Articles on soft tissue

Tenosynovitis – Do You Suffer From Wrist Pain Due to It's Overuse?

Dr. A Mohan Krishna, Orthopedist
Tendons are tough fibrous structures that connect the muscles to the bone and aid in movement of the joint. The tendons that pass across certain joints like shoulder, wrist and ankle joints are enclosed in double layered sheath called tendon sheaths. These tendon sheaths aids in smooth movement of the tendon and reduces risk of tendon damage from friction or pressure over the bone. Tenosynovitis is a condition in which these tendon sheaths get inflamed.Inflammation:The tendon sheaths are lined with specialized tissue, synovial membrane which secretes a lubricating substance (Synovial fluid). This normally enables the inner and outer layers of a tendon sheath to glide over each other, allowing the tendon to move freely.In tenosynovitis, inflammation of the tendon sheath prevents this free movement, but any attempted movement tends to be painful and limited.Causes:Repetitive micro traumaExample like – repetitive usage of mouse and keyboard,Repetitive usage of wrist and thumb during household worksRepetitive use of particular group of muscles. Example: Racquet sports, badminton playersAn acute injury.Infection spreading from a nearby part of the body, such as infection of the finger pulp, or carried in the blood stream.An inflammatory disease involving the synovial membrane, such as rheumatoid arthritis.Tenosynovitis is recognized as an occupational disease.Farmers harvesting sugar cane can have severe tenosynovitis affecting the tendons that extend the wrist. It is otherwise called as “cane cutters disease.”  Dhobis, Housewives who repeatedly twist wet clothes are at risk of developing tenosynovitis of tendons at base of thumb or wrist also called as Dequervain’s Disease.Symptoms:PainSwelling over the affected tendon and joint.Restricted movementDoctor Examination:Pain on making particular movement, such as moving up and down the wrist or ankle or moving the joint at the base of the thumb.The will be swelling along the line of the tendon or, in some long standing cases, the formation of fibrous nodule that can sometimes be seen or felt.A warm feeling over the affected tendon.Grating sensation in the region of the tendon on movement (crepitus).Diagnosis:History:Details of patient’s lifestyle,Work place – computer, Keyboard, mouse etcUnaccustomed exercisesHistory of Rheumatoid arthritis or any joint problemsThe diagnosis usually made clinically by examining the affected part.The doctor may note thatMovement is limited and painfulThe tendon sheaths are visibly swollen.The overlying skin is red and warm to touchX ray:With long standing tenosynovitis an x ray may reveal calcium deposits in the tendon and its sheath.Treatment:The discomfort of severe tenosynovitis may be relieved by cold compresses, while chronic inflammation may respond to heat.Rest:Most cases of tenosynovitis resolve with rest. Initially rest to particular tendon and joint can be achieved by applying braces. In severe cases, resting the affected part in a splint or plaster cast for a short period may aid in recovery but, once the acute phase, has passed, the affected part should be exercise several times a day to prevent the formation of scar tissue that may later cause trouble some stiffness.Medications:Analgesics (pain killing) drugs andNon-steroidal anti-inflammatory drugs (NSAID’s) may also be helpful.Injections: if there is no evidence of infection local steroid injection can help to relive pain and aid in early recovery.In people with rheumatoid arthritis, general measures to treat their disease, anti-arthritis drugs, will be necessary as well as local treatment.Antibiotic treatment will be needed if there are signs of infection.Surgery:In case tenosynovitis is not responding physical therapy or medications a minor surgery to cut the tight fibrous tissue can help to relive pain and stiffness.Prognosis:Most patients recover well from tenosynovitis with rest and treatment.Recurrence:If a person has had tenosynovitis once, it’s likely to recur, especially if the cause is not addressed. It is therefore important to take measures to avoid recurrence by, for example altering working place.

10 Easy Tips for Heel Pain

Dr. Yogesh Kumar, Ayurveda
Women have been wearing high heel sandals to look good but this fashion fad could give rise to Back and Heel problems.Heel and back problems can occur in men also .This problem in medical terms called "The Painful Heel Syndrome".Women with Progressive age, Arthritis, Overweight women are more prone to this problem.The heel pain could be different according to the age groups.Young men tend to have Bursitis while older men have Plantar Fasciitis. Due to increased overload on Foot , Stress fracture, and Osteoporosis, heel pain can occur. Besides that,Foot Pain could be due to Nerve damaging Diseases like Diabetes and Peripheral Neuritis.Below the heel bone, there is a bedding of fat, there lies  some fat in between nervous fibers.In progressing age,the fat layer of the nerves reduces and the nerve fibers deteriorate and because of that the whole weight of the body falls on the heel and heel pain occurs.The Mainstay of the Heel Pain is Physiotherapy.It uses Hot and Cold Fomentation,Short Wave Diathermy,Strengthening and Mobilizing exercises.The Patient should follow the dietary advice ,Eat fat-free diet,Should not consume fried and spicy food and Excess Sugar-containing food. If still, the problem persists,medical help should be taken.Some Useful Tips for Heel PainHot Fomentation For 10 minutes Daily.Use Pain Reveling Gel,Spray or Cream.Use Ice Fomentation For 10 minutes after injury.Exercise for Joint and Heel.Soak the feet in  warm salt water daily three to four times.Oil Massage of the feet daily.Use special footwear with extra padding on a heel. Pull the fingers of the feet first inwards than outwards.For feet, exercise uses the tennis ball.Place the tennis ball under the feet and roll.It increases the blood flow in the feet.Take Sessions of Acupressure from the expert,it reduces the pain by increasing the blood flow.

Effects of Energy & Soft Drinks

Dr. Pawan Sharma, Dentist
Previous scientific research findings have helped to warn consumers that the pH (potential of hydrogen) levels in beverages such as soda could lead to tooth erosion, the breakdown of tooth structure caused by the effect of acid on the teeth that leads to decay. However, the pH level of soft drinks isn't the only factor that causes dental erosion. A beverage's "buffering capacity," or the ability to neutralize acid, plays a significant role in the cause of dental erosion. Popular energy drinks also cause tooth erosion.Clinical Featurefigure 1 Effects of soft drinks ....teethAcid Versus Enamel:-It is well known by the medical profession that disease loves acid,2 and this is particularly true of dental caries.Dental caries, by definition, is tooth demineralization caused by acidic-byproducts of the bacterial fermentation of dietary sugars. The resulting caries lesion involves gradual demineralization of subsurface enamel and dentin, leaving the outer 20- to 50-micrometer-thick surface preserved more or less intact.3 With the consumption of acidic, carbohydrate-rich soft drinks,teenagers are at high risk for caries development,which can be quite aggressive (Figure 1). Eight- to 17-year-old children are at greatest risk. Normally, as the young, immature enamel is bathed by salivary ions and the intercrystallinespaces fill, it becomes progressively harder and more mature. Mature enamel appears as a very dense, less penetrable, glassy hard structure that is fairly resistant to acid attack.However, enamel maturation takes time. The newly erupted enamel in teenagers is immature, and the crystalline structure is porous, chalky, and easily penetrated and dissolved by acids.4 Even in the absence of carbohydrates,soft drinks can be destructive to teeth. These acidic, or lowpH, beverages can contribute to the demineralization of dental hard tissues.Dental erosion is the loss of tooth structure by a chemical process not involving bacteria.5 Initially,enamel will demineralize and dissolve, with the surface appearing dull. Acids can also enter the pits  of enamel and cause subsurface structure loss.6 The solubility of hydroxyapatite increases logarithmic-ally with decreasing pH.Erosion may be caused by either intrinsic or extrinsic sources. The intrinsic causes have been documented to include cases of anorexia nervosa and bulimia, as well as any gastrointestinal disorder that involves increased outputs of gastric acids. Extrinsic sources include acidic medicines such as vitamin C and aspirin, aerosol acid chemicals in the work environment, or the frequent consumption of acid food stuffs or drinks.Simple pH monitors have shown that all types of soft drinks are very acidic,especially the colas, which can have a pH of 2.4 or less . In order to neutralize a glass of cola, it takes 32glasses of high pH alkaline water.2 Exposure of enamel to Coca-Cola® for one hour leads to significant reduction in  ,and scanning electron microscopic evaluation has revealed surface irregularities.ConclusionAs you may imagine, although the erosion and caries processes are as different as their histological appearance,the two conditions occurringcon currently could be deleterious to dental hard tissues. As dental professsionals,we need to educate our patients about the consequences of soft drink consumption and provide suggestions to minimize the risk.We also need to be active in educating school administrators on the negative impact soft drinks have on students’teeth.The place where children spend agre at portion of their day and where they are influenced greatly by their surroundingsis their school. Schools are therefore the most suitable environment to provide health information tochildren in order to achieve the goal ofhealth promotion programs. It isquite a contradiction to teach principlesof good nutrition in health education,then adjourn the class to thereality that the children have highaccessibility to soft drinks right outsidethe classrooms

'Soft Drinks' Have a 'Hard' Impact on your health

Ms. Raminder Kaur Deshmukh, Dietitian/Nutritionist
Now a days it's a trend to gulp down a bottle of cola while dining or socializing with the family and friends. No meal seems to be complete without soft drinks.This is how a soft drink impacts our health:SUGAR OVERLOAD: After the consumption of the drink our blood sugar shoots up, at this our liver convert every single sugar molecule into fat which will lead to weight gain and obesity.ASTHMA: It aggravates the problem of respiratory diseases.KIDNEY PROBLEMS: The artificial sweeteners present in the colas can damage one of the most important organ of our body that is kidney. REPRODUCTIVE ISSUES: Researches have shown that consuming colas on regular basis can have spermicidal effect. Hey man are you listening ??OBESITY: Colas are full of sugar and extra laden calories. Excess intake of colas will give you extra laden calories which will gift you obesity in return. so better avoid colas.OSTEOPOROSIS: Soft drinks contain high phosphorous content which interferes with the body’s ability to absorb calcium and can lead to osteoporosis, cavities and bone softening.RISK OF DIABETES: With sedentary lifestyle this is the major giant killer which has emerged in India. Non diabetic persons should avoid these drinks in order to keep diabetes away and diabetic persons should be careful as it increases blood glucose levels instantly.HEART DISEASE: Soft drink contain high amount of artificial sweetening agents and fructose content due to which there is increase risk of metabolic syndrome which can lead to elevated risk of heart disease. TEETH DAMAGE: Drinking colas can lead to tooth decay as the Ph level of colas is high which can damage the enamels quickly. so for that perfect '32', keep the colas away.METABOLISM LEVEL DECREASES: A glass of warm water can speed up your metabolic rate.A can of Cola can surely be tasty but it really decreases the metabolism and helps in destroying the fat burning enzymes in no time.So let's say "Cheers" with lassi, coconut water,soups and bye to colas.

How to Get Rid of Tennis Elbow

Pranjali Chaudhari, Physiotherapist
WHAT EXACTLY IS TENNIS ELBOW???              It is inflammation of common extensor origin where all tendons attached to the bone on lateral epicondyle of the humerus are affected. The primary muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wristCAUSES                                                                                      1: all of a sudden strain due to jerk or stronger contraction of muscle.   2: overuse of common extensor tendon such as “repetitive” gripping and grasping activities.   3:repeated direct external trauma to lateral epicondyle  4: sudden increase in activities that place stress on the forearm extensors (such as involvement in a tennis tournament over consecutive days)Symptoms1: pain associated with activities in which extensor muscles are active, such as lifting, gripping, and/or grasping.2: The pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle.3:With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.TreatmentModalities such as ultrasound, heat treatments, and interferential therapy will reduce inflammation around extensor tendonsStretching for joint tightness (particularly the wrist, elbow, neck or upper back)Correction of poor postureInclusion of adequate warm-upCorrective rehabilitation of old neck or upper back injuryErgonomic correctionDeveloping work demand related endurance in involved muscle to avoid repetitive strainsGrade 1 exercises for tennis elbowIn tennis players, inappropriate racquet size, grip size, string tension, court surface or ball weight may all contribute to the development of this condition.Proper positioning and handling of a computer mouse.Proprioceptive mobilization of elbowKinesthetic taping with corrected position for extensor tendons

Work on This Muscle to Burn More Fat

Ms. Swati Kapoor, Dietitian/Nutritionist
Do muscles burn fat?The human body will burn more calories to maintain a pound of muscle than it will to maintain a pound of fat. Therefore, the more muscle you build, the more calories your body will naturally burn each day at rest, and this will improve your overall fat loss progress.How Many Calories Does Muscle Mass REALLY Burn?Muscle is an active tissue that is constantly renewing itself, therefore requiring energy (calories).One pound of muscle burns approximately 5-6 calories per day at rest. This would mean if you build 10lbs of muscle it would lead to energy consumption of 50-60 extra calories per day.There are 2 larger main muscle groups of the body. If you work on these muscles, you can keep your metabolism high.1. LegsLeg muscles are the biggest and strongest muscles of our body. They are the largest muscle group. For most people it is quite hard to gain immediate muscle mass on the legs. And unlike biceps or chest, you never see immediate ‘pump’ in your legs post workout, so it can be quite frustrating at times. But working on your leg muscles will make it easier to keep the fat off and metabolic rate high. In fact, strong legs even contribute to muscle gain for the rest of the body. Most of cardio or aerobic exercises are concentrated on the legs. These exercises will help in toning the muscles of the legs. Aerobic exercise is very important for overall health, stress relief, and conditioning of the muscles. You should even focus on heavy weight exercises for the legs such as leg presses and weighted squats for substantial benefit.2. The Back:The back muscles are the other large muscle group in our body. These muscles are very important to our health since they increase overall upper body strength, other than keeping away back pains and age related injuries. Strong, active back muscles burn fat effectively since they are a large muscle group. They even give good overall shape to the body. Focus on basic movements like deadlifts, pull-ups, chin-ups and rows for maximum gain and benefit.Which of the two muscle burns more fat?There is simply more muscle fiber packed into the body from the hips down, and this includes the muscle group that enables the legs to perform vital movements. Leg muscles have the potential to burn more fat because of their size. So focus on your leg muscles to increase your fat burn. But back muscles are also important, so do not skip those either.

Repititive Strain Injury - Are You Always in Pain?

Dr. A Mohan Krishna, Orthopedist
Repetitive strain injury (RSI) is a collective term that covers a range of hand, wrist, forearm, neck shoulder, back, and knee and ankle disorders. The upper limb RSI’s are those that are most commonly encountered.Symptoms include:Sensation of tingling, aching or burning,Swelling and / or numbnessPins and needlesIncessant, nagging pain.There are no characteristic clinical signs in RSI. Due to the ambiguous nature of complaints RSI is included in the chronic fatigue syndrome category of diseases.There are two main groups of disorders are localized and diffuse RSI.Localized RSI:Includes:TenosynovitisCarpal tunnel syndromeEpicondylitis (tennis elbow, golfers elbow)These conditions are characterized by clearly defined symptoms and clinical signs. There is little professional disagreement over the existence of such conditions.Tennis elbow (Picture) is a painful inflammation of the tendon at the outer border of the elbow caused by the over use of the forearm muscles.Diffuse RSI:It includes:Poorly localized or diffuse patterns of painTenderness and loss of function in the upper limbThis group with muscles, nerves,tendons and soft tissues being affected, is controversial one, with opinions varying over origin (aetiology).Causes:The diagnosis of RSI may be made by GP’s, occupational health physicians, orthopaedic surgeons, or rheumatologists. The diagnosis rests largely on reported symptoms and nature of the patients work.Localized RSIs are more specific than diffuse RSI’s and may be more positively identified: for example, conditions such as carpal tunnel syndrome due to median nerve compression at the wrist, tennis and golfers elbow and tenosynovitis have more diagnostic criteria.Diffuse RSI’s on the other hand, are more problematic. The diagnosing clinician can only rely on symptoms, the type of work and its repetitive nature.There are three main causes:Fixed working positionRepititve motionsPsychological stress.The standard vies is that RSI’s are msuculotendinous injuries of the upper limb, shoulder girdle or neck caused by an overload of particular muscle groups, from repeated use, or by the maintenance of constrained postures, which results in pain, fatigue, and a decline in work performance. An alternative hypothesis is that RSI’s are not organic in nature and are not work- related.Some experts believe that the condition is due to conversion hysteria, whereby psychological conflict is converted into imaginary pain. Others consider the problem to be form of compensation neurosis, that is the patients having symptoms but retain a desire for secondary gain such as compensation payments or time off work.Treatment:Treatment of localized RSI’s is usually with well documented stratagies such asSteroid injection therapyRestSplintingOccupational health ergonomicsPhysiotherapeutic methods: in the more diffuse RSIs, treatment is much more difficult and controversial. Many sufferers resort to alternative medicine therapies such as:AcupunctureManipulation from osteopaths and chiropractorsAlexander technique for postureWork place solutions include:A humane working environmentErgonomically designed workstationsJob rotationIncidence:Most information on incidence comes from Australia, where there was a virtual epidemic of cases between 1980  and 1984. The Australian public service carrying out Audit between 1985 and 1987 , found that 2,706 persons years had been lost during the two year period. The prevalence ranged of cases wasOne percent in clerical administrative staff16 percent among data processor operators24 percent among data processorsRSI complainants were more likely to be female- perhaps because of the nature of their work.Understanding RSITrade unions are believed to have had considerable influence in protracting the problems, whereas health professionals such as orthopedic surgeons and rheumatologists have been less sympathetic towards the nature of the disorder.Consequently, the incidence of reporting has lessened markedly since those years. The Australian public service no longer issued statistics after 1987, and this led to a loss of public interest or awareness. A research project in USA in 1998 estimated that RSI disorders accounted for 56% of all occupational injuries.Prognosis:Conditions in the localized group of RSI disorders are amenable to treatment with steroid injections and physiotherapy. Diffuse disorders are far more difficult to treat mainly due to different attitudes of health professional. Often, the disorder will only resolve on change of occupation or satisfactory settlement of compensation. This latter may involve a costly process of litigation.Prevention:Good working practices and the provision of suitable office furniture, for example , may help in the prevention of RSIs. Employment medical services may provide advice, especially with ergonomic design, on providing the optimum work conditions for employees.

Cracked Feet? No More!

Dr. Vijay Adhe, Dermatologist
Everyone desires a healthy and beautiful skin. We spend a lot on skin care products to keep our skin soft and supple. But we tend to neglect one of the most important parts, which bear the weight of entire body - our FEET! One of the commonest problems our feet encounter is cracked soles. The main reason for this is dryness, which is worsened by the cold & dry weather. It’s a well known fact that the skin of soles, lack the oil secreting glands which are needed to keep the skin moisturized. What starts as mild roughness over heel can often progress to deep painful cuts and bleeding if not treated in time. This is aggravated by standing and walking bare foot; working in water for long time, repeated contact with detergents, obesity, wearing improper ill fitting shoes and not moisturizing feet daily. These cracks facilitate the entry of organisms leading to infections like cellulitis, which can pose a threat especially to people who are diabetics.Some common illnesses like diabetes, thyroid disorders, leprosy and various nervous system diseases can cause fissuring over soles. Skin diseases like psoriasis, eczema, fungal infections and some genetic diseases can also result in a similar picture. In women, menopausal stage of life is known to cause fissuring over the heels. Since there are varied causes, it is important to have a consultation with a specialist to find out the reason of cracks and receive appropriate guidance. Some patients need office based treatments like paring for callosity or minor surgery for corn removal.Here are few basic tips to protect your feet:Daily inspect your feet to look for any cracks, calluses, cuts, roughness etc (very important if you are diabetic). Soak your feet daily in warm water for 5-10 minutes followed by gentle wiping (including spaces between the toes) and moisturizing immediately will work wonders for your feet.Moisturizers containing urea, keratolytics like AHA & BHA are more suitable for thick skin of the soles. Soft silicone insoles & heel pads help to distribute body weight equally and reduce pain. Do not hesitate to seek your skin specialist’s help to keep your feet healthy and soft.

Soft Tissue Grafting to Improve the Attached Mucosa at Implants

Dr. Rajat Sachdeva, Dentist
This is in preposition of a treatment planning of an appropriate surgical technique for increasing the width of the attached mucosa in order to maintain Peri-implant health. The soft tissue around gingival being divided into gingival and mobile alveolar mucosa, the gingival width varies individually as 2-9 mm.There is a time-point to distinguish the peri-implant mucosa from the gingival around the teeth:The peri-implant connective tissue has less number of fibroblasts & more collagen fibers’ as compared to gingiva.The junctional epithelium is more permeable with scarce number of blood vessels than that of around the tooth.The peri-implant connective tissue fibers’ run in a parallel direction to the implant or abutment surface without being attached rather being perpendicular to the root cementum.It has been concluded that presence of non-elastic collagen fibers’ in the connective tissue is responsible for keratinization.Based on findings, >2 mm of keratinized tissue is required for maintenance of healthy gingival tissues.However,around the dental implants, the crucial role of an adequate width of keratinized /attached mucosa for the clinical success is still controversial.Recent studies have shown that lack of adequate width ofKeratinized alveolar mucosa around dental implants is associated with more plaque accumulation, inflammation, soft tissue recession, attachment loss. Since implant surgery includes one or two stage bone augmentation procedures, displacement of the mucogingival Junction does occur.hence, in order to regulate the width of keratinized attached mucosa, two different peri-implant soft tissue augmentation procedures can be concluded:Increase in soft tissue volume using a sub epithelial connective tissue graft or soft tissue replacement graftEnlargement of keratinized mucosa width by means of an apically repositioned flap/vestibuloplasty.

Shockwave Therapy – a New Therapy Approach for Physiotherapy

Dr. Rakesh Kumar, Physiotherapist
Musculoskeletal disorders originating from muscles and tendons affects majority of general population. It impairs mobility, causes pain and reduces overall well being. Efforts are made constantly to treat these disorders. But often shows limited success due to wide range of competing technology options available and lack of time from the patient’s part. Shock wave application represents a new therapy approach. Clinical experience has shown that a wide range of functional disorders can be treated effectively with shock wave therapy.Musculoskeletal disorders like epicondylitis, tendinopathies, sciatica, dorsalgia, tensorfascia lata syndrome etc are very detrimental and are caused due to mechanical over-strain, trauma, poor posture, emotional stress or due to some muscular disorder. These disorders leads to physiological changes deep down in the tissues. There is an increase calcium release leading to permanent contracture of actin/myosin filaments and an increase in energy consumption. There is further capillary compression and leads to local ischemia. This causes a local energy crisis. Local ischemia causes bradykinin release, sensitizing the muscle nocioceptors and increase tenderness. Ischemia also causes motor end plate dysfunction and a vicious cycle is produced. During Shockwave therapy, a high-intensity sound wave interacts with the tissues of the body. This leads to a flow of beneficial effects such as neovascularisation in growth, reversal of chronic inflammation, stimulation of collagen and dissolution of calcium build-up. Stimulation of these biological mechanisms creates an optimal healing environment. As the injured area is returned to normal, functionality is restored and pain is relieved. Conventional physiotherapy treatment of these Musculoskeletal disorder includes myofascial massage, electrical stimulation, ultrasound etc with some degree of success rate. Shockwave therapy on other hand is enormously effective, shortens the treatment period and brings better results in long time follow-up. PHYSIOLOGICAL EFFECTS Shock wave travels through a medium and comes to an interface, part of the wave is reflected and part transmitted. The dissipation of the energy at the interface results in generation of the physical, physiological and thus the therapeutic effects. The following are established treatment effects of shockwave therapy:Shock wave create microrupters in tendon which stimulate the growth and remodelling of new arterioles and an increased blood supply. This results better oxygenation leading to faster healing of tendon.Shock waves force collagen fibres in to a longitudinal structure.These newly formed tendon fibres are more dense and stiff.Due to micro trauma to a tendon there is calcification formation. Shock wave therapy starts the biochemical de-calcification.There is an increase in cellular activity. There is release of substance P, prostaglandin E2, NO, TGF β, VEGF, and other inflammatory cytokines.There is transient analgesic effect on afferent nerves. APPLICATIONS FOR SHOCKWAVE THERAPYShock wave applications in physiotherapy is mostly associated with the treatment of chronic muscular and tendon disorders. Most common indications include:Painful shoulder Epicondylitis Low back pain Achilles tendon pain Patellar tendonitis Trigger points treatmentPeriarthritis shoulder Calcar calcanei/heel spur Arthrotic changes - secondary symptoms Achillodynia Lateral & ulnar epicondylitis Muscular strainProlonged joint distortion treatment Groin pain Hip pain Low-back pain CONTRAINDICATIONS AND PRECAUTIONSThere are several areas or pathologies where concern has been expressed with regard to the use of shockwave. This list is compiled from current available evidence and clinical experience:Patients who are haemophiliac or who are on anticoagulant therapy are best not treated with shockwave.Malignancy remains on the contraindication list•Infection in the local area should be treated with strong caution.It is advisable to avoid epiphyseal regionsDuring shock wave therapy, it is crucial that pulmonary tissue is not within the target area of shock waves.Relative contraindications include pregnancy.CASE STUDYA 38-year-old female, right hand dominant, house wife suffered from right elbow pain since nine months. The pain, worsened in the previous two weeks and was characterized as stiff, achy, and sometimes throbbing. On VAS scale she rated 9/10 on the very first day of assessment. The patient was no longer able to do daily activities at home and was unable to sleep at night. Initially she was treated with anti inflammatory and analgesics for 2 weeks.Thereafter she was treated with corticosteroid injection 3 times with no clinical improvement in pain. She was then treated with advance PRP injections which availed no relief but only aggravated the symptoms. The pain was noted to be at its worst in the morning, and was aggravated by extending the wrist to brush her teeth, open doors, and while washing clothes No numbness, tingling or weakness was noted in the hand. The patient denied previous trauma to her right elbow, but did recall a similar pain in his left elbow a few years earlier that resolved on its own with rest. Upon inspection, lateral epicondyle and common extensor origin appear to be inflamed when compared to the opposite side. All active ranges of motion of the elbow joints were full, while flexion and extension in the right wrist were limited due to pain. Passive range of motion, was also limited by patient discomfort particularly at the end range of right wrist flexion, and was able to reproduce the patient’s chief complaint at the right elbow. Resisted wrist extension and grip strength were very painful and the patient declined to provide much effort as this reproduced a sharp pain at the lateral epicondyle. Orthopedically, Cozen’s test (resisted wrist flexion from a flexed elbow and pro-nated/extended wrist position) was positive. Mill’s test, (passive extension of the elbow from a flexed elbow, pro-nated forearm and flexed wrist/finger position) was in- conclusive in that it was uncomfortable but did not produce pain at the lateral epicondyle. The patient was diagnosed with lateral epicondylosis. she was treated six times over two weeks with shockwave. In addition to the soft tissue treatment, a rehabilitation program was performed, which was followed by 20 minutes of interferential current and 10 minutes of ice. After the first treatment the patient reported to feel 80% better, and at the time of discharge there was complete resolution of her symptoms (VAS 0/10 with no pain provocation on examination).Hence shockwave treatment is a good non-invasive and result oriented treatment modality. For details visit www.perfectophysios.com