Tennis Elbow

Hi,
I have had numerous patients with chronic tennis elbow who seem to have little or no improvement with physiotherapy.
I have tried MWM's (mobilisation with movement, a Mulligan technique), taping, stretches, soft tissue massage, trigger point work, pain free isometric strengthening progressing to eccentric strengthening, neural glides and deep friction massage.

Are there any other techniques that anybody has success with?

A number of physio's that i have spoken to also seem to also struggle to improve chronic tennis elbow.

Any advice would be much appreciated.

hey physio7,
I prefer dealing with a specific patient than speaking generally. You can start with his problems by good examination then treat every problem. I think using the same programe for every patient is wrong. So, please chose one patient and examin him carefully and tell us his history and problems and we can discuss his case together.
good luck!

Hi,

With all due resepct, have you been trained in doing MWMs and the other techniques or just tried what others have shown you?

I ask this because I was on a one day course for tennis elbow run by Bill Vincenzino who has written a great masterclass article in Manual Therapy 2003 (?). So we were there with this author and clinician who explained and showed and taught us the techniques that thre were STILL people on the course who couldn't get the techniques right, even with an awesome tutor.

Persist. Also, I have put a protocol on this forum somewhere (?help physiobob?) search for it under lateral epicondylalgia (LE).

BTW - the most of the above techqniues work well fr chronic and acute LE - the logical conclusions are:
1. All your LE patients outliers (not likely)
2. They don't have LE (possibility)
3. You don't do the techniques right (also a posibility)

Whenever i come up stuck like you seem to have, i always start at point 3 and work my thru it...

Good luck!

Hi
I think if you did the treatments right, you did your best. The problem with lat. epicondylitis is that it is no -itis, no inflammation. It is a degenerative overuse process caused by repetetive micro trauma. in early stage it can be treated with several techniques but in later stage (chronic) surgery is indicated most of the time to reduce the tension on the common extensor muscles tendon.
dont want to rob your illusions, but in chronic stage its gonna be a hard way to treat conservatively.
cheers

Dear ALOphysio
Thanks for the advice. I have not been formally trained in MWM's I have been taught by colleagues.
I recently found your protocol in a previous post.
I found that with a patient when i have attempted MWM lateral glide there was an increase in pain free grip strength but there would still be some pain as he gripped strongly. Is this normal or should there be no pain at all if this technique is to be successful.
The techniques i used were based on the pictures from Mulligans book. The patient is now performing pain free grip with his own lateral glide as a self treatment at home.

Do you have any pictures to go with the taping techniques. Most of the taping I have seen is to unload the tendon rather than sustaining a lateral glide.

Could you describe the positioning PA glide to the radiohumeral joint. and the self treatment technique for the patient.

Lastly i didn't understand your comment
"1. All your LE patients outliers (not likely)" could you explain what you mean by this.

Thanks again for your assistance.

hi its great to see your question on tennis elbow.
why cant you try with muscle setting exercise.even i have got very good results with his manure on patients, even on those pts who has undergone steroidal therapy without any results.
so better to try with this. its my advice.

Can you explain what you mean by "muscle setting exercise"

Hello Physio7 :

On the web ,there are free videos for mulligan,s techniques and specifically the gilde .take this link http://www.youtube.com/results?searc...igan+Technique

You will find exactly what you want .

Cheers
Emad

Hi, You can try dry needling on the epicondyle, assess Cervical spine, Thoracic spine and shoulder girdle.

All the best

muscle setting exercise is very simple one. it is well described in any exercise therapy book. i mean do u hav exercise therapy book by have & colby.it is best given in that.

forgive me. what are MWMs.

I have been succeful with the traditional techniques ie.,hotpack, massage (petrisages or trigger point massages) plus ultrasound.
THIS DOES NOT RULE OUT THE IDEA OF ASSESSING EACH PATIENT SEPARATELY FROM OTHERS AND GIVING TREAMENT BASED ON A THOROUGH ASSESSMENT.

MWM = Mobilization With Movment

Cheers
Emad

I would totally concur with Wutti 's comments. In chronic cases of tennis elbow the tendon has been shown to be degenerative and acutely inflammed. The evidence base to support the use of ultrasound and manual techniques in chronic forearm tendonopathies is very poor. The most evidenced based form of treatment is progressive eccentirc extensor loading and extensor stretches, there is also reasonable evidence to support the use of a forearm clasp. Clinically i have foud these methods to be beneficial, however i would suggest that there is an element of natural lifespan to this pathology.

Dear ALOphysio Thanks for the advice. I have not been formally trained in MWM's I have been taught by colleagues. I recently found your protocol in a previous post. I found that with a patient when i have attempted MWM lateral glide there was an increase in pain free grip strength but there would still be some pain as he gripped strongly. Is this normal or should there be no pain at all if this technique is to be successful. The techniques i used were based on the pictures from Mulligans book. The patient is now performing pain free grip with his own lateral glide as a self treatment at home. Do you have any pictures to go with the taping techniques. Most of the taping I have seen is to unload the tendon rather than sustaining a lateral glide. Could you describe the positioning PA glide to the radiohumeral joint. and the self treatment technique for the patient. Lastly i didn't understand your comment "1. All your LE patients outliers (not likely)" could you explain what you mean by this. Thanks again for your assistance.

Thanks for your question Physio7. I apologise for the delay - didn't find it until now!

1. Taught by collegues is obviously not the same as being taught by trained teachers of Mulligan's. In my experience, most people (including myself!) get something wrong is the APPLICATION of the technique. This is where it is an art and not a science.

2. If it is at all possible, go on a course. The increase in painfree grip means that you are doing this technique CORRECTLY. Lateral epicondylalgia means lateral epicondyle pain. There is no -itis, that is NO INFLAMMATION located at the epicondyle. There have been studies done on this which looked at PGE2 (inflamm marker) vs Glutamate (neurotransmitter) and it showed that Glutamate is present and that PGE2 is ABSENT. This is true for LE as well as Achilles Tendinopathy. See Alfredson et al (2000) in Acta Orthop Scand 71(5):475

The MWM protocol (Mulligan's, not mine) states that a 50% reduction in pain must be achieved to ensure good outcomes. The fact that your patient is getting less pain on gripping but some pain at his max grip just means i would work him at 80% of the painfree grip strength (like 80% of weight) - see protocol on this site/discussion.

3. It is great that you have sent your patient off with that self-treatment. I was under the impression that the book had the diamond taping, the 50% reduction rule and the PA glide...?

PA Glide is simple. Place the patient's hand palm down. You should see the Lateral Epicondyle. Find the radio humeral joint line. Then slip between the ridge of ulna and the head of the radius (RU joint). Usually the joint sufaces of the RU joint are now relatively horizontal. Then push from this area (posterior surface if in the anatomical position) to the volar surface of the elbow/forearm/RU joint (anterior surface in anat pos - therefore a PA glide).

I somehow made that sound much harder than it really is!

4. With respect to your home programme of your patient, my protocol also lists a number of weight based exercises to be done at 80%max (i think that is in there...) Have you sent him home with these?

5. My statement about all your LE patient's being outliers (not likely) was in response to your frustration that you have tried all the things you have listed and they are not working. I was trying to point out that the 3 logical conclusions were

1. they are outliers - in other words, patients who do not respond to the treatments listed - this is unlikely because not every patient is an outlier (defeats the meaning of the word!). Research has shown a lot of those techniques DO work. I mention this because it is still a possibility but maybe you should consider the other possibilities...like

2. They don't actually have LE. This is also possible. Think about the variety of structures in the area. The neck, radial nerve, other muscles, etc. But the symptoms are pretty clear cut - use the Pressure Point Threshold or Pain-Free Grip is the protocol to classify your patients better to get better outcomes. Otherwise, and i think this goes for most of us...

3. You just might not be doing the techniques (MWM etc) right. This is especially true if you have colleagues showing you techniques. Especially true if you have colleagues who also cannot get these patients better. Do you know what i mean? Find someone who fixes tennis elbow and watch them work. What they do is not very different but it is the ART of the technique that counts. Best to go on a course where someone has been trained by Brian Mulligan himself and has his proper recognition as a trainer of MWM rather than someone who has just gone on a course and is now running a course (or showing colleagues). Of course, if that person is good and can show you what you may be doing wrong, then listen. If they can't get people better, why do you also want to learn that (how not to get people better).

Now onto some other comments...

Wutti, i don't think surgery is indicated for chronic patients unless they have done the protocol first and given it a real go. i have helped lots of chronic people get back to their ADLs even after years of avoiding aggravating activities like tennis etc. Most patients are caught in a cycle that needs to be broken. We uses the manual therapy and exercise to break this cycle and recondition our patients.

But i have to disagree with you Matt4Physio. Chronic conditions have been definitively shown NOT to have inflammation (Wutti's comments also agree with me on this). I apologise if you have a typo there... as for the evidence, a clinician and researcher Bill Vincenzino is doing a lot of research about Mulligan's techniques and building up the evidence base for them. Clinically they work - Bill will be the first person to tell you though that you have to have the patient diagnosis and classification right in order to get good outcomes. e.g. acute ankle sprain would probably not respond to heat packs to the neck - you use the right treatment for the right condition.

I just did a PubMed (Medline) search on just "Vincenzino". Have a look at the articles there on various areas (C/S, Shoulder, Elbow, Ankle, Foot, Pelvis, etc...

His review on LE is found at Man Ther. 2003 May;8(2):66-79. Review. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective.

With the inflammation, Alfredson is a very well respected researcher and is famous for his Achilles Tendon programme which led to eccentric loading exercises etc. He has found that in LE, there is not any PGE2 (inflammatory marker) present in the ERCB tendon via microdialysis. See Alfredson et al (2000) in Acta Orthop Scand 71(5):475

Therefore, i have to strongly disagree with your statement that inflammation has been shown to be present in Lat Epicondylitis/alagia/etc

You are right when you say that U/S is not beneficial for LE - the evidence is equivocal but manual theapy (by this i mean MWM) on the other hand at least has some evidence to support its use. See Vincenzino's articles, including the review, via pubmed(medline). As does the eccentric programme etc that is including in the protocol above (whic i may have put together but obviously influenced by being taught by Bill Vincenzino.)

But enough from me, What do others think?

Hi, I do agree with alophysio that probably all the patients have not been LE.I have come across many patients in my clinical practice where they do not respond to the conservative methods of treating a LE, primarily because they have the s/s of LE & thats where it end. The pathology is elsewhere. Most are +ve for neurodyanamics, +ve for the radial nerve. Just releasing this would relieve the patients of all their symptoms. I have also come across situations where the problem is at the C6/7 spine, referring the pain to the lateral epicondyle. Mobilising it gives immediate relief to the patient.

have you tried using a lateral epicondylitis arm cuff/clasp?? Might be worth a shot

Hi,

A lot of people do use them but i don't think they really address the problem. Some fo the studies compare the braces to physiostherapy but i do not think the physiotherapy treatment they use is the Mulligans treatment but rather the "standard" treatment of massage, U/S, heat, exercises etc.

It would be interesting if someone wanted to do a study comparing the two...

From a purely experience point of view, the braces help temporarily but i find that specific taping and the MWMs along with the conditioning programme and stretches as outlined in the protocol are the best so far...

I mentioned the protocol but realise it is not on this thread so i put it here again...

Protocol located at physio forum threadhere

Otherwise, you can download it here...The discussion in the thread listed was when Physio Forum was hosted differently and made uploading more difficult. But the file uploading is so much simpler now!!!

Please remember that this is not a magic reciepe. It is simply an aid to assist in the assessment and treatment of LE. It does not replace good clinical reasoning.

It also does not mean you now know how to do MWMs now that you have read a description of it. Please spend the little money it costs to do a proper Mulligans course and learn it properly under expert tuition. It is an art so you need to see how someone who knows what they are doing does it and get correction from them.

Thanks. Comments and questions always welcome.

Originally Posted by alophysio Hi, A lot of people do use them but i don't think they really address the problem. Some fo the studies compare the braces to physiostherapy but i do not think the physiotherapy treatment they use is the Mulligans treatment but rather the "standard" treatment of massage, U/S, heat, exercises etc. It would be interesting if someone wanted to do a study comparing the two... From a purely experience point of view, the braces help temporarily but i find that specific taping and the MWMs along with the conditioning programme and stretches as outlined in the protocol are the best so far...

my friend is currently doing his masters thesis looking at the effect of the cuff on EMG activity of the common extensor origin during submaximal exercise- I'll let you know the outcome when he finishes the study!

aplolgies allophysio it was indeed a typo and was meant to read 'not inflammatory,

thanks

Thanks for all the posts.

I have also had people using clasps to varying levels of benefit. One of the main problems I am finding is that the people who are presenting with tennis elbow are often self employed tradesmen who have to continue work which often aggravates there problem. I have foun braces/clasps useful for these patients as it can help relieve the strain of work.

I do agree ALOphysio about the need to be trained properly and i will look into this in the future.

Do you use the same principle for golfers elbow?
Do you use different MWM?

pressure pain threshold (ppt) is talked about tin the protocol what does this mean.

Hi,

The MWM principle is usually applicable to most joints. The idea is to push the joint in such a way that it produces movement with >50% pain reduction. It can be used successfully with medial epicondylitis as well.

PPT (pressure point threshold) is where researchers developed a machine that applies a measurable force on to an area. The point at which pain is produced is noted. IN other words, is the area more sensitive to touch than to movement or gripping? These patients walk around protecting their elbows from people bumping it and don't readily allow you to touch it. They say the pain is unchanged when gripping or moving or it gets worse in a way that deosn't seem consistent with a movement based pattern.

For these people, central sensitisation is probably a big thing which is why Elvey's lateral glides are part of the treatment. A lot more C/S treatment in these people.

It is all about getting the right diagnosis then classification in order to provide the correct treatment and rehab.

THanks - i hope it helps!

I often find treating the neck and radio-ulnar joint at the same time helps.

This is becoming a useful post guys so thanks for the input. Just so you know there are a few older posts with some other information on tennis elbow, causes and treatment. Take a look in the TAGS section at the top navigation bar and click on Tennis Elbow.

hi.. try modalites like short wave, ultra sound, hydrotherapy, cryotherapy, infrared.. all the modality ised to decrease muscle spasm