Welcome back to part two of the lateral epicondylalgia series. Part 1 covered assessment and clinical anatomy and in this section we are going to focus on treatment considerations and commonly used manual therapy techniques and exercise prescription. From an evidence-based practice perspective, Bisset & Vicenzino published a paper in 2015 which summaries over 200 clinical trials on this topic and is well worth reading. The research is littered with various treatments such as friction massage, ultrasound, laser, acupuncture, manual therapy and exercise. There are two main treatments I would like to review in this blog, manual therapy and exercise. For a more comprehensive overview of treatment Vicenzino’s 2003 masterclass is a brilliant read.
“There is no universally accepted treatment for all patients presenting with LET” (Coombes, Bisset & Vicenzino., 2015, p. 941). But the good news is that despite this, “conservative management is recommended as the first line of treatment for LE” (Bisset & Vicenzino., 2015, p. 175).
In their 2015 paper, these authors propose six factors to be considered when designing treatment programs.
- Tendon pathology
- Severity of pain and disability
- Central sensitisation
- Concomitant neck and shoulder pain
- Neuromuscular impairments
- Work related and psychosocial factors.
- Where on the tendon pathology continuum is your patient?
- Cook & Purdam have used this continuum to show how treatment can differ specifically with regards to exercise prescription.
- Behind this continuum is a second question. Can you decide where on the continuum your patient lies and therefore do you know what to educate your patient about load management?
Severity of pain and disability:
Here we need to consider how our clinical examination correlates with the patient-reported severity and level of disability (taken from the PRTEE). This helps us to make predictions about prognosis and intensity of treatment.
One aspect of LET that adds to it’s complexity is the presence of altered pain processing and central sensitisation. As with many other chronic pain conditions, patients may develop secondary hyperalgesia (seen as reduced pain pressure thresholds), cold hyperalgesia (see with cold sensitivity on ice tolerance tests) and other features of cortical reorganisation. What this means is that if central sensitisation is present, the clinical presentation may not be as clear and assessment not as predictable as just tenderness on palpation over the CEO, weakness and pain with resisted wrist/finger extension and altered grip.
With the discussion around pain processing only increasing, I wonder if it is time we start assessment left and right discrimination in conjunction with cold sensitivity? Especially in patients with severe pain and disability, taking a graded motor imagery approach and training left/right discrimination may offer a novel way to retrain cortical representation of the elbow and movements of the wrist and lower arm. This is just a thought flowing over from my previous reading about graded motor imagery and while no papers include this as a treatment, I feel it is plausible to argue that they should.
Concomitant neck or shoulder pain:
Maitland taught us to assess the joints above and below and with LE we need to carefully consider involvement of the neck. While the CEO muscles are innervated by branches of the radial nerve (C7/8), it is C4-7 that can become symptomatic and involved in LE (Coombes, Bisset, & Vicenzino., 2015, p. 942). It is important to consider treatment of the neck and shoulder for this condition but also how these musculoskeletal comorbidities may impact the rehabilitation and exercise prescription for LE.
The focus here is to address painful grip and weakness through the forearm extensor muscles. We’ll look at this more closely in the next section but for now just consider that we may need to be looking at contributing factors from the shoulder, elbow, forearm as well as local muscle strength and motor control.
Work related and psychological factors:
The last treatment consideration proposed in their 2015 paper is the ‘psycho-social’ contributing factors to LE such as work postures, loads, repetitive movements and other factors. These are all so important to successfully managing the load of the tendon and education of your patient. Yellow flags such as anxiety and depression are also important considerations for treatment and may impact prognosis.
Let’s take a moment to introduce Brian Mulligan and his techniques. Brian Mulligan, a New Zealand Physiotherapist is widely known for his contributions to our profession, SNAGs, NAGs and MWMs. For the peripheral joints specifically we are most interested in mobilisation with movement (MWMs).
“There is nothing new in mobilisation and nothing new in movement to be dealt with in this section. It is the combination of the two modalities that is being advocated” (Mulligan., 2004, p. 87).
For lateral epicondylalgia we are interested in two MWM treatments; the lateral glide of the humeroulnar joint and the posteroanterior glide of the radiohumeral joint. Both of these techniques involve the therapist performing a passive accessory glide with/without a seatbelt while the patient performs a pain-producing active movement in conjunction with the mobilisation (Coombes, Bisset & Vicenzino., 2015, p. 944). The biggest factor emphasised by Mulligan in his book is that these techniques shoulder produced a large reduction in pain (at least 50%) to justify their use. This is why the technique is often seen done with a grip dynamometer as the active component, so that pain and strength changes can be measured during the technique to provide objective evidence of it’s effect.
In his 2003 masterclass, Bill Vicenzino discusses in detail many manual therapy and exercise techniques. What I particularly enjoyed was the reasoning behind choice of technique. Vicenzino describes a systematic approach based on five patient presentations:
- Pain-free grip strength deficit is much larger than pain elicited on direct palpation of the lateral epicondyle.
- Pressure pain threshold deficit is larger than the pain-free grip strength deficit.
- There is a similar magnitude of deficit in pain-free grip strength and pressure pain threshold.
- Past not current history of cervical spine-related pain or dysfunction.
- Night pain.
For each of these categories a different treatment rational is presented. Using the ulnar glide MWM (sustained lateral glide with pain free grip) is discussed for patients in category 1 i.e. when a pain-free grip strength predominates. This technique is indicated for use when there is pain over the lateral elbow with gripping that is worse that the pain felt with direct palpation of the lateral epicondyle (Vicenzino., 2003, p. 71). This technique can be done by the therapist, applied as a taping technique or done as a self-treatment by the patient. All are discussed in detail in the 2003 masterclass.
A few technique tips (Vicenzino, 2003, p. 71):
- Be sure that the stabilising hand doesn’t compress the lateral epicondyle.
- Use only if there is a significant amount of pain relief.
- Aim for a pure lateral glide but if this doesn’t produce pain relief then try explore a slightly more posterior angled glide.
- Don’t release the glide before the active movement as been relaxed.
- Don’t be overly vigorous – especially if you use a seatbelt to produce the glide.
If patients have a poor response to this sustained lateral glide MWM then clinicians may wish to try the posteroanterior glide of the radiohumeral joint as an alternative treatment. Both of these treatments are done with the arm supported on a treatment table, the arm internally rotated and the forearm pronated. The direction of the glide is a PA glide of the radiohumeral joint with the therapist’s thumbs overlapping each other. Just be careful that the contacting thumb doesn’t create a pressure pain over the treatment area.
Alternative techniques discussed for the remaining categories in this masterclass include: high velocity thrust for the elbow, lateral glide of the cervical spine, sustained contralateral transverse pressure of the cervical spine during upper limb movements, and diamond taping of the elbow.
A central focus of management is exercise prescription, which one to choose and what dosage to give? It is likely that no single exercise and dosage is going to suit all patients and the research doesn’t provide a definitive answer either. Therefore, it is ok to assess each patient and see if they response more favourably to eccentric or concentric loads.
“For patients with reactive tendinopathy or irritable symptoms, gentle, painfree isometric contractions of 30 to 60 seconds in duration, performed daily, with the wrist in 20-30 degrees of extension and the elbow in 90 degrees of flexion, may be more appropriate” (Coombes, Bisset & Vicenzino., 2015, p. 944). Concentric and eccentric exercises of the wrist extensors are advocated in the literature for LE patients that are in the degenerative stage of tendinopathy. With degenerative LE, “pain 3/10 may be acceptable during exercise, but not the following morning” (Coombes, Bisset & Vicenzino., 2015, p. 945).
This week Peter Malliaris, author of the Tendinopathy Blog wrote a great article on this topic and exercise prescription. He spoke about a new research trial looking at the combination of concentric-eccentric with isometric exercises for LET and found this combination to be more successful. Check it out here.
Wrist extension exercises can be done with the forearm resting on a table/bench and with the shoulder in a supported position. Each exercise should be done slowly i.e. 6-10 seconds per a repetition.
Supination/pronation exercises can be done with an imbalanced dumbbell/ golfclub/ hammer. The elbow is generally flexed to 90 degrees and stabilised beside the trunk. Again repetitions are done slowly over 6-10 seconds.
With exercise prescription posture is very important. No pain is recommended. Movements are slow. Dosage needs to be tolerated and adequate for strength gains. Allow for sufficient rest of 1-2 minutes between sets. Delayed onset muscle soreness is not a goal.
“In summary, despite conflicting findings, there was evidence from several RCTs of sound methodological quality that exercise may be more effective at reducing pain and improving function that other interventions such as ultrasound, placebo ultrasound, and friction massage, but there may be no difference in effect between different types of exercise” (Bisset & Vicenzino., 2015, p. 175). The authors remind us that successful rehab requires clinical reasoning and choosing a treatment that addresses the physical impairments found during the clinical exam.
What to remember about Lateral epicondyalgia
- It is a self-limiting condition.
- We no longer call it tennis elbow.
- LE involves changes in the muscles, tendons and our pain processing systems.
- It is likely to resolve with time and adequate rest which means tendon loading management.
- Try address load management before treatment to reduce pain and disability.
- Avoiding pain-provoking activities is important in early stages of rehabilitation.
- Addressing ergonomic factors is critical.
- If symptoms don’t improve with 6-12 weeks of appropriate wait-and-see then a multimodal treatment should begin only in a low risk patient.
- You will likely treatment patients for 8-12 weeks to address all contributing factors.
- “Stress-shielding may predispose specific regions of the tendon to structural weakening, making it more susceptible to overload” (Coombes, Bisset & Vicenzino., 2009, p. 253).
- The complexities of trying to successfully manage this condition are mirrored by the wide variety of treatment strategies offered in the literature (Vicenzino., 2003).
- Understanding how the manual therapy treatments and exercises are intended to be used is paramount to the success in implementation. Specificity and quality are key.
- From a pain relief perspective, Mulligan’s MWMs are well advocated.
- From a muscle restoration and conditioning perspective, wrist eccentric extension, forearm pronation and supination, and looking proximally at the biceps/triceps and shoulder muscles are all important to consider.
When it comes to lateral epicondylalgia, there is no quick fix or solution. There is no substitute for a thorough examination but hopefully these two blogs have shown what we need to assess for and how we can use this objective information to specifically tailor treatment approaches. While researching this condition I was reminded again that treatment will always take more thought and more time that you think. Have patience. Nothing complicated was solved quickly.
Amro, A., Diener, I., Bdair, W. O., Isra’M, H., Shalabi, A. I., & Dua’I, I. (2010). The effects of Mulligan mobilisation with movement and taping techniques on pain, grip strength, and function in patients with lateral epicondylitis. Hong Kong Physiotherapy Journal, 28(1), 19-23.
Abbott, J. H., Patla, C. E., & Jensen, R. H. (2001). The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Manual therapy, 6(3), 163-169.
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Coombes, B. K., Bisset, L., & Vicenzino, B. (2009). A new integrative model of lateral epicondylalgia. British journal of sports medicine, 43(4), 252-258.
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