Epicondylitis

[Physiobase]

Heard somebody talking about a massage with ice on the affected area as a treatment on patients with epicondylitis. Anobody that knows if this is a method that is usable? posted by lottiss

[alophysio]

Hi!

Read an article by Dr Bill Vincenzino from Manual Therapy on Lateral Epicondylalgia (?2003). Link is below...

www.sciencedirect.com/sci...e923271d50

In it he states that epicondylalgia is a misnomer since research shows that inflammatory markers are not present during dialysis of the L/E.

Ice massage is just like icing the joint. Ok if it is acute or for temporary pain relief.

I use Sustained Lateral Glides With Pain-Free Grip (SLGWPFG) and Sustained Lateral Glides With Pain-Free Movement (SLGWPFM) to good effect. They are Mulligan Techniques and are covered in the article by Vincenzino.

I have developed a protocol based on the article - if you are interested in it, email me at alophysio@hotmail.com.

As for the article, i suppose you could email him and he might send it to you (?) or get it from your library? His details are listed on the article link above.

I agree with the previous writer. That is, the approach by Bill Vicenzino which uses the Mulligan approach of mobilizaton combined active painfree movement, and followed with strengthening exercises--- works.

[alophysio]

Hi,

I would just liket to add that many people have asked me for the protocol and i sent it on with the only proviso that they provide feedback on it...

I have officially have had *NO* responses.

It is quite disappointing since I didn't ask for much. I would prefer the feedback only because if someone has anything valuable to add, i would like to *share* this information.

The alternative is to ask people to pay for my time...

Thank you for letting me express my disappointment.

[Physiobase]

Hi alophysio

Perhaps you should ask for feedback via the email addresses you used to send them your protocol. This is not really the place to let out any disappointment with them as they probably aren't reading this post again. It has after all only been 8 weeks and I am sure that in eight weeks very few, if in fact any, would have had any body through the clinic that would be appropriate to "trial" the approach on.

Anyway if you do email them and get any feedback then please do post it. Also ask them to post their comments and feedback directly. Oh and if you would like to share in a more open way why not post your protocol here in the forum. Afterall all that is what we are trying to do - get everyone to share information and not buy it.

[somasimple]

hi All,

Alophysio, the abstract is too short and I can't get the interest of the method sionce it is not described in it.

Have you the paper? Caould you send it via email?
Thanks in advance.

[alophysio]

Dear Somasimple,

A SLGWPFG is listed below. It involves stabilising the humerus from the lateral side then gliding the Radius/Ulna laterally then asking the patient to grip something (preferably a grip dynamometer)

A SPAGWPFG is listed below. It involves finding the radial head and applying a PA glide (from an anatomical position perspective). That usually means that if the patient is supine with palms flat on the bed, you would glide the radial head from the lateral side to the medial.

SLGWPFM and SPAGWPFM is basically the above but instead of gripping, you ask the patient to move into flexion or extension.

Any questions, just post them.

Dear physiobase,

In the interest of sharing information, here is my protocol - as requested...I am sorry but transferring the nice format I had in Word to here doesn't come thru so easily... Is there a way to post a PDF file to be downloaded?

My only request for this protocol is that if you use it, please reference it properly...

Copyright Antony Lo (2005) – Developed mainly from Vicenzino, Bill (2003) Lateral Epicondylalgia: A Musculoskeletal Physiotherapy Perspective. Manual Therapy 8 (2) : 66-79 and various course notes on "Tennis Elbow"
Lateral Epicondylalgia
Treatment Protocol

Subjective Examination Points to Note:

* Body chart:

* History:
* Onset
* When
* How
* What Symptoms:
* Then
* Now

* Risk Factors:
* Training Error (eg. Technique, fitness, periodisation)
* Equipment Faults (eg. Recent changes, inappropriate equipment)
* Biomechanical (eg. Trunk, shoulder girdle, local)

* Aggravating and Easing Factors:
* Functional Interference
* Activity
* Position

* Pain Questionnaires:
* 5 Functional Activities Pain VAS
* Patient-Rated Elbow Questionnaire (MacDermid 2001)
* American Shoulder and Elbow Surgeons – ASES-e

Objective Examination Points to Note:

* Observation:
* Habitual movement patterns or postures
* Carrying angle

* Muscle Bulk / Atrophy / Hypertrophy / Swelling

* Functional Activity Evaluation (Commonly involves gripping)

* Motion:
* Active and Passive (F, E, Sup, Pron, CM ± WB/Distraction)

* PAMs:
* Positional Fault
* Movement Impairment
* Reactivity

* Muscle Tests:

* Stress Test:
* Stability (eg. Varus, valgus, PLRI)
* Diagnostic Specific
* Condition Specific
* MWM

General Treatment Goals

* Restore Muscle Function
* Early and Substantial Pain Relief
* Manual Therapy
* Tape
* Self-Treatment
* Endurance Base First
* Strength Second
* Restore Motor Function (Functional Basis)

Manual Therapy

* General Principles:
* x6-10 reps MWM provided there is substantial pain relief and no latent pain
* Apply glide, patient either grips or moves elbow, release glide

* If Pain-Free Grip (PFG) Strength Deficit predominates over (Or Equal To) Pressure Pain Threshold (PPT):

* Step One:
* Painful Grip:
* Elbow SLGWPFG ± Belt (Sustained Lateral Glide With Pain-Free Grip)
* Painful Movement:
* Elbow SLGWM ± Belt (Sustained Lateral Glide With Movement)
* Step Two (If Step One Not Effective):
* Radio-Humeral Joint SPAWPFG (Sustained PA-glide With Pain-Free Grip)

* Step Three (If Step One and Two Not Effective):
* HVTRHJ (High Velocity Thrust to the Radio-Humeral Joint)

* If Pressure Pain Threshold (PPT) predominates over Pain-Free Grip (PFG) Strength Deficit:

* Step One:
* Evaluate C/S and Upper Quadrant Neural Structures and Treat Abnormal Findings
* Elvey’s Lateral Glide of the C/S (C5/6/7)
* C/S or T/S STWULM (Sustained Transverse-pressure With Upper Limb Movement)

Taping:
* Painful Grip:
* Tape For Elbow SLGWPFG Manual Technique
* Tape to be applied with SLGWPFG
* Tape from medial to lateral, inferior to superior across cubital fossa
* Painful Movement:
* Tape For Elbow SLGWM Manual Technique
* Tape in Elbow Flexion if Extension painful
* Tape in Elbow Extension if Flexion painful
* Tape to be applied with SLGWPFG
* Tape from medial to lateral, inferior to superior across cubital fossa

* Tape For Radio-Humeral Joint SPAWPFG Manual Technique
* Tape to be applied with SLGWM
* Tape #1 from lateral to medial, posterior to anterior around radial head to anterior aspect of ulna
* Tape #2 from lateral to medial, posterior to anterior across cubital fossa to posterior aspect of humerus

* Diamond Tape of the Elbow
* For lateral elbow pain present most of the time
* Particularly useful for resting pain or pain at night
* All tape to be from inferior to superior in direction
* Tape #1 and #2 from common lateral aspect of the forearm to anterior and posterior joint-line of elbow
* Tape #3 and #4 from anterior and posterior joint-line to common lateral aspect of the humerus


Self-treatment
* x6-10 reps provided there is substantial pain relief and no latent pain
* Patient applies glide, either grips or moves elbow, release glide
* Painful Grip:
* Elbow SLGWPFG ± Belt (Sustained Lateral Glide With Pain-Free Grip)
* Patient to apply lateral glide to forearm while blocking humerus with belt or against a doorjamb or corner of wall then produce a pain-free grip

* Painful Movement:
* Elbow SLGWM ± Belt (Sustained Lateral Glide With Movement)
* Patient to apply lateral glide to forearm while blocking humerus with belt or against a doorjamb or corner of wall then produce a pain-free movement

* Radio-Humeral Joint SPAWPFG (Sustained PA-glide With Pain-Free Grip)
* Patient to apply PA glide to R-H Joint then produce a pain-free grip

Exercise Programme:

* Stage 1: Endurance Base

* Stage 1a: For most patients…
* Load = x12-15 Repetition Max (RM)
* x8secs (4secs up/ 4secs down)/rep
* x12-15 reps/set
* x1-2mins rest between sets
* x3 sets/session
* x1 session/day
* Progress to Stage2

* Stage1b: For deconditioned patients with DOMS after doing Stage 1a…
* Load = x12-15 Repetition Max (RM)
* x8secs (4secs up/ 4secs down)/rep
* x12-15 reps/set
* x1-2mins rest between sets
* x1 set/session
* x2 sessions/day
* Progress to Stage 1a


* Stage 2: Strength Base
* Load = x6-8 Repetition Max (RM)
* x8secs (4secs up/ 4secs down)/rep
* x6-8 reps/set
* x1-2mins rest between sets
* x3 sets/session
* x1 session/day
* Progress to Stage 3


* Stage 3: Restore Motor Function (Functional Basis)

* The exercise to be done are functional tasks
* Load = x6-8 Repetition Max (RM)
* x6-8 reps/set
* x1-2mins rest between sets
* x3 sets/session
* x1 session/day
* Progress to heavier and harder tasks

Exercises:

* Load Type:&nbsp &nbsp &nbsp &nbsp
* Isometric
* Eccentric Only
* Theraband
* Free Weights
* Theraband Flexbar
* Core Set of Exercises:&nbsp &nbsp &nbsp &nbsp
* Wrist F&nbsp &nbsp &nbsp &nbsp
* Wrist E&nbsp &nbsp &nbsp &nbsp
* Wrist RD
* Wrist UD
* Wrist Supn
* Wrist Pron
* Gripping (With Theraputty/Grip Dynamometer / Eggserciser)
* Other UL Exercises:
* Tricep Extensions
* Bicep Curls
* Chest Press
* Shoulder Press
* Bent-Over Rowing
* Scapula Retractions
* Any others you feel are appropriate&nbsp &nbsp &nbsp &nbsp &nbsp &nbsp &nbsp &nbsp

Patient Information Sheet:

* Most “Tennis Elbow” problems are treatable using physiotherapy.

* Your physiotherapist will use:
* “Hands-on” manual techniques
* Taping
* Teach you how to treat and tape yourself at home
* Teach you how to do exercises and stretches at home to help your arm strength
* Research has proven that this system we use IS EFFECTIVE.

* Your physiotherapist will need to see you for 2-3 sessions for the first week
* This is to:
* Assess and begin manual therapy and exercises
* Teach you how to treat and tape yourself at home
* Teach you how to do exercises and stretches at home to help your arm strength

* Your physiotherapist will then need to see you for 1 session every week/fortnight
* This is to:
* Review your exercises and self-treatment to make sure you are doing them correctly
* Progress your exercises and stretches as you get better
* Make sure you are actually doing your exercises

* Your physiotherapist will not use:
* Ultrasound, Laser or any other machines
* Massage or “frictions”
* Voltaren or Feldene gel
* Research has proven that these treatments DO NOT HELP your condition.

* It is important to understand that during the programme, there should be no pain !
* Please tell your physiotherapist if you are getting pain during treatment and they will stop.
* When you do your self-treatment at home, you SHOULD NOT get pain – Stop if you do !
* When you do your exercises at home, you SHOULD NOT get pain – Stop if you do !

* It is important to understand that you will feel good during and after your treatment and self-treatment at home but the pain will come back for about 3 weeks.

* THIS IS NORMAL !!
* STICK WITH THE PROGRAMME !!
* Research shows that this programme will be effective in gaining a long-term solution to your pain

* It is important to follow the exercise programme your physiotherapist gives you.
* You will see stable strength improvements within 3-6 weeks.

* You should avoid:
* Picking up objects with your palm facing down
* Any activity that aggravates your symptoms

* You should do:
* Your exercises
* Your stretches
* All activities that do not aggravate your symptoms
* Listen to your physiotherapist !!

If you have any questions or concerns, please ask your physiotherapist or call **** on ********.

Thank you !

[alophysio]

Having reviewed the post above, I noticed that the nested levels did not come through well. Please note that there are indents that i put in there that did not appear in the post...Sorry!

[Physiobase]

Thanks alophysio for sharing the above protocol.

You can post messages in an html format to keep indents etc. To do this you must first click the html radio button at the top of the message window when posting. This would give you more freedom.

You could also put a pdf download link if you have the document on a server somewhere where it can be downloaded. If you don't have this access we would be happy to host the document for you, just email it to physiobase@gmail.com, regards PhysioBob

[alophysio]

Thanks physiobase... Sending you the PDF file...

Hi, me Bikash in Bangalore,India. With my own research work with the Orthopaedics, I used Cryotherapy arm bags(-15degree C),Ultrasonic therapy and MF Surged current through Gynma Uniphy Phyaction (guidance E) equipment(Holland) by 2 electrodes.This gave me best satisfactions.Provided the patient is sincere to his treatment schedules.
bikuda2003@yahoo.co.in

[alophysio]

Hi.

I am sorry but electrotherapy is a waste of time. There is no evidence that it works in epiconylalgia.

If you are doing research on this, please get a hold of the article mentioned above for a good review of the treatment options.

This protocol works. However, it depends on both the physio and the patient knowing what they are doing!

[arkesh_physio]

i agree to alophysio that electro is ineffective in case of epicondylitis.i find maitlands technique very effective.
alophysio's article is very informative.

[arkesh_physio]

.

I totally agree with allophysio... electrotherapy though the only thing taught at UG level in india.. is a time waste..
I treated a patient with epicondylitis with US for 8 -12 sessions and got no results and using mobilizations and manual therapy the guy was showing fast improvement..
With electrotherapy, we're just like technicians.. we need to take physitherapy beyond a set of 6-8 machines.. its more of a healing touch that is reqd...

I often teach my patients with acute lateral epicondylitis to do ice massage. I find that most people tolerate it more than holding a gel ice pack in place. I get them to hold an ice cube inside a face cloth and rub it over the area until it melts (be sure to place a towel under the elbow to collect the water).

Willeseden