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Physical Therapist Management of Fluoroquinolone-Induced Achilles
Tendinopathy
Physical Therapy Volume 82 · Number 12 · December 2002
Print Version
Case Report
Physical Therapist Management of Fluoroquinolone-Induced Achilles
Tendinopathy
Brenda L Greene
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Background and Purpose. Use of fluoroquinolone antibiotics is reported
to be a cause of adverse musculoskeletal effects, such as
tendinopathies and tendon ruptures. The purpose of this case report is
to describe the management and outcomes of a patient with bilateral
Achilles tendinopathy secondary to fluoroquinolone antibiotic use.
Case Description. The patient was a 41-year-old man who developed
bilateral Achilles tendon pain on the third day of levofloxacin use.
The physical therapy intervention consisted of an initial phase to
reduce stress on the tendon through the use of crutches and orthoses
and a second phase to progressively stress the tendon through exercise
and functional activities. Outcomes. After 11 weeks of physical
therapy (14 treatments), the patient's pain decreased from 3/10 to
1/10 on a visual analog scale and his Lower Extremity Functional Scale
score increased from 28/80 to 71/80. Discussion. An overlapping
2-phased intervention approach based on connective tissue remodeling
principles may be effective in elimination of pain and restoration of
function following fluoroquinolone-induced Achilles tendinopathy.
[Greene BL. Physical therapist management of fluoroquinolone-induced
Achilles tendinopathy. Phys Ther. 2002;82:1224-1231.]
Key Words: Achilles tendon, Fluoroquinolons, Lower extremity,
Musculoskeletal disorders, Physical therapy.
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Achilles tendon disorders encompass a variety of medical diagnoses,
such as tendon rupture, tendinitis, and tendinopathy. In the past
decade, the medical literature has increasingly reported the onset of
tendinopathy and Achilles tendon ruptures secondary to fluoroquinolone
antibiotic use.1-4 A recent increase in the prescription of
Ciprofloxacin,* a fluoroquinolone antibiotic, has resulted from the
increased exposure of US citizens to anthrax. With increased
fluoroquinolone use, the potential exists for greater incidence of
adverse effects, such as Achilles tendinopathy.
Fluoroquinolones are antibacterial agents that hinder bacterial
nucleic acid replication by inhibiting the DNA-gyrase enzyme.5
Fluoroquinolones have become more popular since the 1980s when a
longer half-life was achieved, allowing once-daily doses and improved
effectiveness against a broad spectrum of gram-negative and
gram-positive bacteria.4,6 The fluoroquinolone antibiotics are
indicated for infections of the upper and lower respiratory tract,
urinary tract, and skin.6 The most frequently reported adverse effects
of fluoroquinolone antibiotics are gastrointestinal distress, skin
reaction, headache, and dizziness,5 although adverse effects also are
known to occur in the hepatic, renal, and musculoskeletal systems.6
Tendinopathy and rupture have been reported as infrequent adverse
reactions that occur most often in the Achilles tendon. The exact
incidence of tendinopathy is unknown, but it has been estimated to be
15 to 20 cases per 100,000 medicated people.4 In 1995, the Food and
Drug Administration (FDA) updated the warning label for
fluoroquinolones to include a warning about tendon pathology and
possible rupture. The warning label recommends discontinuing
fluoroquinolone use at the first sign of tendon pain or inflammation
and refraining from exercise until the problem is diagnosed.7
The pathophysiology of drug-induced tendinopathy and rupture is poorly
understood. The sudden onset of symptoms after a single dose, in some
cases, suggests a direct toxic effect of fluoroquinolones on the cells
and fibers of the tendon.8 Movin and colleagues3 found histological
evidence of abnormal collagen fiber structure and arrangement, and
altered fibril to matrix ratio with a resultant increase in the
extracellular matrix. One hypothesis of the etiology is that the
histological changes result in decreased tensile loading capacity of
the tendon such that normal functional activities overload the
tendon.9 The literature does not explain why drug-induced tendinopathy
and rupture occur more frequently in the Achilles tendon, but the
rapid and immense tendon loading during weight-bearing activities,
such as walking and running, may make the Achilles tendon more
vulnerable than other tendons.10 Risk factors believed to be
associated with Achilles tendinopathy and rupture are use of
corticosteroids, increasing age (over age 60 years), chronic renal
disease, and rheumatoid arthritis.8,9
The purpose of this case report is to describe the management and
outcomes of a patient with bilateral Achilles tendinopathy secondary
to fluoroquinolone antibiotic use. A problem-solving approach was used
to classify and manage a patient with an unfamiliar condition. As
physical therapists become a point of entry into the health care
system, awareness of fluoroquinolone-induced tendon disorders is
important.
Case Description
Patient Description
The patient was a 41-year-old man who was being treated for acute
maxillary sinusitis with the antibiotic medication Ceftin.† After
taking the medication for 18 days, his sinusitis symptoms persisted,
and his physician discontinued Ceftin and prescribed levofloxacin (500
mg 1 time per day), a fluoroquinolone antibiotic. On the third day of
taking the prescribed dose of levofloxacin, he reported soreness
around both Achilles tendons to his physician's office. He described a
feeling "as if something was rubbing against my sneakers." On the
fifth day, he reported severe pain with walking, and he was advised by
his physician's office to discontinue the antibiotic medication.
Independently, he began taking 9 Advil‡ (200 mg) per day for the pain.
Two days later, while out of town, he went to the emergency department
due to severe pain with standing and an inability to walk. Two days
later, he was seen by a physiatrist, who diagnosed his condition as
bilateral Achilles tendinopathy. At that time, he was referred for
physical therapy.
The following day, 5 days after discontinuing the levofloxacin, he
began physical therapy with his first physical therapist. He attended
a total of 10 physical therapy sessions over the next 4 weeks.
According to the patient and the office staff, the first 7 physical
therapy sessions consisted of an initial evaluation, a combination of
ultrasound and low-voltage electrical stimulation applied to the
tendon, Achilles tendon stretching, and ice. He was instructed in a
home exercise program that consisted of Achilles tendon stretching,
plantar-flexion strengthening, and 10 minutes of walking twice daily.
The Achilles tendon pain did not subside. The last 3 visits consisted
of only the exercises. On the 10th visit, the exercise program was
expanded to include 10 minutes of walking on a treadmill.
After 10 treatments, the patient discontinued physical therapy because
he believed he was not improving. His physiatrist prescribed axillary
crutches and then referred him to an orthopedist specializing in foot
and ankle disorders. He received heel lifts from the orthopedist and
underwent a magnetic resonance imaging (MRI) scan of the ankles and
hematological studies. The MRI results were normal, indicating no
tendon rupture or degeneration. His hematology results were normal for
electrolyte levels, sedimentation rate, hematocrit, hemoglobin, and
platelet levels. He discontinued all medications except Klonopin,§ a
benzodiazepine, which he was taking prior to his Achilles tendinopathy
for an unrelated disorder. He had no history of acute trauma or
cumulative trauma, and he had no risk factors associated with
fluoroquinolone-induced tendinopathy prior to his diagnosis. He had no
history of similar conditions in the past, although he did report an
incidence of plantar fasciitis more than 20 years ago. Prior to his
diagnosis, he was very active, walking and bicycling 4.8 to 8 km (3-5
miles) per week. Nine weeks after he discontinued the levofloxacin, he
consulted me.
Examination: Tests and Measures
Pain. On a numeric pain rating scale from 0 ("no pain") to 10 ("worst
pain imaginable"), the patient reported 1/10 pain bilaterally in the
Achilles tendon region at rest and 3/10 pain after weight-bearing
activity of short duration (5 minutes or less) The test-retest
reliability for the 11-point numeric pain scale is .67 to .96.11 The
reported Pearson correlation coefficient between the numeric pain
scale and the visual analog scale is r=.80.11
Posture. Observation of standing posture revealed that the left
calcaneus was positioned in 4 degrees of varus as measured by a
goniometer with one arm aligned to a line bisecting the calcaneus and
the other arm parallel to the floor (calcaneal-to-vertical angle). The
calcaneal-to-vertical angle was 0 degrees on the right. Intraclass
correlation coefficients (ICCs) for intrarater reliability have been
reported to be .91 to .92 for this measurement in patients with
diabetes mellitus.12 Both feet appeared to have a high medial
longitudinal arch. These findings are indicative of a supinated
subtalar joint position.13
Range of motion. Active range of motion was measured with a standard
goniometer; the results are presented in Table 1. Other
researchers14,15 have found the ICCs for intrarater reliability of
goniometric measurements of ankle dorsiflexion and plantar flexion to
be .86 to .90.
Orthoses. The patient was wearing 1-cm bilateral semirigid heel lifts
prescribed by the orthopedist, presumably to decrease the tension on
the Achilles tendon during walking. Evidence supporting the
effectiveness of heel lifts to decrease tension in the Achilles tendon
is limited. Lee et al,16 in their study of 13 subjects, reported the
use of external rubber heel lifts of 1.9 cm and larger. The
researchers reported that wearing heel lifts was effective in
decreasing peak muscle activity in the gastrocnemius muscle, as
measured by surface electromyography, in men without Achilles tendon
problems.16 Decreased electromyographic activity could relate to
decreased active tension in the Achilles tendon during the stance
phase of gait.
Gait. The patient ambulated with axillary crutches and a swing-through
gait pattern. He was able to ambulate without the crutches for the
gait analysis. The patient walked with short steps and had decreased
plantar flexion at both ankle joints during the late stance phase. He
also had a bilateral lack of calcaneal eversion beyond neutral during
early stance phase, indicative of decreased subtalar joint pronation.
Although observational gait analysis is a common and convenient
examination procedure, the intrarater reliability is moderate to
poor.17
Muscle strength. Using manual muscle testing,18 the tibialis anterior
and tibialis posterior muscle strength were 5/5 bilaterally. With the
weight-bearing muscle test for the gastrocnemius and soleus muscles,
strength was 4/5 on the right and 5/5 on the left. The patient
reported no pain during muscle testing, but he did note a mild pulling
sensation in each Achilles tendon during muscle testing. According to
Lamb,19 reliability of manual muscle testing has not been well
established, but appears to have face and content validity.
Palpation. No ankle joint effusion or soft tissue edema was palpable.
The gastrocnemius/soleus muscle bellies, musculotendinous junction,
Achilles tendon belly, and Achilles tendon insertion were not tender
to palpation.
Work, community, and leisure integration. The Lower Extremity
Functional Scale (LEFS)20 was used to measure his functional status.
The LEFS is a relatively new questionnaire consisting of 20 items
rated on a 0 to 4 scale; a higher score indicates greater functional
ability. Based on a sample of 98 patients referred for physical
therapy with any lower-extremity musculoskeletal condition, the
reported correlation coefficient for test-retest reliability within a
24- to 48-hour period was r=.86.20 The correlation between the LEFS
scores and scores on the physical function subscale of the Medical
Outcomes Study 36-Item Short-Form Health Survey (SF-36), as determined
by a Pearson correlation coefficient, was .80. The patient's initial
score was 26/80, indicating a low functional level.
Patient response to the examination. The patient had no notable
increase in symptoms during the examination, although he reported a
mild pulling sensation in each Achilles tendon during muscle testing
of the calf. Twenty-four hours after the initial examination, he
reported 3/10 level pain that was present at rest and during activity.
The pain was located in the Achilles tendon region bilaterally,
particularly near the insertion. The patient's pain level took several
days to return to the pre-examination level of 1/10.
Evaluation
Evaluation of the examination findings formed the basis for the
hypothesis that the patient's decreased functional level was due to
the decreased capacity of the Achilles tendon to accept normal loading
forces. Based on the pathophysiology of drug-induced tendinopathies, I
believed that the fluoroquinolone antibiotic had altered the
microscopic structure of the tendon and the ability of the collagen to
resist tensile forces during normal weight-bearing activities. Based
on the signs and symptoms, the patient did not appear to have a
primary inflammatory problem; however, an inflammatory response was
induced after mechanical overloading. I determined that the patient
had impaired motor function and muscle performance associated with
connective tissue dysfunction of the Achilles tendons. The physical
therapist diagnostic classification was Pattern 4D, "Impaired Joint
Mobility, Motor Function, Muscle Performance, and Range of Motion
Associated with Connective Tissue Dysfunction."21
Little literature exists to guide intervention planning and the
formulation of a prognosis. The prognosis for full functional recovery
without physical therapy is highly variable.8,10 Case reports indicate
that recovery generally occurs within 2 months after the cessation of
antibiotic use8,10; however, continued pain and disability in up to
26% of the cases has been reported.3,8 Tendon rupture reportedly
occurs in 24% to 30% of the cases up to 90 days after the cessation of
antibiotic use.4,8 The prognosis for full functional recovery with
physical therapy has not previously been reported for tendinopathy
secondary to fluoroquinolone use.
Intervention and Re-evaluation
I took an overlapping 2-phased intervention approach. The first phase
consisted of techniques to protect the tendon from overload stresses,
and the second phase consisted of graduated loading of the tendon and
muscle. Based on the patient's response to the initial physical
therapy program and my initial examination, the tendon appeared to
overload easily, causing inflammation. To protect the tendon from
overloading forces, techniques were used to "unload" the tendon during
weight-bearing activities. The patient was advised to continue using
axillary crutches and the heel lifts for the purpose of decreasing
tendon loading. Although he was instructed in a 2-point gait with the
crutches because it is a more natural pattern, the patient reported
that he often continued to use the swing-through gait pattern. During
the third week of therapy, I recommended use of a counterforce
Achilles tendon brace|| (Figure) during functional weight-bearing
activities, excluding exercises. The counterforce brace for the
Achilles tendon is a nonelastic constraint with a tension strap that
crosses the Achilles tendon. Empirical evidence supports the use of
counterforce bracing in the upper extremity for decreasing pain in
patients22,23 and decreasing muscular activity in people who are
asymptomatic24,25; however, contradictory evidence also exists.26 The
underlying mechanisms proposed to explain the effects of counterforce
bracing are that the pressure from the tension strap either broadens
the musculotendinous attachment or limits muscle expansion at the time
of contraction resulting in decreased stress within the tendon.23
During the initial examination, the patient had foot alignment
abnormalities that may contribute to abnormal forces around the ankle.
Given that the primary problem seemed to be inadequate ability of the
connective tissue to resist tensile loads, rather than cumulative
trauma due to abnormal forces related to foot alignment, I chose not
to address foot alignment. Intervention for the abnormal foot
mechanics would have been a future option if the patient made
insufficient progress.
I designed a progressive exercise program (Tab. 2) to address the
hypothesis that graduated loading of the tendon and muscle would
improve the tendon's ability to withstand tensile forces through the
process of connective tissue remodeling. As a result of remodeling,
the patient's functional ability was expected to improve.
The exercise program emphasized progressive loading of the Achilles
tendon over the next 3 months. The patient had access to a Total Gym
machine,# so he used this apparatus. The incline board of the
apparatus was set at the lowest level, nearly horizontal to the floor,
so only a fraction of his body weight was being resisted during
exercise. The resistance was increased by moving the incline board up
one level at a time, as tolerated by the patient. The patient kept a
weekly log of his exercise progression for his core exercises
(isotonic exercises of the hip extensor, knee extensor, knee flexor,
and ankle plantar flexor muscle groups that targeted muscles that were
considered critical to the restoration of his functional losses). The
patient's weekly log is presented in Table 2. The values in the chart
are the highest values achieved that week. In addition to isotonic
exercises, he used a towel to passively stretch into ankle
dorsiflexion with the knee extended and flexed for 5 repetitions in
each position (20-30 seconds, once a day), and he used the rocker
board in sitting for 1 to 2 minutes to regain neuromuscular control.
Beginning the fifth week, he walked in a pool in waist to chest-deep
water on an intermittent basis (1-4 times per week). He rode his
24-speed bicycle outdoors in the lowest gear with the arch of his foot
contacting the pedal to decrease the force on the Achilles tendon. He
rode his bicycle daily for 40 to 60 minutes.
The patient was seen 2 times a week for the first 3 weeks and then 1
time per week for the next 8 weeks (except for his vacation) to
monitor his progress and revise his home program. Across the 11 weeks
of physical therapy, resistance of the lower-extremity exercises was
gradually increased, as noted in Table 2. By the sixth week, the
patient was standing and walking for 5 minutes without crutches but
with the counterforce braces. During week 11, crutch use was
discontinued. After 11 weeks of physical therapy (14 visits), he
continued with a home exercise program for an additional 3 weeks.
After 3 weeks of home exercises, he was seen for one more follow-up
visit to reassess his progress and adjust his home exercise program.
During the final visit, the home exercise program was adjusted to
include plyometric exercise consisting of a partial squat on the Total
Gym machine with acceleration during the extension phase of the
exercise and controlled flexion back to the squat position, 10
repetitions, jogging in place for 2 to 3 minutes, and jumping up a
step with one foot, 5 repetitions each foot, once per day. Plyometric
exercise attempts to reproduce the stretch-shortening cycle found in
functional activities and is proposed to improve muscular performance
through both mechanical and neurophysiologic mechanisms.27
Outcomes
After 11 weeks of physical therapy (14 visits), the goal of an
improved functional level was achieved, and a follow-up visit 3 weeks
later indicated continued functional improvement. The increase in the
patient's LEFS scores, shown in Table 3, corresponded to his exercise
tolerance. For the first 6 weeks, he tolerated minimal exercise
progression, but during the last 5 weeks his exercise tolerance
markedly improved, and his LEFS scores increased.
After 11 weeks of physical therapy, his step length appeared to have
returned to normal, although decreased bilateral pronation during
loading response and early mid-stance was still present. Right
plantar-flexion strength returned to 5/5 using the weight-bearing
muscle test.18 The re-examination procedures did not exacerbate the
patient's symptoms.
Discussion
This case report described a patient whose Achilles tendinopathy was
an adverse side effect of short-term antibiotic use. It illustrates
the importance of awareness of relationships between adverse drug
effects and musculoskeletal conditions. This case report also
describes a patient's recovery from fluoroquinolone-induced
tendinopathy. Decreased load-bearing ability of the tendon suggests
that the first phase of rehabilitation should be a protective one.
During the first month of rehabilitation with his first physical
therapist, this patient's tendon was not protected and his symptoms
worsened. Later, the heel lifts, counterforce bracing, and crutch use
were all intervention strategies designed to decrease the tensile load
transmitted to the Achilles tendon during walking. Although little is
known about connective tissue healing subsequent to drug-induced
toxicity, the literature does provide insight into connective tissue
mutability and response to mechanical stress, in general. Too great a
load results in microfailure and potentially macrofailure of the
connective tissue,28 but lack of loading results in connective tissue
atrophy and weakness.29 For this reason, it was necessary to find a
balance between loading and unloading the tendon and to progressively
stress the tendon over time in an attempt to increase the tendon's
ability to tolerate greater stresses. The progressive exercise program
was designed to gradually load the Achilles tendon in a controlled
fashion. During the first 6 weeks, the patient was able to tolerate
minimal progression of the exercise program, but during the last 5
weeks, his ability to resist loading increased weekly.
This case report also demonstrates the use of a problem-solving
approach to synthesize the examination findings and classify a patient
with a condition unfamiliar to me. The treatment plan was based on the
judgment that the patient's decreased functional status was due to an
alteration in the connective tissue due to the antibiotic use. By
understanding the nature of connective tissue remodeling, the
intervention was designed to first protect the tendon and then to
progressively load the tendon. During the initial 6 weeks of
protection, however, when the tendon was structurally and mechanically
altered from the toxic effects of the fluoroquinolone antibiotic, the
progression was slow in comparison with the relatively faster initial
recovery from acute overuse injuries that I have observed. The
patient's improvement was nonlinear in that he made little progress in
the first 7 weeks and made rapid progress in the last 4 weeks. In
fluoroquinolone-induced tendinopathy, the tendon has the potential to
rupture even after the cessation of medication usage.6 Adequate
protection of the healing tendon, which lasts until the tendon regains
its tension-bearing capacity, probably is important. The time frame
for this patient's recovery was consistent with the range stated in
Pattern 4D of the Guide to Physical Therapist Practice--2 weeks to 6
months and 3 to 36 visits.21 His entire recovery process took 5½
months and a total of 24 physical therapy visits. He had 10 visits
with his first physical therapist and 14 visits with me.
Case reports are a good approach to describe relatively infrequent
pathologies, such as Achilles tendinopathy secondary to
fluoroquinolone antibiotic use. However, due to the lack of controls
in case reports, the experiences with this patient may not be
generalizable to other patients and the patient's recovery could have
resulted from factors other than the physical therapy intervention.
Conclusions
Achilles tendinopathy is a relatively infrequent adverse effect of
fluoroquinolone antibiotic use. The pathophysiology is poorly
understood, but the toxic effects of the drug are believed to alter
the structure and biomechanical properties of the connective tissue.
By applying principles of connective tissue biomechanics, a balance
between initial protection of weakened connective tissue and
progressive tendon loading was sought. Further documentation of other
cases would be helpful to establish a typical course of recovery, and
research is needed to determine the effectiveness of the 2-phase
approach described in this case report.
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References
1 Huston KA. Achilles tendinitis and tendon rupture due to
fluoroquinolone antibiotics. N Engl J Med. 1994;331:748. Medline
2 McGarvey WC, Singh D, Trevino SG. Partial Achilles tendon ruptures
associated with fluoroquinolone antibiotics: a case report and
literature review. Foot Ankle Int. 1996;17:496-498. Medline
3 Movin T, Gad A, Guntner P, et al. Pathology of the Achilles tendon
in association with Ciprofloxacin. Foot Ankle Int. 1997;18:297-299.
Medline
4 Harrell RM. Fluoroquinolone-induced tendinopathy: What do we know?
South Med J. 1999;92:622-625. Medline
5 Hooper DC, Wolfson JS. Drug therapy: fluoroquinolone antimicrobial
agents. N Engl J Med. 1991;324:384-394. Medline
6 Lipsky BA, Baker CA. Fluoroquinolone toxicity profiles: a review
focusing on newer agents. Clin Infect Dis. 1999;28:352-364. Medline
7 Szarfman A, Chen M, Blum MD. More on fluoroquinolone antibiotics and
tendon rupture. N Engl J Med. 1995;332:193.
8 van der Linden PD, van Puijenbroek EP, Feenstra J, et al. Tendon
disorders attributed to fluoroquinolone: a study of 42 spontaneous
reports in the period 1988 to 1998. Arthritis Care Res.
2001;45:235-239.
9 Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am.
1999;81:1019-1036. Medline
10 Ribard P, Audisio F, Kahn M-F, et al. Seven Achilles tendinitis
including 3 complicated by rupture during fluoroquinolone therapy. J
Rheumatol. 1992;19:1479-1481. Medline
11 Finch B, Brooks D, Stratford PW, Mayo N. Physical Rehabilitation
Outcome Measures. 2nd ed. Hamilton, Ontario, Canada: Canadian
Physiotherapy Association, 2002.
12 Diamond JE, Mueller MJ, Delitto A, Sinacore DR. Reliability of a
diabetic foot evaluation. Phys Ther. 1989;69:797-802. Medline
13 Root ML, Orien WR, Weed JM. Clinical Biomechanics: Normal and
Abnormal Functions of the Foot. II. Los Angeles, Calif: Clinical
Biomechanics Corp, 1977.
14 Elveru RA, Rothstein JM, Lamb RL. Goniometric reliability in a
clinical setting: subtalar and ankle joint measurements. Phys Ther.
1988;68:672-677. Medline
15 Boone DC, Azen S, Lin C-M, et al. Reliability of goniometric
measurements. Phys Ther. 1978;58:1355-1360. Medline
16 Lee KH, Matteliano A, Medige J, Smiehorowski T. Electromyographic
changes of leg muscles with heel lift: therapeutic implications. Arch
Phys Med Rehabil. 1987;68:298-301. Medline
17 Krebs DE, Edelstein JE, Fishman S. Reliability of observational
kinematic gait analysis. Phys Ther. 1985;65:1027-1033. Medline
18 Daniels L, Worthingham C. Muscle Testing: Techniques of Manual
Examination. Philadelphia, Pa: WB Saunders Co, 1972.
19 Lamb RL. Manual muscle testing. In: Rothstein JM, eds. Measurement
in Physical Therapy. New York, NY: Churchill Livingstone, 1985:47-55.
20 Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity
Functional Scale (LEFS): scale development, measurement properties,
and clinical application. Phys Ther. 1999;79:371-383. Medline
21 Guide to Physical Therapist Practice. 2nd ed. Phys Ther.
2001;81:9-744.
22 Froimson AI. Treatment of tennis elbow with forearm support band. J
Bone Joint Surg Am. 1971;53:183-184. Medline
23 Nirschl RP. Tennis elbow. Orthop Clin North Am. 1973;4:787-800.
Medline
24 Groppel JL, Nirschl RP. A mechanical and electromyographical
analysis of the effects of various joint counterforce braces on the
tennis player. Am J Sports Med. 1986;14:195-200. Medline
25 Snyder-Mackler L, Epler M. Effect of standard and Aircast tennis
elbow bands on integrated electromyography of forearm extensor
musculature proximal to the bands. Am J Sports Med. 1989;17:278-281.
Medline
26 Wuori JL, Overend TJ, Kramer JF, MacDermid J. Strength and pain
measures associated with lateral epicondylitis bracing. Arch Phys Med
Rehabil. 1998;79:832-837. Medline
27 Voight M, Tippett S. Plyometric exercise in rehabilitation. In:
Prentice WE, Voight M, eds. Techniques in Musculoskeletal
Rehabilitation. New York, NY: McGraw-Hill Inc, 2001:168-169.
28 Thorson E, Szabo R. Common tendinitis problems in the hand and
forearm. Orthop Clin North Am. 1992;23:64-74.
29 Cummings G, Tillman L. Remodeling of dense connective tissue in
normal adult tissues. In: Currier DP, Nelson RM, eds. Dynamics of
Human Biologic Tissues. Philadelphia, Pa: FA Davis Co, 1992:45-68.
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Copyright 2002 by the American Physical Therapy Association.
Author Information
BL Greene, PT, PhD, OCS, is Assistant Professor, Division of Physical
Therapy, Department of Rehabilitation Medicine, School of Medicine,
Emory University, Atlanta, Ga. Address all correspondence to Dr Greene
at Emory University, 1441 Clifton Rd, Rm 160, Atlanta, GA 30322 (USA)
(bgree02@emory.edu).
The author thanks Jill Sitlinger, PT, MPT, Cert MDT, OCS, for her
consultation on the case, and she thanks Bruce Greenfield, PT, MMSc,
OCS, and Marie Johanson, PT, MS, OCS, for their thoughtful comments.
--------------------------------------------------------------------------------
Article Information
This article was submitted November 7, 2001, and was accepted June 30,
2002.
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