Tennis Elbow

[ginger]

"tennis elbow" is not an elbow problem at all , which explains why so many have trouble with this. "Lateral epicondyliitis" used to be the popular name for this, till it was discovered that no inflammatory conditions were present at the condyle. This condition is , in most cases , entirely referred from C567. Mobilsisation at those levels , as well as similar attention at adjacent levels of the vertebral spine, will entirely eliminate this problem, without attention to the arm at all , provided therapists use Continuous Mobilisation ( CM ) and resolve hypertonicity around these facet joints. By doing so the inflammaory event that does exixt , at the joint and nerve root , will also resolve , and remove the irritation giving rise to elbow symptoms. This approach has been working well for me and my many students , for many years.

[Dugal]

This is not true.

Lateral epicondylALGI shows distinct tissue degradation of the extensor muscles, particularly ECRB. Look for papers by Alfredson et al.

I agree that LE isn't just about the elbow, but I don't think it is all about the Cx. I think that chronic LE is a pain state with the concurrent tissue degradation. Your Cx glides, in my opinion, provide pain relief for patients with LE to exercise in pain free manner, similar the the lateral glide MWM presented by Mulligan and evidenced by Vicenzino et al.

[ginger]

Dugal , that would sound plausible , along with the other highly credentialled arguments alluding to protein and cartilage breakdown, presence of chemical irritants etc etc , what I'm saying is however that in the period during which I have managed so called LE, ( more than twenty years ) since I stopped treating the elbow and became alert to the neuralgic events , my success rate with this otherwise perplexing issue has risen to near 100 percent . All without touching the elbow at all. One to three treatments, all to the relevant facet behaviour, some to dural length if indicated, but esssentially no exercise at all . Results are immediate, at the time of treatment, prove to be very long term ( years ) and able to be learned by anyone with the willingness to think beyond pathology and become alert to neurology and its relationship to hypomobile facet joints.

[alophysio]

Hi Ginger,

Perhaps in your clinical experience you have come across patients who have been incorrectly labelled "LE". I too believe in treating the C/S, mobilisation of the lower C/S, the nerves and fascia. All of that is part of the usual assessment of LE (it is posted around here somewhere...)

However, there is no doubt that there are patients who really have a mechanical problem at the elbow. A simple way to find out is to treat the C/S only and find that their pain and dysfunction has not changed. Also, it would seem that treating the C/S only is not revolutionary - if it really worked that well for LE (nearly 100%), then surely it would have been reported many times over and researched thoroughly.

I do believe however that many practitioners focus too much on the elbow and not on the whole patient.

What is your particular background? What treatment styles do you use? e.g. Maitland, Mulligan, Nordic, etc

[ginger]

You are quite right of course , it is important to exclude from the group I alluded to, those whose elbow pain can be attributed to trauma. Though I do not exclude those whose "trauma" is listed or described as "overuse ", A notion I find most unsatisfactory in the aetiological considerations of this and any other MSK condition .
There is a difference in my aproach , I use a method I call Continuous Mobilisation to deal with the protective responses at the spine and restore normal facet mobility. The method has been developed over many years , and now occupies most of my clinical time.
CM was developed out a frustration with the somewhat mechanical and formula driven types of Mobs , such as Maitland. This approach can be read about in detail on the Rehabedge site under Manual therapies.
For the group that has no major trauma ( but may include "overuse', including those who actually play sport ) , my success rate does indeed approach 100 percent.
I am keen to pursue the kind of research that you have mentioned , however as a private practitioner, the resources needed and time required have always stopped me. This does not mean I have not been out there putting my method on the line as it were. This forum is one of a number that I contribute to , learn from and am otherwise encouraged by .I also lecture and teach whenever I can in Victoria.
If you are interested I'm happy to share any details you want to know about.


Thanks for your interest.

[Physio Bed]

Hi guys,

The other thing to think about is PIN (posterior interosseous nerve) entrapment as a diagnosis. It presents with very similar objective signs as would LE and often would exist concurrently. This responds well to radial nerve mobilisations and may go some way to explaining your success too Ginger...!!

[ginger]

The position I have found to be the most effective , in MSK treatment, is to assume referred events are taking place till proven otherwise, by thorough attention to the relevant facet joints with CM.
It is rare to find a peripheral joint pain problem not caused by direct trauma , that does not have a significant component of cause , by neuralgic means. certainly in cases where trauma has been a feature , this remains true, though there are cases obviously where local pathology plays a role. The point I make as I apply myself, is to remove that which can be easily removed first ( referred pain and other altered behaviours and sensations ) , such that effective testing may not then be blurred by false neuralgic positives. In most cases the pain and dysfunction ,certainly in LE, and numerous other peripheral joint problems , is entirely eliminated by this attention . Thus by hindsight , I have been able to show in many hundreds of cases over many years, that referred pain is , according at least to my own clinical evidence , the most common cause of MSK problems.

[Physio Bed]

"It is rare to find a peripheral joint pain problem not caused by direct trauma , that does not have a significant component of cause , by neuralgic means".....


So how do you explain OA of the hip or knee (not due to trauma) where symtoms are relieved dramatically with arthroplasties?? You also, mention that your thoughts are based a lot on your clinical experience, which is important. Do you have any recent research that would support your above statement relating to peripheral pathology being so rare??

[ginger]

It is as well to remember that diagnoses , by and large made without the benefit of the patient being a corpse and being examined by a coroner, are best guesses, based , we would hope , on best available evidence , common sense and the science of medicine. Many diagnoses offered to physiotherapists are clearly wrong , or at best , offered without the kind of tactile relationship consistant with examination protocols common to physiotherapy. It is fair to assume that in many cases where the "OA" and other pathological explanations are given for hip and knee pain , that the kind of thorough , manual therapy inclined examinations and post treatment testing routinely done by physios , are left out of the diagnostic routines of many GPs.
This is not a negative or disrespectful position to take , we all ( we would hope ) take our own brand of skillfullness to the table when we examine and assess, not someone elses.
Gps are generalists, physios who regularly work in the MSK arena , if not initially , then with practice , become akin to specialists. Particularly so when able to cross the floor as it were and discuss cases with both medical and paramedical colleagues. Who amongst the practitioners regularly seeing orthopaedic cases regularly, would not say words to the effect, It is as well that physiotherapy stands somewhere between Gps and surgeons , to filter and reduce those who without such attention , by themselves and others , would ultimately find their way , wrongly, prematurely or both , to the surgeons table .
OA certainly does occur , to joints, adding to the distress of those unfortunate to have progressed to the point of pain and disability. No doubt about it . My point , Mr Bed, is, are we keen and alert to the prospect that diagnoses like these are skewed by a lack of the very sensitivity and understanding that goes hand in hand with a willingness , indeed reson dete, to percieve pain as a companion to pathology , rather than to dysfunction.
We occupy a special position in the medical team . A position not so rigidly defined by issues of safety by exclusion , of pathological threats to life and limb. We are the group , who by our interest in function , will often see alternatives to surgery , to pills and potions , to bed rest , to the otherwise ultrconservative regimens predicted by medicines answers,. particularly to MSK problems.
This, really ,is our reason to be.
Referred pain is the most commonly mistreated , misdiagnosed, and misunderstood issue in medicine . By remaining alert to the prospect , even under the shadow of a confirmed diagnosis of OA related breakdown, I am able to offer significant problem solving to many whose future had been considerably altered by the prospect of only medical or surgical answers to MSK problems. I recommend readers become skilled in and alert to spinal neuralgic events in their assessments for this reason.

[Physio Bed]

Ginger,

I certainly agree that the CNS has an overwhelming contribution to someones pain state and adapts itself to an ongoing pain state. What I am trying to suggest is that pathology also may exist concurrently with the central signs. Obviously these exist in different proportions in different patients groups.

However... are you telling me that someone who walks into your clinic with a diagnosis of hip OA and objective signs that support this would be treated by mobilisations of the PIV joints?????

[ginger]

I'm sure I just said that, but, yes , that is exactly what I do . No need to reiterate the position I have already made clear. Were I not to do this , I would not know , and could not know, what contribution was made to pain and dysfunction from neuralgic means. Clearing tests are virtually useless, have always been so. One cannot percieve referred pain in a way that would identify it as such, tests for joint function routinely offer false postives when blurred by neural interference. The logic of spine first makes more sense of course once you have seen this approach work over and over again. With the experience of having reduced and eliminated pain and dysfunction hundreds and hundreds of times in the face of diagnoses including OA, tenosynovitis , frozen shoulder , PFS, migraine, achilles tendinosis, shin splints , tennis elbow, Ilio tibial band synd. etc etc etc . It is clear to those who approach MSK problems this way , that desigated pathology does not , by itself, exclude the possibility that these signs are less relevant , in the aetiology of pain , than neurology . One only has to treat a few people with so called iliotibial band syndrome by twenty minutes of L4 mobs to witness the elimination of this referred event to have a taste for this approach.

[Mairi]

I'm sure I just said that, but, yes , that is exactly what I do . No need to reiterate the position I have already made clear. Were I not to do this , I would not know , and could not know, what contribution was made to pain and dysfunction from neuralgic means. Clearing tests are virtually useless, have always been so. One cannot percieve referred pain in a way that would identify it as such, tests for joint function routinely offer false postives when blurred by neural interference. The logic of spine first makes more sense of course once you have seen this approach work over and over again. With the experience of having reduced and eliminated pain and dysfunction hundreds and hundreds of times in the face of diagnoses including OA, tenosynovitis , frozen shoulder , PFS, migraine, achilles tendinosis, shin splints , tennis elbow, Ilio tibial band synd. etc etc etc . It is clear to those who approach MSK problems this way , that desigated pathology does not , by itself, exclude the possibility that these signs are less relevant , in the aetiology of pain , than neurology . One only has to treat a few people with so called iliotibial band syndrome by twenty minutes of L4 mobs to witness the elimination of this referred event to have a taste for this approach.

Do you ever use planning sheets during your subjective assesment to write down your thoughts on : 3 key diagnoses then what it could be and might be ?
I know this detracts from the original thread but I don't understand your reasoning for the majority of problems arising centrally rather than perif.

In particular your thoughts on OA.

Think about a footballer with early onset OA...
In particular a footballer with no preivous injuries who sustained medial meniscal damage and subsequently showed with OA on Xray a year or 2 after the injury.

Where is the neural component in this?
I think you're right, at this stage there would be a component- but I don't think your reasoning for why it is there is the same as mine.
I would think that there would be compensatory postural adjustments, ie decreased weight bearing on injured side, decreased strenth, having a 'knock on' effect at the back.
This in turn may 're-refer' (if you can put it like that!) as well.

I don't think always the neuro is the issue and i don't think it's appropriate to go in a treat this and only treat this.
Treat the cause of problem, in this case, weak quads, hams, glut med etc strengthen the knee, propriception, correct posture and you won't get secondary Lx problems and Lx neuro.
You may be reaching the stage where there is a combination, but perhaps not targeting the No. one problem on your planning sheet!

m

[alophysio]

Hi Ginger,

Sorry, i only found your reply today...Your offer of more information is appreciated and welcome (you can PM me if you like).

I am interested in your 20 minutes of L4 mobes to sort out ITBFS...What do you do for the 20 minutes ??

Secondly, i think you would like LJ Lee's course in the thorax coming to Melbourne later this year (?November??). Check it out - she is very good with the whole spine and its effects on the peripheral system.

Good luck!

[ginger]

Mairi,

"Treat the cause of problem, in this case, weak quads, hams, glut med etc strengthen the knee, propriception, correct posture and you won't get secondary Lx problems and Lx neuro"
since when do weaknesses in quads, hams or gluteals cause either knee pain or OA?
what has proprioceptive loss got to do with the cause of pain ?( or OA for that matter )
please explain what posture has to do with these issues in terms of aetiological relationship, and the reverse, it's potential , when addressed, to affect either pain or OA?
Let's be clear, I'm not saying these elements ought not be a part of physio interventions where knee pain is present , just interested in how you have been able to confidently claim a causal relationship.
In fact there is no reason to think weakness , per se, is involved in a pain or OA causing mechanism at all. Do all those who are weak in the legs get OA or knee pain?, some ? a few ? . Inferring cause is difficult under even RCT conditions . experiencing a relationship is another matter entirely.
Were you , or anyone skilled in continuous facet joint mobilisation techniques ( particularly CM ), to approach a person with retropatella knee pain and find hypomobility at L3, and then mobilise that joint , untill protective paravertebral tone was normalised around that joint, you would find within ten to fifteen minutes of beginning CM , that the complained of retropatella pain , along with altered VMO recruitment would be returned to a normal pain free state, or approaching same.
similarly where LE/tenniss elbow is felt , a similar result would be evident after mobs to C456. In this way it is possible to assert a RELATIONSHIP, between facet joint behaviour and responses and complained of pain. Thus alerting the skilled therapist to the prospect , that continued efforts with the same focus , may reveal further improvements to the features of LE. This scenario , is what I allude to and one I see repeated over and over in MSK conditions . Better still , This method is not a temporary means to relieve pain, but in fact the best means to entirely eliminate LE ( and FYI PFS ). generally one to three treatments, with some attention needed to biomechanical concerns which gave rise to the spinal dysfunction .

[Mairi]

I think I just haven't explained myself clearly!
I'm talking about someone who sustains a specific injury, ie 'twisting the knee' giving medial meniscus damage.
Then, because of poor rehab, they go on to devolp early OA due to postural compensations, ie reduced weight bearing on the injured leg because of pain.
This you would assume would give weakness of that lower limb, and perhaps imbalance of postural muscles and then secondary Lx problems.
Facet joints may then be hypomobile, but they are not causing the knee pain, the injury and poor rehab are!
This is obviously a hypothetical situation, I can see how you would get results if there was an element of facet joint hypomobility, but I don't think in all cases as you suggest, that this is the main issue to address.

Rehab the knee injury properly, and you won't get postural adjustments and in turn you won't get secondary problems in the Lx.

[Physio Bed]

Very interesting discussions guys... well done!!!!

Ginger, do you think you could save many of the athroplasties going to surgery these days with your spinal mobilisations????

[ginger]

Mr Bed, yes. I do. along with others saved from tibial resection and transfer for PFS, various reassignement surgeries to "fix " "rotator cuff syndrome " and other spinal operations routinely and obscenely offered and performed for troubling pain problems where surgery ought to have been routinely and emphatically denied.
Don't you?

[alophysio]

Hi Ginger,

I agree that if we had gotten to these patients sooner, then problems like rotator cuff, hip replacement, especially what i consider stupid surgery like tendon transfers etc would be avoided.

However, once the damage has been done, then surely the damage has been done, right? I suggest to the patients that if their function is not too limited, then surgery might not be so necessary. If they can't walk properly or they have constant pain, then get the surgery done.

I much prefer to catch these people before it gets to that stage. I am astounded as to how many people tell me that they didn't know physio can fix this or that. We need to get them either educated or in the clinic and show them we can help.

Anyway, i am still a little sceptical that spinal mobes can fix most things (and that comes from a self-confessed spinal physio who thinks most things come from the spine, partic the pelvis and thorax!!)

[ginger]

damage is damage, pain is pain ,the two don't necessarily follow. Neither does OA with disability, disc disease with chronic spinal pain or tendon irritation with "shear forces ".
Step one. ask and consider the question , could the pain be referred ?. Clearing tests are useless.
Best to follow a protocol that considers and tests the proposal, that a hypomobile spinal joint(s) that is/are neurologically relevant, could , by systematically and enthusiastically eliminating that joint/nerve from the picture by treatment, show by hindsight, that it contributed to the pain/dysfunction.( or it did not )
Step two. If relevance is proven in this way, continue with protocol one.
Step three . if no change after mobs, move to a "local " strategy .

OK , well I have simplified the business a lot. However, in my own considerations of MSK disorders, REGARDLESS of any medical diagnosis, I invariably find , that no one has considered the prospect of referred events at all. Certainly not in a useful way.
My point then , is , if not for this protocol , many go on to continue to suffer needlessly from perfectly fixable pain/dysfunction.
The list of "diagnoses " is quite long.
The prospect of referred events is much higher than many believe.
ten to fifteen minutes is all it takes to perform step one. well worth the effort.

[Yarok]

Hi guys
very informative

to Ginger re.with so called iliotibial band syndrome by twenty minutes of L4 mobs to witness the elimination of this referred event to have a taste for this approach.
if is no signs of L4 for disfunctions after assessment, do you still mobilise/manipulate it ?

thanks Yaro

[Dugal]

Hi guys
very informative

to Ginger re.with so called iliotibial band syndrome by twenty minutes of L4 mobs to witness the elimination of this referred event to have a taste for this approach.
if is no signs of L4 for disfunctions after assessment, do you still mobilise/manipulate it ?

thanks Yaro

Further to this approach of treating the spine for peripheral conditions, some new research has shown improvement of symptoms of patellofemoral pain syndrome following lumbar manipulation (see study I attached). I haven't read the primary resource, the study cites a paper that found increased VMO activity on EMG following Lx manip. These are people without back pain/signs.

I find this very interesting!

[ginger]

Hi Yaro, your assessment method will determine much of course. I have found the most persuasive and sensitive method is to attempt passive mobs at the considererd joint ( obviously for lateral thigh pain this will be L4 ) and discover if the two important signs are present , resistance and pain. If both are present then the joint will improve with Continuous Mobs till relaxation and comfort are restored, this may take up to ten minutes in some cases. A re-check of the complained of symptoms at the lateral thigh will then reveal a change , provided as is commonly true, referred events were taking place. This is almost always true in cases formerly thought to have been "ilio tibial band syndrome " where 'tightness'of the itb had been incorrectly assumed to be the initiative for pain.

[alophysio]

Hi Ginger,

Thanks for the information.

I was wondering what happens when the pain is not simply from the facet joint. For examply, each spinal nerve contributes a nerve supply to the facet joint above AND below, the disc directly, the PLL and ALL and vertebral artery nerve plexus, the sympathetic trunk etc. Then there is the fact that a spinal level can lead to symptoms emanating from up to 4 levels in a superior AND inferior direction (i.e. 8 levels supplied by the one spinal level). This is often the reason why rhizotomy, diagnostic nerve blocks etc don't always work properly...

i do agree that many people do not consider referred pain but surely it is harsh to suggest that nobody in the past has considered it - chiros and osteos make their living off this principle. Perhaps we as physios do not consider it. e.g. a patient of mine has had 6 months of "physio" to her knee without success (I/F, exercises, massage, U/S) but on my initial assessment (a simple routine one), i was not able to reproduce the pain locally (knee) but able to reproduce the exact pain on L/S examination. Also found a pelvic dysfunction driving the whole process - that is pelvic dysfunction led to uneven loading on the facet joint during loaded manoeuver leading to referred pain to the knee.

Also, i will look into the continuous mobes thing - haven't done so yet - it just seems to take a long time (10-20mins). Are you briefly able to state the proposed mechanisms and simple explanation of its technique?

Thanks!

BTW - what does "Eill Du et mondei" mean?? I cannot find an answer in any translators!

[ginger]

alo alo, go to Rehabedge and look in the manual therapy section for post entitled, "Continuous Mobilisation " also go to open forum and search for "The physiology of spinal pain, a theoretical model", then get back to me.
G

[ginger]

My post script is a latinised version of a saying popular amongst those I shared a house with during university in the early eighties, when asked when they would take their turn as cook/cleaner/dishwasher/ and so on.