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610 Indian Journal of Research & Development, March 2020, Vol. 11, No. 03 To Study the Effect of Rotator Cuff Exercises on Tennis

Swapnil Ramteke1, Subrat Samal2

1Asso. Professor, Department of Sports Physiotherapy, 2Asso. Professor, Department of Musculoskeletal Sciences, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi (Meghe), Wardha

Abstract Aims and Objectives: To study effects of Rotator Cuff Strengthening Exercises in Patients with Tennis Elbow. Sample size: 30 patients (15 in each group). Study Design: Randomised Contro Trial. Sample and Sampling Method: 30 patients were randomly selected and assigned in 2 groups, as Group 1(control group), Group 2 (Interventional group) in equal numbers The total subjects of 30 were included in the study the inclusion & exclusion criteria were Inclusion Criteria: Athletes complaining of elbow , Both male and female athletes, Age group 18-40 yrs, Subjects willing to participate. Exclusion Criteria: Subjects with pain in any other region, Subjects with , elbow, , cervicothoracic .

Result: There was no significant difference is found in the ages of both the group. Mean pain on VAS in group A it was 4.66 ± 1.77 and in group B it was 7.13±1.30.

Conclusion: The inferences from the present study suggest that Rotator Cuff strengthening protocol is significantly effective in Reducing pain,Improving functional activity.

Keywords: PRTEE, Lateral Epicondylitis, Rotator Cuff, Tennis, Elbow, EMG, , Varus Torque, Theraband.

Introduction waiters, as well as activities of daily living.1,2,3,4 Tennis elbow is a painful condition affecting the tendinous Lateral epicondylitis or lateral epicondylalgia, tissue of the origins of the wrist extensor muscles at known colloquially as tennis elbow, shooter’s elbow or the lateral epicondyle of the humerus, leading to loss of simply lateral elbow pain, is a condition where the outer function of the affected limb3,4. Therefore it can have part of the elbow becomes sore and tender1. Since the a major impact on the patient’s social and professional pathogenesis of this condition is still unknown, there life5,6. Pain around the lateral epicondyle is known by is no single agreed name1,2. While the common name a variety of names and was described as periostitis, “tennis elbow” suggests a strong link to racquet sports, extensor carpi radialis brevis (ECRB)-tendinosis and this condition can also be caused by sports such as epicondylalgia7,8,9,10. The most commonly used names swimming and climbing, the work of manual workers and are “tennis elbow” and “lateral epicondylitis”. The use of the terms “periostitis” and “epicondylitis” was questioned over time, as histological studies failed to show inflammatory cells (, lymphocytes, Corresponding Author: and neutrophils) in the affected tissue.11,12,13 Dr. Subrat Samal Ravi Nair Physiotherapy College, Datta Meghe Microscopical studies by Nirschl et al showed mainly Institute of Medical Sciences (Deemed University), fibroblastic tissue and vascular invasion that led him Sawangi (Meghe), Wardha–442001 (M.S.) to describe the condition in 1999 as “angiofibroblastic e-mail: [email protected] tendinosis”. These findings left the researchers to Mobile No. 8007685011 conclude that a more appropriate term for the condition is Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 611 “lateral elbow tendinosis”, which defines a degenerative Outcome Measures: Pain, functional scale, muscle process characterized by an abundance of fibroblasts, strength vascular hyperplasia, and unstructured collagen14,15. Tools Used: The term tendinosis or implies the absence of chemical inflammation. It has been postulated that • Therabands tendinosis or tendinopathy is acquired by overuse • VAS Scale of a hypovascular zone, which leads to subsequent neovascularisation.16 • Mirror • Dumbells The need for this study is to check the efficacy of strengthening rotator cuff muscles in the treatment of • General assessment form for collecting the lateral epicondylitis. The role of the rotator cuff in the demographic data of the subjects treatment of lateral epicondylitis is not that well studied. • PRTEE [Patient Related Tennis Elbow Evaluation] Also to study the effect of weakness of the rotator cuff on the upper limb biomechanics leading to overuse of the Methodology Extensor Carpi Radialis Brevis37. More stress is placed Procedure: Thirty Players of 18-40 years of age on the treatment of elbow. Understanding the pattern of with the h/o pain in lateral epicondyle & diagnosed with injury and the underlying causes in the whole kinematic lateral epicondylitis were taken and screened by using a chain will lead to a better treatment plan. Hence to questionnaire given for their inclusion in the study and stress the role of rotator cuff strengthening, this study assessed for pain & Functional Activity using Visual is performed. Analog Scale (VAS) and muscle strength. Patients were Aims and Objective: To determine the effects randomized into two groups. Group B (15 patients will of Rotator Cuff Strengthening on Pain & Functional receive conventional treatment mainly electrotherapeutic Activity. modalities, elbow exercises taping) and Group A (15 patients will receive rotator cuff strengthening along Source of Data: Physiotherapy Center Seawoods with good scapular control and conventional treatment). Polyclinic, Seawoods Navi Mumbai. The players were explained about the respective Method of Collection of Data: Thirty Players procedures which they would be undergoing for a of 18-40 years of age with the h/o pain in lateral period of 6 weeks and were made to sign a consent form epicondyle & diagnosed with lateral epicondylitis were before their participation in the study. The protocol was taken and screened by using a questionnaire given for followed for 10 sittings six days a week. After that, a their inclusion in the study and assessed for pain & home exercise program was given to both the study as Functional Activity using Visual Analog Scale (VAS) well as the experimental group. The home program for and muscle strength. Patients were randomized into two the study group included groups. Group B (15 patients will receive conventional treatment and Group A (15 patients will receive rotator Isometric wrist extensor and flexor training: cuff strengthening along with good scapular control and Active elbow range of motion exercises: The home conventional treatment). program for the experimental group included. The players were explained about the respective Isometric wrist extensor and flexor training, Active procedures which they would be undergoing for a period elbow range of motion exercises, Strengthening of the of 4 weeks and were made to sign a consent form before infraspinatus, supraspinatus, subscapularis along with their participation in the study. scapular muscle rhomboids, serratus anterior levator scapulae and trapezius using therabands. Sample Size: 30 Dependent Variable: PRTEE Scale and VAS Sampling Design: Simple Random Sampling Independent Variable: Rotator cuff strengthening Study Design: Randomised Control Trail the program. Study Duration: 6 Weeks Control Variable: Age between 18-40 yrs 612 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 Data Analysis:

Table 1: Gender wise distribution of patients

2-value p-valueא Gender Group A Group B Male 11(73.33%) 11(73.33%) 1.00 Female 4(26.67%) 4(26.67%) 0.00 NS,p>0.05 Total 15(100%) 15(100%)

Table 2: Comparison of PRTEE Score in both the groups at pre and post-test

Descriptive Statistics:

Group N Mean Std. Deviation Std. Error Mean Group A 15 69.46 10.51 2.71 Pre Test Group B 15 63.86 14.53 3.75 Group A 15 25.86 8.15 2.10 Post Test Group B 15 46.06 11.91 3.07

Table 3: Student’s unpaired t test

Mean Std. Error 95% Confidence Interval of the Difference t Df p-value Difference Difference Lower Upper Pre Test 1.20 28 0.237NS, p>0.05 5.60 4.63 -3.88 15.08 Post Test 5.41 28 0.000S, p<0.05 -20.20 3.72 -27.83 -12.56

Discussion than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were The short term results of this prospective “severe” and “disabling.” While 42% over 50 identified randomized study in athletes with lateral epicondylitis severe and disabling symptoms9. More women (36%) showed that treatment with rotator cuff strengthening than men (24%) considered their symptoms to be with therabands and conservative management showed severe and disabling and in which Tennis elbow is more significantly reduced pain during activity and improved prevalent in individuals over 40, where there is about a function1. The aim of our study was to compare the 4-fold increase among men and 2-fold increase among effectiveness of adding rotator cuff strengthening to the women8,9,. Observations of the patterns of activation conservative approach. To try to limit bias patient they and joint kinematics of novice tennis and advanced evaluated treatment. The patient recorded the amount of payers, using kinematic data in conjunction with a lateral epicondylitis pain on a PRTEE score and VAS. computer model, have revealed substantial eccentric Patient satisfaction with treatment was also assessed contractions of the extensor carpi, which are likely the [satisfied/not satisfied] cause of repetitive microtrauma leading to tennis elbow Lateral epicondylitis is a troublesome condition to injuries and Adopting the technique seen in advanced treat and frequently brings athletic careers to an end2,3. players probably helps limit the eccentric contractions 21,22 Response to initial therapy is common, but so is relapsed and reduces the likelihood of injury . Tennis grip 24,25 (18% to 50%) and/or prolonged, moderate discomfort size was believed to play a crucial role in the past . (40%)5. Keutenn and coworkers reported that 53% of However, based on fine-wire electromyography studies athletes had to stop their sporting career due to chronic in which muscle activity in extensor carpi radialis recurring lateral epicondylitis however we cannot longus and brevis, extensor digitorum communis, exclude that some of these patients had other defects flexor carpi radialis, and pronator teres were measured, as well6. In tennis players, about 39.7% have reported tennis racquet grip size (1/4) above or below because of current or previous problems with their elbow6,7. Less relatively very few studies evaluating the effectiveness Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 613 of shoulder muscle strength particularly rotator cuff 2007;32(8):1271-1279. 26,28 in the development of lateral epicondylitis . In one 6. Weitz W. Zur Dynamik des Herzens bei Dilatation study conducted by Aguinaldo AL, and Chambers H und Zur Behandlung des Lungenödems. Klinische studied the correlation of throwing mechanics with Wochenschrift. 1922;1(9):405-408.. elbow valgus load in adult baseball pitchers52. They 7. Buchanan A. “TENNIS ELBOW.”. BMJ. 1930; concluded that Valgus torque at the elbow during 1(3603):171-171.. baseball pitching is associated with 6 biomechanical variables of sequential body motion and a condition of 8. Kaminsky SB, Baker CL; Baker (December 2003). late trunk rotation, reduced shoulder external rotation, “Lateral epicondylitis of the elbow”.Techniques and increased elbow flexion appeared to be most closely in Hand & Upper Limb Surgery 7 (4): 179–89. related to valgus torque29,32. Sidearm pitchers appeared DOI:10.1097/00130911-200312000-00009. PMID to be more susceptible than overhand pitchers to reduced 16518219. elbow valgus torque32,33,34. 9. Alizadehkhaiyat O, Fisher A, Kemp G, Vishwanathan K, Frostick S. Upper limb muscle imbalance in Injuries or adaptations in some areas of the kinetic tennis elbow: A functional and electromyographic chain can cause problems not only locally but as distal assessment. Journal of Orthopaedic Research. links must compensate for the lack of force and energy 2007;25(12):1651-1657. delivered through the more proximal links51. This 10. Tennis elbow [Internet]. En.wikipedia.org. 2019 phenomenon, called catch up is both inefficient in the [cited 1 July 2019]. Available from: https:// kinetic chain and dangerous to the distal link because en.wikipedia.org/wiki/Lateral_epicondylosis it may cause more load or stress than the link can safely handle, these changes may result in anatomical 11. Ferrara L, Cohen A. 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