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.

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[ramywhite]

hey physio7,
I prefer dealing with a specific patient than speaking generally. You can start with his problems by good examination then treat every problem. I think using the same programe for every patient is wrong. So, please chose one patient and examin him carefully and tell us his history and problems and we can discuss his case together.
good luck!

[alophysio]

Hi,

With all due resepct, have you been trained in doing MWMs and the other techniques or just tried what others have shown you?

I ask this because I was on a one day course for tennis elbow run by Bill Vincenzino who has written a great masterclass article in Manual Therapy 2003 (?). So we were there with this author and clinician who explained and showed and taught us the techniques that thre were STILL people on the course who couldn't get the techniques right, even with an awesome tutor.

Persist. Also, I have put a protocol on this forum somewhere (?help physiobob?) search for it under lateral epicondylalgia (LE).

BTW - the most of the above techqniues work well fr chronic and acute LE - the logical conclusions are:
1. All your LE patients outliers (not likely)
2. They don't have LE (possibility)
3. You don't do the techniques right (also a posibility)

Whenever i come up stuck like you seem to have, i always start at point 3 and work my thru it...

Good luck!

[wutti]

Hi
I think if you did the treatments right, you did your best. The problem with lat. epicondylitis is that it is no -itis, no inflammation. It is a degenerative overuse process caused by repetetive micro trauma. in early stage it can be treated with several techniques but in later stage (chronic) surgery is indicated most of the time to reduce the tension on the common extensor muscles tendon.
dont want to rob your illusions, but in chronic stage its gonna be a hard way to treat conservatively.
cheers

[physio7]

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.

[jigs_physio]

hi its great to see your question on tennis elbow.
why cant you try with muscle setting exercise.even i have got very good results with his manure on patients, even on those pts who has undergone steroidal therapy without any results.
so better to try with this. its my advice.

[physio7]

Can you explain what you mean by "muscle setting exercise"

[emad]

Hello Physio7 :

On the web ,there are free videos for mulligan,s techniques and specifically the gilde .take this link http://www.youtube.com/results?searc...igan+Technique

You will find exactly what you want .

Cheers
Emad

[Yarok]

Hi, You can try dry needling on the epicondyle, assess Cervical spine, Thoracic spine and shoulder girdle.

All the best

[jigs_physio]

muscle setting exercise is very simple one. it is well described in any exercise therapy book. i mean do u hav exercise therapy book by have & colby.it is best given in that.

[maposat]

forgive me. what are MWMs.

I have been succeful with the traditional techniques ie.,hotpack, massage (petrisages or trigger point massages) plus ultrasound.
THIS DOES NOT RULE OUT THE IDEA OF ASSESSING EACH PATIENT SEPARATELY FROM OTHERS AND GIVING TREAMENT BASED ON A THOROUGH ASSESSMENT.

[emad]

MWM = Mobilization With Movment

Cheers
Emad

[matt4physio]

I would totally concur with Wutti 's comments. In chronic cases of tennis elbow the tendon has been shown to be degenerative and acutely inflammed. The evidence base to support the use of ultrasound and manual techniques in chronic forearm tendonopathies is very poor. The most evidenced based form of treatment is progressive eccentirc extensor loading and extensor stretches, there is also reasonable evidence to support the use of a forearm clasp. Clinically i have foud these methods to be beneficial, however i would suggest that there is an element of natural lifespan to this pathology.

[alophysio]

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 tennis 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?

[l1nda83]

I often find treating the neck and radio-ulnar joint at the same time helps.

[physiobob]

This is becoming a useful post guys so thanks for the input. Just so you know there are a few older posts with some other information on tennis elbow, causes and treatment. Take a look in the TAGS section at the top navigation bar and click on Tennis Elbow.

[rana_sh]

hi.. try modalites like short wave, ultra sound, hydrotherapy, cryotherapy, infrared.. all the modality ised to decrease muscle spasm

[alophysio]

Hi Rana Sh,

I am sorry but electrotherapy and modalities etc are just a band-aid - why not fix the problem rather than just the relieve the symptoms temporarily.

We have already discussed that "epicondylitis" is not the proper term because there is no inflammation present - this is proven with microdialysis of the extensor tendons.

If you want a protocol based on research, look in this post - i have posted it up higher.

Your patient's will not think "wow" when you relieve their pain for up to 1 hour. They will think you are wonderful if you actually fix their problem.

I am just studying "patient satisfaction" at the moment and there are 3 factors that are incorporated into the care of a patient:
1. Information - they want to know what is wrong
2. Caring - they want to know you care about what is wrong
3. Effectiveness - they want your treatment to work - you don't need a degree to put on a hot pack or ice or even put on TENS etc. Anyone can look up the book and put a machine on. Medical reps do it all the time. What you have a degree in is "using your brain".

Sorry about sounding like a rant! I just get frustrated when people can't see the big picture...

[asha]

Short Wave Diathermy for Tennis Elbow? !!!!! Its unheard of. Not done.
asha

[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...

[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.

[rana_sh]

hi..about concidering tennise elbow an inflamatory disease, lots of books look at it as an inflamatory, one of this book, is theraputic exersice for carolyn kisner. there is a whole stage of inflamation mintained from 7 to 14 days, depent on the case it self, and there is signs of inflamation and tenderness. about the electro therapy, and as one of the thing i well know, that one of our aims as a physiotherapist it to redused the pain cased by any disease.. by the way in my post i didn't mintion any electrical modalities. i mintioned ultra sound and modulity used to decrease spasm and will known to breake down the adhesion. as i know the second stage of the course of tennise elbow is the fibroplasia, when new collagen formed, and as i know the collagen fibers formed in this stage are badly orianted, and if the case is a chronic case the bad oriantation of the colagen may be progress and adhesion or a bad spasm developed, so we need modalites to breake down the adhesions and re-organized this fibers, these modalites help.. i work out with many cases of tennise and golfer's elbow, and these modalites give me the result i want.. i do respect my paitent, and i'm saying things based on books i read.. Thanks alot

[alophysio]

Hi rana sh,

I meant no disprespect...

Textbooks are a source of good information - i have recommended many of them.

However, in terms of evidence based medicine, they tend to represent Level 4 evidence (opinion of respected clinicians) unless they present evidence from the body of published research.

Alfredson et al (2000) in the journal acta orthopaedica scandinavia 71(5):475-9 reports that microdialysis of the Ext carpi radialis brevis in 4 tennis elbow patients compared to 4 controls showed high levels of glutamate but no protaglandin E2. In other words, glutamate (a neurotransmitter) was probably mediating the pain and there was not any inflammation.

Here is the abstract for those of you (like me) who can't be bothered to look up references!

We used the microdialysis technique to study concentrations of substances in the extensor carpi radialis brevis (ECRB) tendon in patients with tennis elbow. In 4 patients (mean age 41 years, 3 men) with a long duration of localized pain at the ECRB muscle origin, and in 4 controls (mean age 36 years, 2 men) with no history of elbow pain, a standard microdialysis catheter was inserted into the ECRB tendon under local anesthesia. The local concentrations of the neurotransmitter glutamate and prostaglandin E2 (PGE2) were recorded under resting conditions. Samplings were done every 15 minutes during a 2-hour period. We found higher mean concentrations of glutamate in ECRB tendons from patients with tennis elbow than in tendons from controls (215 vs. 69 micromoL/L, p < 0.001). There were no significant differences in the mean concentrations of PGE2 (74 vs. 86 pg/mL). In conclusion, in situ microdialysis can be used to study certain metabolic events in the ECRB tendon of the elbow. Our findings indicate involvement of the excitatory neurotransmitter glutamate, but no biochemical signs of inflammation (normal PGE2 levels) in ECRB tendons from patients with tennis elbow.

Now he has done the same thing in people with Achilles tendon problems. It is a fairly well known and accepted fact nowadays that Achilles tendinopathy is not an inflammatory problem after the first couple of weeks and there is even some debate as to whether it is present at all!

As for U/S, i consider that electrotherapy but i take your point. The studies on the effectiveness of electrotherapy are equivocal (they go both ways) but one thing to remember from our clinical experience is that what we see as worthwhile and working may not be working for the reasons we think.

For example, asprin is the classic example. The ancients used to think that because inflammation is "hot", they put something cold like willowbark into the system by chewing on it to counter-act the effects of the "heat" of inflammation. Hippocrates mentions it in his writings hundreds of years before Christ but it had been known for thousands of years before that.

But it was only since the 1800s when bayer was able to isolsate the salicin compund that we have asprin in it's form today and we know why it works - it is not because it is "cool".

What i am trying to say is that using ice is great for inflammation. When the cardinal signs of inflammation are present (pain, redness, loss of function, swelling, heat) then you have to treat it as "inflammation".

Pain in itself is not actually a "sign" but a "symptom" so having pain alone is not an indication of inflammation. We also know that pain can be present where there is no inflammation.

Loss of function is often also present wherever pain is present so these 2 on their own aren't good enough for me to be called "inflammation".

I need to see the redness, feel the heat and swelling.

Also, how long does it take for your treatments to "cure" their pain to less than 50% for more than an hour or two??

With the stated procedure above, you can achieve results using manual therapy within minutes that last for more than an hour or two. This may take a little while depending on their chronicity but you can see significant drops in pain and increases in strength, function and satisfaction within one week.

If your treatments take longer than 6 weeks to get better, then could it not just be that natural recovery has run its course?

About shortwave - i consider this electrotherapy as well - i think it is because it requires electricity to make it work!!! (my mistake if this is wrong!).

Is muscle spasm the main problem in epicondylalgia? Because if it is, surely massaging and frictions and releases would be all that is required to make this problem better. Anyone can massage their own arm. Yet we can see that this is not a solution. It cannot simply be sorting out the muscle spasm that is the solution.

I am interested to hear more of what you believe. Obviously i cannot know who you are or what you believe in only a few short posts!

[Dugal]

I'm not gonna jump on a high horse.

I'd check out the Cx spine if I were you.

Read Bill's masterclass - it's illuminating

[alophysio]

You are right, i am sorry.

It is, of course, only an opinion (what i believe that is)