Tennis elbow

[Physiodawn]

Chronic tennis elbow appears to be quite variable in its response to physiotherapy treatment.
Up until now, if the ULTT are negative I have treated the tendonopathy with local treatment with mixed results.
:hat

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[mageshanand]

hey have you tried taping for tennis elbow, it gives quite good results. thats an option which you can consider, the next time when some one comes to you with tennis elbow

[handson]

Would you mind elaborating on what taping you use? Just circumferential to mimic a brace, or more unloading or kinesio taping?

[Physiodawn]

I tend to use a taping technique that 'lifts' the musclulo-tendonous and shifts it laterally. This effects the line of pull on the tendon. I have had some success with this taping technique but no in every case.

I do local treatments with frictions to the tendon if its chronic, and I apply ultrasound to the tendon and accupressure to any trigger points .

I have used the Mulligan MWM: lateral glide+ resisted wrist extension or power grip. The theory behind this is that the line of pull in incorrect on the wrist extensor muscled and the MWM corrects this line of pull. It can reduce pain on the resisted muscle action but does not seem to give lasting results.

If ULTT reproduces symptoms I treat the neck/thoracic/shoulder girdle as appropriate.
Does anyone look to upper limb mechanics as a primary treatment of tennis elbow in every case?

[Physiobase]

Why do they have tennis elbow? Do they play tennis? or its it pain the the region of the proximal radioulnar joint. Perhaps if we can find the cause here that might shed better light on the best treatment. Are they doing anything particularly wristy, Do they have poor proximal shoulder control that causes an over-activity in the forearm extensors? I would start to look for these contributory factors.

I agree with the unloading principal of taping to facilitate reduction in pain while things 'heal' and the mechanics of the movement are addressed. 8o

[Bravocosta]

Greetings...

In the case of so called "tennis elbow" it is important to consider treatment beyond locally treating the elbow site as it is prone to recur. Check carpal gliding with wrist extension, pronation supination ROM etc... Look at the upper arm and shoulder during pronation / supination for compensations . If you consider repetitive tasks such as "checkout person", why is it that not everyone in this job develops tennis elbow ? Probably because of limitation elsewhere ie-lacks wrist extension... causes abonormal stress at the lateral elbow to compensate causing a chronically agitated extensor complex. If there is a history of a fall onto the same hand check for "pushed radius"syndrome etc... .

ie- look elsewhere .........cheers.....Thomas

[Aamir]

Can anyone of you guys can tell me the meaning of "ULTT"

[somasimple]

ULTT = Upper Limb Tension Test replaced now with ULNT =Upper Limb Nervous Test

[mageshanand]

hey guys did you go thru the general forum, mobilization of the spine is suggested, i wonder which one of these is the best and if all have a role to play, then from which approach should we start .......

[nickhedonia]

while there may well be a role for consideration of the role played by local structures in the aetiology of lateral epicondylar pain, it is overshadowed by the importance of firstly understanding the likelihood of referred pain and altered sensations derived from spondylosis. In your atempts to assess this likelihood, it is not a requirement to be able to reproduce epicondylar pain , only to be able to find that c56 facet joints , when attempts to move these joints are made, that significant pain is felt at these joints.
Anterior/posterior mobs will be more likely to reproduce pain radiating towards the elbow, than P/A mobs. Both approaches are effective. It will only waste precious time to tape, ultrasound,strap, stretch, mobilise or massage elbows while the cervical spine is left untreated.

[Physiodawn]

If symtoms appear to be local (eg from over use of wrist extensors) would you do cervical/shoulder girdle treatments as a primary treatment? :rolleyes

[somasimple]

Hi,

Of course. In a sciatica case, patient may have pain in the limb but we know that the problem is lumbar and possibly local.

[nickhedonia]

to physiodawn, an emphatic yes to cervical mobilisations as the primary treatment, what may follow once you are certain of the changes to the pain picture should include stretches to subscapularis and brachial dura. Don't leave the thoracic joints out of the picture as referred events including para thoracic muscle tone increases will hamper full recovery.
cheers

[Physiodawn]

Thanks,
but what is your clinical reasoning for that?

In the case of a sciatica the syptoms are peripheral but on assessment there will be a positive SLR/slump test. In sciatica the cause of pain is clear.
I do agree that cervical/thoracic treatment is important but if ULTT is negative and symptoms appear to be local (pain on palpation, resisted etc) what is the clinical reasoning for using it as a primary treatment??

[Physiodawn]

nickhedonia thanks for your comments on 10/03/05, I do think the mechanics of whats happening higher up is hugely significant in the way the upper limb moves and thus the line of pull of muscles. That is why I brought this topic up, I wanted to hear other opinions on tennis elbow treatment in general.
If the apparent local symptoms were in part due to referred pain and altered sensations, I thought you migh expect some kind of sensitivity to ULTT2radial bias, even if it doesnt reproduce the elbow symptoms as such. Are you saying that C56 pain is enough?
Thanks Dawn

[nickhedonia]

To physiodawn, when attempting a differential diagnosis , where the possibility of referred pain etc exists ( as would be true for most musculoskeletal pain) tests can be useful. Such as neural tension tests, dural stretches generally, active movements ,assessments of tight structures etc. What must be borne in mind however is that no test is 100 percent accurate, certainly not the slump or its brachial equivalent. False negatives will lead to innapropriate treatment. I have found that it is better to assume there is referred pain and other altered sensations unless proven otherwise, especially in the light of tenderness elicited at the relevant facet joint with mobs.
I suggest two methods to be more certain of joint involvement. "Traction rotations "performed with patient sitting , where therapist grips the head using forearm hand and chest, while exerting traction and rotating the head into the direction of the percieved referred pain. This will in most cases ,where cervical joints are involved, relieve some of this pain immediately. try 3 by 20 seconds moving the head back and forth into and out of rotation.
AP mobs are also very good to reveal referred pain , if not down to the elbow then along the C5 and C6 dermatome. Continuous AP mobs through a range that just causes discomfort ( but not necessarily the referred pain) for up to ten minutes will confirm the diagnosis by inference, when referred pain is relieved.
All the best

[Physiodawn]

Thats great, thanks!
:rollin

[Ozben]

In addition to the above I have found it very useful to brace the wrist. This is particulary effective when overuse of the wrist is a predominant factor. Add in icing and waiters tip stretches plus avoidance of aggravating factors from your subjective assessment. When this fails go to the neural tension, cervical joint assessment route (hardly ever a factor). If no progress, ultrasound investigations may be useful in determining if a tear is present and orthopedic involment is required.

[nickhedonia]

To Ozben, I wonder if a new thread may be the right way to go if I take issue with the idea of "overuse" for a moment. The notion that the human body is capable of a phenomenon leading to pain on the basis of continued and relentless movements of a limb or joint is a popular one . In my investigations however into pain causing mechanisms and their solutions , the most common unreported and mistreated of all pain causing phenomena is referred pain and its corrollory altered sensations. In paticular that derived by the inflammatory events of spinal facet joints and their adjacent nerves.
It is common for doctors of medicine to acribe seemingly local phenomena ( of the elbow and epicondyles for instance) as the result of "overuse", when in fact the pain is referred from spinal joints. At least in my own approach to the solution of so called "tennis elbow", if I were not to treat relevant spinal jpoints first, I would never know wether the pain etc are referred or not. Neuralgic pain is the perfect mimic.
I am at a loss to se the logic in ANY treatment that is offered before the prospect of referred events are systematicaly and thouroughly explored. In the course of the past 10 years at least I have not come across a single example of "tennis elbow" or lateral epicondylitis , where referred events did not contribute a significant sourse of all symptoms, 100% in most cases. It could be that your patient population is skewed in a different way.
If the term "overuse" is put forward with the suggestion that continuous use of a limb or joint may lead to its breakdown, then I think it is an invalid term. While injury may certainly occur in athletes when vigorous forces are repeatedly made through a limb( throwing injuries of baseballers etc), this is seen to be by ballistic effects where natural resistance is ignored . This is a different phenomenon from the one suggested in cases where gentle repeated movements are made ( ie moving the computer mouse) and pain results from an entirely different mechanism. Tbe point i wish to make here is that "overuse" suggests breakdown by movement when in most cases this is shown to be not the case.
I welcome your thoughts and experiences on this.
Cheers

[somasimple]

Ozben,

overuse of the wrist

Actually, research found no such overuse and revised this idea to a unkown illeness!

Just try to understand why there is a wrist complaint?

[Ozben]

I am also at a loss to understand why treatment would be offered when the patient's symptoms are not understood. As well as assessing the local structures with resisted static contraction, joint rom, stretch and palpation one should do your quick tests as per the clinical reasoning model. It is common knowledge that other structures will refer and should be tested. It is relatively easy here to organise ultrasound investigations of the affected area and that will help in determining pathology that is present from tendon damage to entrapment of the posterior interosseous nerve. Excessive lateral glide of the proximal radius is also relatively easy to assess manually and is often a cause. That is when taping is particuarly effective. As for the overuse part I have found that overuse does not usually consist of when"gentle repeated movements are made ( ie moving the computer mouse)." Rather my client base are process workers, vineyard workers, timber workers and data entry workers. All use their hand in different ways. However prolonged (over many hours, day after day) of near isometric contraction of the dorsal musculature (not movement) does lead to pain and breakdown of musculotendinous strutures (think ischaemia). My own elbow is sore after a weekend using the chainsaw. In another life I was a compositor and worked a linotype machine. It had a mechanical keyboard which we pounded all day long. With the advent of computerised typesetting and the move to electronic keyboards many staff complained of lateral epicondylitis. The difference was the lack of movement required by the new keyboards-not increased movement! As part of a treatment plan I believe patient education is vital. The patient cannot be educated unless they understand the precipitating and aggravating causes of their problem. That cannot happen unless the therapist understands the mechanism. Treatment cannot be applied unless the therapist understands the pathology of the complaint. To do otherwise is to be entertaining the patient while nature takes its course.