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 Wikipedia reference-linktennis 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?