Tennis Elbow

[physio7]

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.

Similar Threads:

• Sore Elbow - Darts Player (Not tennis or golfers elbow)
• Tennis Elbow
• Tennis Elbow
• Is all of this because of Tennis Elbow?
• Tennis Elbow

[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

[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.

[alophysio]

Hmmm. Still don;t know what your postscript means....

Here is the intial post that Ginger made on rehabedge.com that i found...

After many requests for detail on the continuous method, I offer here a short examination of the method I call Continuous Mobilisation. Applied to spinal zygo apophyseal facet joints with care, this method provides the means to restore normal pain free function to hypomobile facets joints.

As this is a brief consideration of the method and reliable results considerably influenced by application, I urge the reader to practice on live humans to bridge the skills gap should there be one.

I will skip any further introduction and mention of physiological detail and examination protocals , these will be/have been dealt with elsewhere.

METHOD.part one
unilateral passive mobilisation of facet joints requires therapists hands to be a connection to the ongoing protective state implicit in the activity associated with spinal joint pain. As such it is necessary to be sensitive to changes in the state of tone of intrinsic muscles intimate to facet joints. Any attempt to move a facet joint which has a protective hypertonic load ( of muscle) will be met with resistance and pain. Pain can be of differing intensities, feel and irritability. ( by irritability I refer to the prospect that any attempt to move joints in a highly irritated state may be followed by pain not associated with passive or active movements, initiated by that attempt to mobilise)
By this sensitivity it will be noted that as passive movements are attempted and continued, a changing picture of pain and resistance emerges.
Movement is applied in a natural direction predicted by the angles of therapists hand and arm, where he/she stands at the side of the patient nearest to the joint being mobilised.
Pressure is sufficient only to acknowledge both pain and resistance at the joint. Continuous movements then at a rate of 2 per second are provided such that both these variables are able to be monitored. At or around 30 seconds of continuous mobs there will be noted the first level of alteration to both variables. That is , pain will be felt to reduce at the same time as muscular tension providing resistance reduces. Further attention to the same joint will produce still more reductions till A. either no further improvements are noted, or B. a full pain free resistance free condition is established.
The effect of successful mobilisation will be noted in several ways.
Active and passive facet ROM will be improved. This will be associated with improvements to comfort locally as well as distaly. It will be noted that as these local improvements are appreciated , so will the prospect of a reduction in distal pain and dysfunction associated with the spinal segmental innervation of those related structures.
The improvements to facet mobility are essentially permanent. That is, provided that there are no severe local irritations given by pathology or injury, protective responses leading to facet hypomobility and inflammatory events of joint and nerves are restored to normal. Inflammatory events associated with these states of hypomobility are usually dissipated over a 24 hour post treatment period. Some liklihood of a post treatment painfull facet joint period exists. This can be viewed as an unfortunate feature of this form of treatment , but not a contraindication for it's use. In my experience about 20 percent of individuals will experiece a post Rx period of tenderness, which last pproximately 24 hrs. Usually noted is a highly irritated facet joint, or group of joints prior to Rx, in this group.
Summary
Continuous facet joint mobs is NOT
forcefull
difficult
contraindicated by the presence of age or disease related arthropathies, "instability", or previous injury .
Continuous facet joint mobs DOES NOT require
Your attention to detail in the placement of your thumbs- at or over the lateral mass , as near as able to the facet joint will be fine. Provided that , the two basic criteria are met, that is resistance and pain.
Periods of five minutes of continuous mobs are commonly associated with continued improvements to some facet joints as above, longer periods are usefull also , though strain the limits of the thumb comfort of those new to the method. Practice will lengthen considerably the time able to comfortably mobilise. A lot of pressure is rarely more useful than less, pain and resistance is the key.

My question still stands...

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...

2. How is this method different to Maitland?
3. How can you be sure you are moving the facet joint?

Thanks Ginger.

[rockin ronnie]

Ginger, i am fascinated with your said successes in treatment of these conditions,

a question or two if i may...

your example of treatment of lateral thigh pain/ITB with mobilisation of L4:

purely hypothetical scenario:

patient presents with lateral thigh pain, i assess their single leg 1/4 squat form looking for ability to maintain neural lumbar spine/pelvis/knee/ankle positions and find they are sub optimal in one or more of these areas.

I mobilise their L4 affected side, and they report an improvement in their symptoms.

Would you suggest that it is unecessary to address core stability, lower limb alignment issues in this scenario?

If they report no improvement in their symptoms, would you suggest persisting with the continuous moblisations, perhaps varying the dosage?

thanks in advance, i am loving your responses, ps 12yo female rep basketballer with >1 year history of achilles pain/local thickening and tenderness, i have been treating for 4 months, slowly improving, working very hard on her eccentric strengthening program etc, biggest gains in weeks after mobilising her lumbar spine, i am excited!

[Physio Bed]

Ginger,

Interesting discussion. I do agree that some surgeries are done needlessly and surgeons very quick to get patients on the table. However, for my 85yo lady at the moment with AVN of her femoral head, I don't feel mobilisations of her upper Lx spine is going to benefit her too much.... In fact, this poses the question of duty of care. If I did continue to mobilise her spine without referral on to an orthopaedic surgeon, am I putting myself in a possible law suit??? Could I justify treating her back with only anecdotal evidence to back me up??

Which brings me to my next question... Can you give me any references/papers to back up what you're saying or is it indeed just low level anecdotal evidence you are basing this on..??

[ginger]

Mr Rockin , any lateral thigh pain not directly caused by local trauma ( abrasions/contusions/ fractures/surgery ) will almost certainly be the common garden variety referred pain , from L4. Further attention to biomechanical contribution from the foot/ankle ( pronation ) will be of some value, particularly where SIJ dysfunction has not been addressed. I fail to see however , how attention to the rest on your list could be of any concern or relevance. Long term pain freedom is usually able to be gained with successfully restoring normal mobility to L4 . I have not personally found the need to explore the prospect of biomechanical advantage/disadvantage by attention to hips, knees or pelvises in other ways.

[alophysio]

HI Ginger,

Any responses on the other questions??

[ginger]

Bed

"However, for my 85yo lady at the moment with AVN of her femoral head, I don't feel mobilisations of her upper Lx spine is going to benefit her too much.... In fact, this poses the question of duty of care. If I did continue to mobilise her spine without referral on to an orthopaedic surgeon, am I putting myself in a possible law suit??? "

Who has made the diagnosis that this woman's pain is from her hip?, her doctor/ surgeon ? or yourself.
medical opinion invarably points the finger at pathology as the driver for pain. sometimes this is correct, sometimes this is not. The only way to be certain is to perform a differential diagnostic routine , sufficiently sensitive and oriented to the very real prospect that spinal referred pain may be occurring . All too often , the staff at hospitals where I have worked , along with geriatric rehab centres etc, will take on a rehab role as if the answers were all provided neatly by pathology, as expained by your example.
Left undealt with are the scores of chronic pain sufferers who , for want of someone to fully and comprehensively explore the referred pain theme, will suffer needlessly. In my own explorations of such cases , it is common to discover that not only did referred pain exist, and was able to be eliminated by CM to the relevant joint(s) , but that with hindsight , it became clear , that pathological 'answers' were either entirely wrong , or incomplete.
To not explore these very real prospects would , in my view , constitute a refusal to act according to the duty of care you mention.

[Yarok]

Hi
Ginger, you didnt answer if is no signs of disfunction of L3,L4, with lateral pain/ache do u still mob it?

re; Continuous Mobilisation looks OK, but i would save the time using postizometric relaxation towards restricted direction or opposite,

thanks

[ginger]

I would mob it/them to detect wether pain and resistance were present, if not ,then no.
What is postizometric relaxation ?

[rashimk]

hi all,

i am a post graduate student.. can you please help me by suggesting some websites/ physiotherapy journals/ manual therapy journals from where i can get full text articles?
i am working on selecting a topic for my dissertation...

thanks...

[Dr Damien]

Hiya, unfortunately tennis elbow when chronic can be such a pain for physios and patients alike. The sad thing is that the modalities that have been mentioned above are designed to address inflammation mainly. Tennis elbow most recently has been identified as a tendinopathy rather than tendinitis which means that the shortwaves, the Ultrasound etc will not have much effect if there isnt any inflammation to battle. Moreover, there can be a strong resistance to treatment if the causative overuse activities are not concentrated on.The choice of friction massage is debatable because when done too deeply, there can be a mimicking of the overuse rub on bone making the condition worse. Other suggestions for treatment is injection therapy and the modification of activities that cause overuse. You can refer the patients who are resistant to treatment to a specialist in injection therapy,however you must monitor that the patient those not receive too many injection treatments due to the risk of steroid related joint anthropathies,infertility and osteoporosis.
My advice is to refocus your attention to the modification of activities because it is not likely the modalities mentioned above will be of much help, having said that not all patients will respond to treatment alike which means some may benefit from these modalities but treatment without investigating the causative activities in my opinion is useless as the condition is degenerative thats why it affects mainly adults in their thirties to fifties because they are quite active and have the natural degenerative processes begun already.

Modify your patients activities...

[ginger]

interesting to note there are so many of you still struggling to come to terms with this referred pain event.

[alophysio]

My dear ginger,

you are almost sounding chiropractic

I believe that your methods work for a certain diganosis and classification. Patients who have spinal dysfunction can indeed have referred pain. In having their pain mediated at the spinal level may also benefit. In having the nerve supply improved to areas of dysfunction will improve healing processes etc.

But sometimes we are dealing with peripherally mediated pain. In other words dysfunction at the distal site. If this is the primary problem, then altering the pain from the spine will only succeed in altering the signal to the brain, not dealing with the problem.

Any dogmatic adherence to one theory is dangerous in there complex bodies of ours. I really do wish there were simple treatments like continuous facet joint mobilisation that solve all problems. And you know that i like that fact that it is manual therapy so i will go in to bat for it before so many other treatments. But we have to use our diagnostic skills and treat according to what we find (including checking the C/S and T/S in tennis elbow ).

[Yarok]

HI dr Damien

what do you suggest meaning injection therapy, what do you want to inject?

thanks
Yaro

[alophysio]

Hi Yaro, i am guessing it is corticosteroid injection therapy. These have been shown to have a good pain effect in the short term but in the long term (>6months) these patients do WORSE than non-injected patients. It really isn't a good option.

Perhaps Dr Damien has another opinion...

[ginger]

Alophysio, there is a powerful construct that exists in the minds of most physios , provided at undregrad level and often further ingrained by the pathology driven attentions and answers provided by doctors of medicine. What must be resisted , is the slavish acceptance of medical diagnosis in areas where medical intervention has historically been a poor solution . I speak of course of MSK problems. It is important to understand that , by and large , we physiotherapists are the front line in MSK observations, handling and interpretation based on the steep learning curve provided by manual therapy interventions. We do= we observe=we learn=we modify=reinterpret.
This near perfect opportunity is mostly unavailable to those who treat with either exercise , pharmaceuticals, or modalities , either alone of as part of a multi treatment protocol.
It is clear to me having picked up the pieces so many times, after these kinds of interventions, after multiple attentions paid to the painfull structure(s) by others, after patients had suffered needlessly with referred events, when no-one had bothered to properly diagnose a referred event, that undergrads need better training . Both medical and physiotherapy.
The kind of thinking you display is perfectly reasonable, make a careful analysis of all before you, keep in touch with reality rather than dogma, eyes and senses alert to the origin rather than product of pain. In my own searches for and treatments of the cause of tennis elbow, I invariably find , when no direct trauma has been a part of a persons Hx, that the central spine is the cause . That by attention to the relevant upper thx and lower Cx facet joints/nerves and occasionall dural length, a full and speedy long term resolution is gained , usually within three treatments, to "tennis elbow". this is true for a long list of pain issues and neuralgic problems often mistreated with local rather than central interventions.
I am yet to come across a "tennis elbow " problem ,. in nearly twenty years of careful searching , that was not a referred pain event and eminently fixable in short order in the fashion I call Continuous Mobilisation. There is a temptation in the minds of those who have spent years digesting complexity as a student , to believe that MSK problems are also complex. This is rarely so. My first instruction to my own students is to think simply and observe with hindsight as a test of any method or diagnosis. What works and is safe is a good motto. Attention to the central spine with CM for "tennis elbow" is not a means to modify temporarlly pain behaviour, but a method whereby the cause of neuralgia is directly and effectively targeted and eliminated.
It is neither usefull or time effective to treat a possible referred event with a multi pronged multi target approach . Best to make the following observations.
Pain intermittant and variable ?
pain persistant over more than two weeks?
Pain increases with activity/fatigue ?
Pain decreases with rest/sleep?
Are the relevant facet joints positive for a. resistance and b. pain , when overpressures are applied when performing a unilateral mob ( grade three maitland)
When the percieved pain is in a cervical distribution ( "tennis elbow"), can this pain be reduced with traction rotations ( more on this if requested )
or stimulated with AP unilateral mobs of the relavant facet ( for "tennis elbow" , C5/6)
All the above are positive in a display characteristic of neuralgia.
When in doubt, mobilise and observe. It will only take five to ten minutes of Cm to firmly establish the relationship between central cause and distal pain, after which any attentions paid to the distal, is time wasting to say the least.

[alophysio]

THanks ginger for the reply. I appreciate the detail and the time taken to write your reply.

I hear you and agree with what you wrote.

Having said that, your statements above have clarified the classification of patients you treat with these conditions - no direct trauma.

Secondly, i have tried your method on my clients but without significant success. Also having said that, these patients triggered off these events with some form of trauma - e.g. excessive out of the ordinary wrist extension work, lifting heavy grates that unexpectedly shifted etc.

I still maintain that accurate diagnosis and classification is required to determine the best course of action.

Perhaps it is a sad indictment on our profession that not many physios actually check for C/S referral - but if it makes you feel any better, i do!

Thanks again Ginger.

[ginger]

Alophysio , I would not classify those you have described as having had trauma, Trauma as i would accept it as a participant in pain, would be a fracture , bruise ( periosteal ) neural injury, whiplash etc. The types you have indicated fit perfectly within a group I would identify as most likely to have neuralgic/neural pain. It is possible that it is your method that may fail you , rather than your intention/willingness or perhaps even your perspective. I know you have read my pieces on CM. It is possible that your approach could be more a maitland than CM. Speculation here. By all means give me a call . PM me and I'll give you my number.
Cheers

[maithili85]

hi
i think MWM and pain release phenomenon techniques are really helpfull in chronic tennis elbow patients.In MWM, if u get proper direction of glide,it helps to relieve the pain.Along with this,a proper ergonomic advice and stretching n strengthening exercise program does help to give adequate relief to patients.It's definitely worth a try.

[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!

[alophysio]

Indeed. Thanks for posting the article.

Using manipulation in this way is not the only way to manipulate. THe problem is that this particular technique is difficult to do and tender on the ASIS. Also, it is fairly non-specific.

I prefer a "log-roll", short lever technique.

I have also found that Maitland mobilisations and MWMs, and other types of treatment to the L/S, where appropriate, are helpful in PFPS.

But back to Tennis Elbow, for chronic tennis elbow, if you have followed the protocol listed above somewhere by me and the problem still does not improve, look elsewhere.

As Ginger suggests, the C/S is an obvious place to start but i have also found that the ribs are amazingly common problem areas.

One particular pattern i have noticed is the 3rd rib leading to anterior shoulder pain which can be felt down the biceps and then forearm.

I think it is the fascial pull from pec minor holding on tightly to a dysfunctional 3rd rib. Treatment to sort out the dysfunction (wherever it is) usually results in improved shoulder and arm function and less C/S problems as well.

Any other ideas??