is important for appropriate tissue healing. Exercise is an extremely important component in the self-treatment of lateral epicondylitis. It consists of several segments. The first is aerobic exercise. Aerobic exercise is exercise which is sustained for 20 minutes or longer-an important part of any program. Those individuals who have an overall higher fitness level are less likely to experience an overuse injury as long as the exercise they choose is done in moderation and progresses slowly.
   
      The second component is flexibility. The wrist extensor stretching is performed to obtain and maintain optimum muscle length. The stretch described in figure 3 is held for 15 seconds and repeated three times. It is important to pull the hand downward with enough intensity so that a gentle to moderate stretch is felt. Do not pull hard enough to cause pain. The stretch should be done before and after activity.
   
      The Third component, wrist extensor strengthening, is described in figures 1, 2, 5 and 6. The dowel rod and dumbbell exercises should be started with the elbow bent. If this exercise can be performed free of pain, then you may progress by fully extending the elbow. It is suggested that you start with light resistance. If you can perform 20 repetitions without pain, then you may add another pound to the dumbbell's weight. Normally, physical therapists suggest that the patient perform three sets of 20 repetitions with the dumbbell exercise, and five to six repetitions of the dowel rod exercise with the weight starting at the floor.
   
      Often overuse injuries are a result of problems at a more proximal or distal site. Figure 4 demonstrates an exercise used to strengthen the muscles in the back of the shoulder. In most cases of lateral epicondylitis, these muscles are found to be in a weakened state. We are unsure which comes first, the elbow pain and then the shoulder weakness or vice versa. But, we are sure that for a complete recovery there can be no "weak links." Perform this exercise by pushing the back of your wrist (not the hand) into the wall. Perform five to ten repetitions and hold each repetition for a five to ten count. The exercise program should be performed one to two times per day, excluding the aerobic program which should be performed three times a week.
   
      In addition to aerobic conditioning, flexibility and strengthening, consideration should be given to the ergonomics of the situation. For aerobatic pilots, special consideration is the diameter of the stick grip. A grip with too small of a diameter will require increased grasp effort thus increasing the stress upon the wrist extensor mechanism. A tip from the sorts medicine field to assure appropriate handle size - measure from the base of the middle finger to where the hand meets the wrist.
   
      There are many other exercises and modalities that a physical therapist uses in the treatment of lateral epicondylitis which are beyond the scope of this article. If your symptoms persist, it is recommended that you seek further medical advice. As always, early intervention is the key to success in the treatment of overuse injuries.
   
   
   Article reproduced from Sport Aerobatics, February 1998, with permission