Lateral epicondylitis (tennis elbow)

Lateral epicondylitis (also called tennis elbow) is an overuse injury occurring in the lateral side of the elbow region, where the tendons of the forearm muscles attach (see picture below). Repeating the same motions, again and again, leads to damage from overuse of the forearm muscles and tendons, causing pain and tenderness on the outside of the elbow. Despite it’s name suggest a strong link to racquet sports, this condition can also be caused by activities of daily living, playing guitar, climbing, etc.
It is the most common overuse injury of the elbow and accounts for approximately 90% tendinopathy at the elbow (10% of elbow pain is caused by medial epicondylitis). The muscles attaching at the lateral epicondyle are the:

  •  Extensor carpi radialis brevis
  • Extensor carpi ulnaris
  • Extensor digitorum
  • Extensor digiti minimi
  • Supinator
  • Anconeus


Overuse or repetitive strain:

1. Concentric wrist extension and supination (screw driver).
2. Repetitive eccentric wrist flexion (tennis racket, badminton, hammer).
3. Repetitive finger flexion and extension (typing).
4. Repetitive ulnar and radial deviation (grocery scanner).

Improper technique (check hints).
Often associated with rotator cuff pathology or imbalance, bicipital tendinitis.

History. Symptoms of tennis elbow develop gradually, usually the pain begins as mild and slowly worsens over weeks and months. Patients may complain of pain at the lateral epicondyle (lateral area of the elbow) and weakness on grasping (example lifting a book or turning a door knob). Symptoms are often worsened with forearm activity and there is usually no specific injury associated with the start of symptoms.
Physical examination. Patients with lateral epicondylitis may show:
1. Local tenderness around lateral epicondyle and tendon attachment, no local swelling and no signs of inflammation.
2. Normal active and passive ROM.
3. Pain with resisted wrist extension, extension or flexion of middle finger.
4. Pain at the end ROM of wrist flexion when elbow is extended.
• Provocative test. Cozen’s test, Mill’s test, middle finger extension test (muscle test of extensor digitorum) may confirm the diagnosis.

• X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbow, such as fracture or athritis.
• MRI may be ordered if your symptoms are related to a neck problem, such as herniated disk or arthritis in the neck.
• EMG may be ordered to rule out nerve compression.

Non surgical treatment can give excellent results, however patients should be warned that it can be slow to respond thus avoiding to get discouraged.
Early phase:
1. Avoid aggravating/repetitive activities such as playing tennis, opening car door, for as long as it takes (2-3 weeks usually are enough).
2. Ice
3. Osseous mobilization/manipulation of wrist, elbow, shoulder and spine.
4. Tape, K-tape, Cho-pat.
5. Cross friction massage, myofascial release, TrPs
6. Dry needling/Acupuncture HT3,PC5, PC6, SI3,SI4,SI7.
7. Ultrasound
8. Vitamin supplements.

Post acute phase:
1. Massage therapy
2. Osseous mobilization/manipulation of wrist, elbow, shoulder and spine.
3. Ultrasound.
4. Ice after treatment and after activity.
5. Stretching rotator cuff, biceps, forearm muscles
6. Strength core stability and rotator cuff. If you are a tennis player:
• Change racket, avoid high string tension and use a bigger grip.
• warm-up and stretch.
• strength core stability and should girdle muscles.
• Avoid graphite racket (transfer too much of impact to the hand).
• Use new/dry balls and play on slower surfaces.
• Use a brace for few weeks.
• Improve technique and use 2 hand back hand

Read the research: Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial.


• A poor backhand technique in tennis may cause lateral epicondylitis. If the wrist is bent when striking a back hand the huge forces are transferred through the tendons to the elbow rather than through the entire arm.
• Check the racket, a small racket grip makes the muscle working harder increasing the forces through the tendon.
• Check the strings, if the strings are too tight, more shock and energy will be transmitted through the forearm from the ball.
• Remember rotator cuff may refer pain to elbow.
• Proper grip sizing for tennis racket: middle finger to palm crease or one finger width gap between finger tip and heel of hand when gripping handle.
• Isokinetic eccentric training has been shown to be an effective treatment for chronic lateral epicondylosis, however this treatment option may not be available, may be too expensive, or may be impractical for many patients (isokinetic dynamometers are expensive and not widely available).
• Lateral epicondylitis is often associated with rotator cuff imbalance.


Dott. Emanuele Luciani
Osteopathphysiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
(number 8232
 "Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome 
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Muscle Strain

A strain is an injury to a muscle or tendon in which the muscle fibers tear. Acute muscle strain injuries are quiet common in athletes and lead to significant pain, disability and time away from work and athletic pursuits.
The most important factors leading to muscle strain are over-training, strenuous exercise, lack of recovery, previous injuries and poor nutrition.
It usually involves bi-articular muscles (muscles that cross two joints) such as hamstrings and rectus femoris. Hamstring injuries are common in runners, footballers and rugby players. For example lumbar flexion with a straight leg as happens when a player attempts to pick up the ball whilst on the run is a common action for hamstring injury as places excessive tensional load while the hamstring is under an eccentric contraction, thereby causing an indirect overload injury of the msk unit. Furthermore restricted ankle dorsiflexion, bio-mechanical anomalies at the lumbopelvic, thigh or leg region,restrictions in the spine, muscle imbalance may increase the risk of hamstring injuries.
Muscle strain are categorized in three distinct categories:
1) Grade 1: Mild strain, few fibers have been damaged. Minor swelling and discomfort with minimal or no loss of strength function. Healing within 2-3 weeks.
2) Grade 2: Moderate strain, extensive damage to muscle fibers. Mild swelling and discomfort with moderate loss of strength and function. Healing occurs within 3-6 weeks.
3) Grade 3: Sever strain, complete rupture of a muscle. Loss of strength with total loss of function. May require surgery. Healing can be up to 3 months.
Swelling, bruising or redness, or open cuts due to the injury.
Pain at rest.
Pain when the specific muscle or the joint in relation to that muscle is used.
Weakness of the muscle or tendons (A sprain, in contrast, is an injury to a joint and its ligaments.)
Inability to use the muscle at all.
For Grade 1, Grade 2 and Grade 3 strains the immediate treatment plan will comprise of the RICE protocol (Rest, Ice, Compression,Elevation) which has the aim to avoid further muscle damage and minimizing the bleeding, preventing formation of a large hematoma which has an impact on the size of the scar tissue at the end of the regeneration and accelerating regeneration.
After the RICE protocol, early mobilization is advised to improve the healing process. Controlled exercise after 72hours can be initiated, such as isometric training, later introducing some load within the limits of pain and finally controlled isotonic training using high repetition and low resistance.
Stretching exercises will help the alignment of the scar tissue and his extensibility, moreover improving the flexibility of the muscle.
Isokinetic exercises are excellent in the early phases of muscle healing, helping strengthen without full weight-bearing for the first 6/8 weeks.
Resistance bands can be used once the muscle has healed and gains its strength. The number of sets and repetitions should be increased progressively.
Warm up before participating to any activity.
Cool down and stretch after the performance.This will help prevent DOMS (Delayed Onset of Muscle Soreness) due to the inability of removing muscle lactic acid as well as aid in preventing overuse injuries.
Maintain good muscle strength and flexibility will prevent further damage
Improve your diet.

Dott. Emanuele Luciani
Osteopath, physiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
(number 8232
 "Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome 
Continue reading


Osteoporosis is a systemic skeletal disease, which is characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and an increased risk of fractures.

The risk of fractures is best captured by BMD (bone mineral density). The World Health Organization (WHO) defines the BMD:

  • Normal: T>-1
  • Osteopenia: T between -1 and -2.5
  • Osteoporosis: T<-2.5

(Measures of BMD are often cited with T-score or Z-score)

Fractures can occur in any site, however the most common are those involving the thoracic and lumbar spine, distal radius and proximal femur. Females more affected than males.There are different types of osteoporosis:

  1. Type I: postmenopausal osteoporosis is thought to result from gonadal (estrogen, testosterone) deficiency.
  2. Type II: senile osteoporosis occurs in women % men due to decreased formation of bone and decreased renal production of 1.25 (OH)2 D3 occurring later in life.
  3. Type III: secondary osteoporosis due to medications (glucocorticoids) or other condition causing bone loss.

Causes Exact etiology is poorly understood (unless is Type I, II or III). However there are many risk factors such as:

  • Long-term use of medications associated with low bone mass or bone loss such as corticosteroids, some anti-seizure medications, Depo-Provera, thyroid hormone, or aromatase inhibitors. Long-term use of corticosteroids (more than 5 mg/day for more than 3 months) is a specific risk factor.
  • History of medical conditions such as diabetes, thyroid imbalances, estrogen or testosterone deficiencies, early menopause, anorexia nervosa, rheumatoid arthritis, chronic liver disease, renal disease.
  • Significant loss of height
  • Weight loss or low BMI (body mass index)
  • Smoking
  • Sedentary lifestyle (individuals with a sedentary adolescent lifestyle should be considered at higher risk of osteoporosis. Those who currently have a sedentary lifestyle may also be at higher risk).
  • Age: the BMD decreases, and consequently the risk of osteoporosis increases with age.
  • Sex: women are at greater risk.
  • Family History.
  • Ethnicity:white women have a greater risk of getting osteoporosis.
  • Menopause: early menopause should be considered at higher risk of osteoporosis than others at a similar age.
  • Inflammatory bowel disease or malabsorption.

Diagnosis Usually osteoporosis is asymptomatic until a fracture occurs. Patient may experience loss of height, increased kyphosis (dowager hump) and may complain of severe back pain.

Diagnostic imaging:

The standard technique for determining bone density is the Dual-energy X-ray Absorptiometry (DEXA or DXA) preferably anteroposterior spine and hip. Other tests may be used, but they are not usually as accurate as DXA.

They include ultrasound techniques, DXA of the wrist, heels, fingers, or leg (peripheral DXA) and quantitative computed tomography (QCT) scan. X-Ray conventional radiographs should not be used for the diagnosis or exclusion of osteoporosis, therefore when plain films are interpreted as severe osteopaenia, it is appropriate to suggest referral for DXA. 



Prevention: fundamental as most patients are asymptomatic until fracture occurs, calcium and vitamin D intake are recommended.Reduce tripping hazards at home (see hints). 


  • Alendronate (Fosamax) increases bone density and decreases risk of fractures.
  • Bisphosphonates are useful in decreasing the risk of future fractures in those who have already sustained a fracture due to osteoporosis (ex. Alendronate-Fosamax-).
  • Denosumab is also effective for preventing osteoporotic fractures.
  • HRT (hormone replacement therapy) maintain estrogen levels however it seems increases the risk of breast cancer, stroke and heart disease, thus the long term risks are greater than benefits.

Lifestyle changes:

  • Smoking cessation.
  • Decrease or eliminate alcohol consumption.
  • Exercise more especially between the 20’s and 30’s to help increase the bone mass and continue through life.

Physiotherapy: gentle mobilization and massage therapy to relieve musculoskeletal issues. Extension mobilization of the thoracic spine may offer benefit.


Calcium supplements 500-1000 mg/d + vitamin D 400-800 IU (An average daily intake of 1000 mg of calcium can most easily be obtained from 600 ml (1 pint) of milk with either 50 g (2 oz) hard cheese (eg Cheddar or Edam), one pot of yoghurt, or 50 g (2 oz) sardine). Prevention at home to avoid falls and hip fracture among elderly:

  • Lighting should not be too dim or too direct, and light switches should be accessible.
  • Carpets and rugs should be tacked down.
  • Bathrooms should have a chair for bathing or skid-resistant mats, grab bars should be placed where needed and the toilet seat needs to be tall enough for easy transferring.
  • Chairs need to be stable (without wheels) and have arm rests.
  • Kitchen items that are frequently used should be at waist level or on low shelves, a rubber mat should be placed in front of the sink and non-slip wax should be used on the floor.
  • Stairways need handrails and steps should not be slippery.

Exercising and osteoporosis 

Resistance training refers to training where an overload resistance is applied. The resistance can be low, usually referred to as muscular endurance training, or moderate to high, called strength training. Strength training needs to be of a high intensity to produce gains in strength and BMD. Any form of strength training should be site specific i.e. targeting areas such as the muscle groups around the hip, the quadriceps, dorsi/plantar flexors, rhomboids, wrist extensors and back extensors. Weight-bearing activity is carried out when standing. Low impact weight bearing activity is characterised by always having one foot on the floor. Jumping (both feet off floor) is termed high impact training. High impact training is not suitable for patients with osteoporosis. Weight bearing exercises should be targeted to loading bone sites predominantly affected by osteoporotic change such as hip and spine. To be effective all exercise programmes need to be progressive in terms of impact and intensity as fitness and strength levels improve. Programmes should begin at a low level that is comfortable for the patient. An initial assessment by a suitably trained individual such as a physiotherapist will give the patient a reference point from which to start the exercise programme


Dott. Emanuele Luciani
Osteopathphysiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
(number 8232
 "Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome 
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Lumbar stenosis

The lumbar stenosis is a narrowing of the lumbar spinal canal, causing potential neurologic symptoms due to compression of the spinal cord and/or spinal nerve roots. The lumbar stenosis may cause low back pain as well as pain or abnormal sensations in the legs, thighs, feet or buttocks, or loss of bladder and bowel control. It usually affects elderly (+50) but also younger patients may be affected, male>female.

The cause of lumbar lumbar stenosis can be divided into congenital or acquired.

  1.  Congenital (rare): the spinal canal may be narrow due to congenitally short pedicles, thickened facets and lamina, or excessive scoliosis.These anatomic changes may lead to clinically significant stenosis if additional elements such as herniated intervertebral discs or other space-occupying lesions further narrow the canal and contribute to the compression (below the normal lumbar vertebra).
  2. Acquired (most common) such as:
  • spinal injuries (car accidents and other major trauma can cause dislocations or fractures of one or more vertebrae)
  • degenerative or arthritic changes of the ligaments, facet joints and intervertebral discs (osteophyte, disc herniations or bulge, flavum ligaments hypertrophy, etc).
  • tumor (abnormal growths can form inside the spinal cord).
  • spondylolisthesis.


  • History. Typically, the earliest complaint is back pain. Several months to years after the back pain was first noticed, the patient may experience leg fatigue, pain, numbness and weakness. The leg pain may be bilateral, involving the buttocks and thighs and spreading distally toward the feet (neurogenic claudication). Symptoms are often worsened by activity and standing (**consider also vascular claudication**) and are relieved by bending forward, lateral bending, sitting or lying down. Patients may complain also of difficulty walking even short distances and do so with a characteristic stooped or anthropoid posture in more advanced cases.
  • Physical examination. The back of the patient should be examined, recording the shape, mobility and flexibility. SLR test (Lasègue’s sign) may be negative. The neurologic examination may not reveal significant sensorimotor deficits at rest or in a neutral position. Deep tendon reflexes may be decreased, absent or normal, depending on the chronicity of the caudal root compression. Upper motor neuron signs, such as hyperactive deep tendon reflexes or the presence of pathologic reflexes, such as the Babinski’s sign or Hoffmann’s sign, are typically absent unless there is injury to descending long tracts. With the onset of walking, sensory deficits may appear, and motor weakness or reflex changes may be elicited. Therefore, it is extremely important to perform a thorough neurologic examination before and immediately after symptoms appear following a short period of ambulation. Similarly, changes in the neurologic examination with variations in posture should also be recorded.
  • X-ray: is not diagnostic but may demonstrates degenerative changes in the vertebrae or disc spaces, disclose some forms of occult spina bifida or reveal spondylolisthesis (shown below) or scoliosis in some patients.
  • MRI: imaging modality of choice to evaluate soft tissue encroachment. The MRI depicts soft tissues, including the cauda equina, spinal cord, ligaments, epidural fat, subarachnoid space and intervertebral discs.(**MRI abnormalities have been documented in 20% of asymptomatic subjects**).
  • CT: Computed tomography (CT) scans can create cross-section images of your spine. Your doctor may also order a myelogram. In this procedure, dye is injected into the spine to make the nerves show up more clearly. CT scans with intrathecal contrast injection are able to demonstrate the lumbar subarachnoid space and nerve roots with enhanced sensitivity, but this is an invasive test with potential morbidity.

Conservative treatment versus surgical treatment is controversial.

Conservative treatment often alleviates symptoms or halts their progression. Patient should be active and follow the agreed management plan. Bed rest and wearing an elastic lumbar binder is not recommended, as may lead to deconditioning of the paraspinal musculature (in the long term).
1. Avoid heavy lifting and excessive trunk extension.
2. NSAIDs for acute flare-ups.
3. Stretch and strength training (ex. trasversus abdominis, ileopsoas stretch etc)
4. Lumbar traction.
5. Osseous manipulation/mobilization (flexion-distraction adjustments preferred).
6. Massage.
7. Electrotherapy (TENS, IFC, US).
8. Acupuncture.
9. Exercise (read the tips).

Surgery is indicated if a well-conducted conservative management fails and is reserved for patients who have intolerable pain, progressive neurological deficit or cauda equina syndrome (weakness of the muscles of the lower extremities innervated by the compressed lumbar roots, urinary retention/incontinence, saddle anesthesia, fecal incontinence).
• Partial laminectomy/arthrectomy or laminarthrectomy
• Interspinous process distraction

Lying prone or in any position that extends the lumbar spine may exacerbates the symptoms, presumably because of ventral in-folding of the ligamentum flavum in a canal already significantly narrowed by degenerative osseus changes. Urgent hospitalisation if the patients complains of sciatic leg pain and/or severe back pain, with altered sensation over saddle area (genitals, uretha, anus, inner thighs), urine retention or incontinence. Bed rest is no longer recommended as it could lead to deconditioning of the paraspinal musculature. Patients often find activities/exercises for lumbar stenosis that are done in a bending-forward position are more comfortable (stationary bike and swimming are suggested) and jogging, contact sports should be avoided. However the best exercise is one that will become part of one’s daily routine. Pick something that is personally rewarding, fun and enjoyable for the patient. Do not exercise through pain and other symptoms. When a canal size is too narrow for the dural sac size that it contains, stenosis occurs. An identical canal size can therefore be stenotic for one person while not being stenotic for another who happens to have a smaller dural sac size. Lumbar spinal stenosis is therefore a clinical condition and not a radiological finding or diagnosis.

Surgery vs conservative treatments
1. In patients with symptomatic lumbar stenosis, the implantation of a specific type of device or decompressive surgery, with or without fusion, is more effective than continued conservative treatment when the latter has failed for 3 to 6 months. (Kovacs et al., 2011)
2. Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis (Atlas et al., 2005).
3. Patients with lumbar stenosis should receive a trial of the proposed conservative, aggressive treatment before surgery is considered (Theodoridis et al., 2008).
4. The outcome was most favorable for surgical treatment. However, an initial conservative approach seems advisable for many patients because those with an unsatisfactory result can be treated surgically later with a good outcome (Amundsen et al., 2000).


Dott. Emanuele Luciani
Osteopath, physiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
(number 8232
 "Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome 
Continue reading
18 March 2017
Lateral epicondylitis (also called tennis elbow) is an overuse injury occurring in the lateral side of the elbow region, where the tendons of the forearm muscles attach (see picture below). Repeating...
26 May 2017
Leg length discrepancy is a condition where the length of one leg is different than the other (shorter or longer) because of either or both a functional (muscle/posture) or structural (bone/cartilage...


Dott. Emanuele Luciani - Via Luigi Perna 51 Cap 00142 Rome - Cell 3488977681 - P.I  12195241000 -

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