TRAINING issue 15 By Joan Watt, MA, GradDP, MCSP SRP

Continuing Professional Develop- ment (CPD) is the process of systematic maintenance, improve- ment, and broadening of knowledge and skills. It develops the personal qualities necessary for the execution of professional and clinical practice. CPD should continue throughout the practitioner’s working life. This article gives advice on what consti- tutes CPD and how you can go about doing it.

The concept of lifelong learning should be recognised as an essential prerequisite to maintaining clinical competence. CPD should constitute a balance between informal learning in the workplace, self- assessment and formal structured devel- opment.

There was a time, not so long ago, when people gained their professional qualifica- tion and worked until retirement without ever again attending any course or exam- ining their own work practices. These days are gone and all health professionals must now provide evidence of CPD - and rightly so - for the advancement of the person and the profession.

The changes currently being brought by the Health Professions Council involve a mandatory record of CPD. A recognisable path of professional development and life long learning in a specific field such as sports medicine can only lead to better practice, more competent practitioners and effective treatments.

So where should you begin, what is acceptable as CPD and how should you do it?

This article attempts to answer these three questions and give some hints and ideas on where to start and what to do. This is by no means the only way available to provide CPD, but it should give you a place to start on a plan that will help provide the development needed.

Where to begin Keeping a CPD portfolio is a very good starting place. It is a lot of work and does require dedication and a bit of discipline. You will be surprised when you begin how

Jan 03 Promoting Health Through Exercise THE MULTIDISCIPLINARY JOURNAL FOR PROFESSIONALS WORKING WITH EXERCISE RELATED INJURIES

• Packed with practical tools and aids • Photocopiable advice sheets • Rehabilitation programmes • ‘Read it now - use it in an hour’

Inside

News & education

News round-up

Indexed in SPORTDiscus

Research round-up from the clinical journals

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Injury management & diagnosis

Injury psychology

Vascular issues in the upper limb

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Rehabilitation focus

Rehabilitation of tennis elbow

Book reviews 14

LOOKING AHEAD

C P D

much information you already possess but have not considered relevant.

What is acceptable The collection of items for your portfolio can and will be very varied but applicable to your needs and practice.

● Learning needs analysis - a good start to CPD to appraise your current position ● SWOT analysis - Strengths, Weaknesses, Opportunities, and Threats - this form of analysis can be extremely beneficial in highlighting actions required to obtain the necessary skills for good practice ● Attendance at courses is always the first thing to jump to mind when thinking

of CPD, but this is only one of the many ways to develop your skills ● Case studies can be very useful and lead to suggestions and recommendations for future practice ● Reflective diary - if you decide to doc- ument your sport involvement over a sea- son, major event or even longer you can at the end of that time write a summary ● Critical event /experience - this will be a reflection of a one-off incident ● Annual reports - recording and writing up for training involvements, clinical situations and on-tour details.

How to do it Learning needs analysis

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REHABILITATION FOCUS TENNIS ELBOW

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graphite, vibration also dampens out faster.

AN INTEGRAL APPROACH

‘String vibration dampers’ are unlikely to contribute enough to prevent injury (4), although they are frequently used.

Racket mechanics ● A lighter racket may help but reducing

weight also reduces power and may cause more problems with shock or jar

● Heavier rackets recoil less and ‘twist off’ less

● Softer strings reduce ‘peak force’ of impact

● More flexible shafts soften the feel of initial impact

● Softer grip materials have the same effect, as does holding the racket less firmly.

Off-axis impacts and grip strength A wider racket head is less likely to twist if hit ‘off-axis’. Studies have shown little difference in resultant ball velocity with different grip strengths in off-axis impacts (5). It takes little grip force to prevent the handle rotating within the hand on off centre impacts so all but top level players should consider using the lightest effective grip thus helping to pre- vent elbow problems (6).

By Dr Simon Petrides, MB, BS, DO, Dip.Sp.Med

First described by Runge in 1873 (1) lat- eral epicondylitis affects 40-50% of recre- ational tennis players, mostly over the age of 30. It can be responsible for months or even years taken away from tennis in the vain hope of a cure by rest alone. Unfortunately, rest alone is rarely helpful.

Factors contributing to tennis elbow 1. Age 30+ 2. Frequency of play 3. Force and flexibility of forearm exten- sors ie. grip tightness

4. Unskilled players are more prone (2) 5. Racket factors ie. weight, string ten- sion, grip size and cushioning, head size

6. Older balls 7. Single handed backhand 8. Poor technique.

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Backhand technique This is perhaps the most important aspect to address in ascertaining the cause of lateral epicondylitis and in preventing recurrence.

Faults include: a) Poor body position ready for stroke (ball contact should be out in front)

b) Leading elbow c) Dropped racket head d) Opening up too early - ie. premature trunk rotation

e) Using tennis for fitness conditioning f) Perception of tennis as an upper body sport.

The single handed backhand uses a long fulcrum and consequently increases forces at the elbow. It is also associated with a greater incidence of tennis elbow than the ‘double handed’ backhand (3).

In the ‘one handed topspin backhand

drive’ six body movements/positions should be addressed: 1. Step toward ball 2. Hip turn and transfer of momentum 3. Trunk rotation 4. Upper arm movement about the shoulder

5. Slight forearm movement 6. Hand and racket position.

In tennis elbow sufferers, the co-ordinated sequencing of these movements is often aberrant and results in greater load on the elbow. In unskilled players, the ball strike is more frequently off the ‘sweet spot’ causing more vibration, shock and twisting momentum of the frame in the hand.

Racket vibration Striking off the sweet spot causes a larger amplitude of oscillation and vibration. A stiffer racket will have lower amplitudes of vibration which is why graphite is a popu- lar material for racket manufacture. With

Grip size EMG studies have shown that the extensor muscle activity remains at around 37% of ‘Maximum Voluntary Contraction’ for all ranges of grip sizes (small, medium and large) (7) though recommendations seem to suggest that smaller grip sizes will increase the incidence of tennis elbow.

Muscle activity In the backhand groundstroke the exten- sor carpi radialis brevis (ECRB) has high- est activity in the acceleration and early follow through phases. These high levels maybe responsible for the development of injury (8) (Fig.1). If the extensor group is already nearly at full contraction then vibration and twisting movements are transferred directly through the muscle to the teno-periosteal junction.

Pathology The result of all these factors is ‘overuse’ and inflammation of the ECRB tendon insertion at the teno-periosteal junction (9). Other tendons can be involved such

Extensor carpi-radialis longus

Extensor carpi-radialis brevis

Extensor digitorum

Extensor carpi ulnaris

Subcutaneous olecranon bursa

Anconeus

Extensor digiti minimi

©1999 Primal Pictures Ltd

Figure 1: The extensor muscles surrounding the elbow joint

as ECRL, ECU and extensor digitorum.

Microtrauma is generated by the impact and vibration produced by ball strike (10) and by repetitive eccentric and concentric contractions. This results in microtears, fibrosis, granulation tissue deposition and mucinoid degeneration (11) collectively called angiofibroblastic hyperplasia.

Diagnosis The pain of tennis elbow is characteristi- cally on the outer aspect of the elbow and is exacerbated by wrist extension and gripping. It is relieved by rest and aggra- vated by return to play. There is tender- ness just anterior and distal to the lateral epicondyle. Although several other sites have been described, this position is by far the most common.

joint degeneration, compression neuropa- thy of the radial nerve and radial tunnel syndrome (12). In the latter, the pain is more distal in the muscle belly and proxi- mal forearm at the leading edge of supina- tor. It is also more vague, diffuse and aching in nature.

Treatment Treatment in the first 48 hours 1. Early treatment should include ‘relative rest’ of the elbow but maintenance of general fitness

2. Icing can help in the first 48 hours to reduce swelling.

3. Non-steroidal anti-inflammatory med- ication can be used in the first few days but is of little use in the more chronic lesion

4. A wrist splint in 20 degrees of wrist extension can off load the elbow espe- cially in the acute stage.

Treatment after 48 hours ● Deep transverse frictional massage is helpful (13) (Fig.3)

Figure 3: Deep transverse frictions

Figure 4: Forearm extensor muscle stretch Figure 2: Resisted extension of the wrist

Pain is experienced on active resisted extension of the wrist (Fig.2), which is sen- sitised by extension of the elbow. Resisted finger dorsiflexion is characteristically painful especially with the middle finger.

Differential diagnosis It is necessary to exclude radio-capitellar

Figure 5: Mills’ manipulation SportEX 15