Lateral Epicondylalgia

[jamesmayur]

Treatment Protocol Copyright alophysio (2007)
Developed mainly from Vicenzino, Bill 2003 Lateral Epicondylalgia: A Musculoskeletal Physiotherapy Perspective. Manual
Therapy 8 (2) : 66-79 and various course notes

Subjective Examination Points to Note:

Body chart:
History:
Onset
When
How
What Symptoms:
Then
Now
Risk Factors:
Training Error (eg. Technique, fitness, periodisation)
Equipment Faults (eg. Recent changes, inappropriate equipment)
Biomechanical (eg. Trunk, shoulder girdle, local)
Aggravating and Easing Factors:
Functional Interference
Activity
Position
Pain Questionnaires:
5 Functional Activities Pain VAS
Patient-Rated Elbow Questionnaire (MacDermid 2001)
American Shoulder and Elbow Surgeons – ASES-e)
Objective Examination Points to Note:
Observation:
Habitual movement patterns or postures
Carrying angle
Muscle Bulk / Atrophy / Hypertrophy / Swelling
Functional Activity Evaluation (Commonly involves gripping)
Motion: Active and Passive (F, E, Sup, Pron, CM ± WB/Distraction)

PAMs:
Positional Fault
Movement Impairment
Reactivity
Muscle Tests:
Stress Test:
Stability (eg. Varus, valgus, PLRI)
Diagnostic Specific
Condition Specific
MWM

General Treatment Goals
Restore Muscle Function
Early and Substantial Pain Relief
Manual Therapy
Tape
Self-Treatment
Endurance Base First
Strength Second
Restore Motor Function (Functional Basis)
Early and Substantial Pain Relief

Manual Therapy
x6-10 reps provided substantial pain relief and no latent pain
Apply glide, patient either grips or moves elbow, release glide
If Pain-Free Grip (PFG) Strength Deficit predominates over (Or Equal To) Pressure Pain Threshold (PPT):
Step One:

Painful Grip:
Elbow SLGWPFG ± Belt (Sustained Lateral Glide With Pain-Free Grip)

Painful Movement:
Elbow SLGWM ± Belt (Sustained Lateral Glide With Movement)

Step Two (If Step One Not Effective):
Radio-Humeral Joint SPAWPFG (Sustained PA-glide With Pain-Free Grip)

Step Three (If Step One and Two Not Effective):
HVTRHJ (High Velocity Thrust to the Radio-Humeral Joint)
If Pressure Pain Threshold (PPT) predominates over Pain-Free Grip (PFG) Strength Deficit:

Step One:
Evaluate C/S and Upper Quadrant Neural Structures and Treat Abnormal Findings
Elvey’s Lateral Glide of the C/S (C5/6/7)
C/S or T/S STWULM (Sustained Transverse-pressure With Upper Limb Movement)
Taping

Painful Grip:
Tape For Elbow SLGWPFG Manual Technique
Tape to be applied with SLGWPFG
Tape from medial to lateral, inferior to superior across cubital fossa

Painful Movement:
Tape For Elbow SLGWM Manual Technique
Tape in Elbow Flexion if Extension painful
Tape in Elbow Extension if Flexion painful
Tape to be applied with SLGWPFG
Tape from medial to lateral, inferior to superior across cubital fossa
Tape For Radio-Humeral Joint SPAWPFG Manual Technique
Tape to be applied with SLGWM
Tape #1 from lateral to medial, posterior to anterior around radial head to anterior aspect of ulna
Tape #2 from lateral to medial, posterior to anterior across cubital fossa to posterior aspect of humerus

Diamond Tape of the Elbow
For lateral elbow pain present most of the time
Particularly useful for resting pain or pain at night
All tape to be from inferior to superior in direction
Tape #1 and #2 from common lateral aspect of the forearm to anterior and posterior joint-line of elbow
Tape #3 and #4 from anterior and posterior joint-line to common lateral aspect of the humerus

Self-treatment
x6-10 reps provided substantial pain relief and no latent pain
Patient applies glide, either grips or moves elbow, release glide

Painful Grip:
Elbow SLGWPFG ± Belt (Sustained Lateral Glide With Pain-Free Grip)
Patient to apply lateral glide to forearm while blocking humerus with belt or against a doorjamb or corner of wall then produce a pain-free grip
Painful Movement:
Elbow SLGWM ± Belt (Sustained Lateral Glide With Movement)
Patient to apply lateral glide to forearm while blocking humerus with belt or against a doorjamb or corner of wall then produce a pain-free movement
Radio-Humeral Joint SPAWPFG (Sustained PA-glide With Pain-Free Grip)
Patient to apply PA glide to R-H Joint then produce a pain-free grip
Exercise Programme:
Stage 1: Endurance Base
Stage 1a: For most patients…
Load = x12-15 Repetition Max (RM)
x8secs (4secs up/ 4secs down)/rep
x12-15 reps/set
x1-2mins rest between sets
x3 sets/session
x1 session/day
Progress to Stage 2
Stage1b: For deconditioned patients with DOMS after doing Stage 1a…
Load = x12-15 Repetition Max (RM)
x8secs (4secs up/ 4secs down)/rep
x12-15 reps/set
x1-2mins rest between sets
x1 set/session
x2 sessions/day
Progress to Stage 1a
Stage 2: Strength Base
Load = x6-8 Repetition Max (RM)
x8secs (4secs up/ 4secs down)/rep
x6-8 reps/set
x1-2mins rest between sets
x3 sets/session
x1 session/day
Progress to Stage 3
Stage 3: Restore Motor Function (Functional Basis)
The exercise to be done are functional tasks
Load = x6-8 Repetition Max (RM)
x6-8 reps/set
x1-2mins rest between sets
x3 sets/session
x1 session/day
Progress to heavier and harder tasks
Exercises:
Load Type:
Core Set of Exercises:
Other UL Exercises:
Isometric
Wrist F
Tricep Extensions
Eccentric Only
Wrist E
Bicep Curls
Theraband
Wrist RD
Chest Press
Free Weights
Wrist UD
Shoulder Press
Theraband Flexbar
Wrist Supn
Bent-Over Rowing
Wrist Pron
Scapula Retractions
Gripping (With Theraputty/Grip Dynamometer / Eggsercis

Patient Information Sheet:
Most “Tennis Elbow” problems are treatable using physiotherapy.
Your physiotherapist will use:
“Hands-on” manual techniques
Taping
Teach you how to treat and tape yourself at home
Teach you how to do exercises and stretches at home to help your arm strength
Research has proven that this system we use IS EFFECTIVE.
Your physiotherapist will need to see you for 2-3 sessions for the first week
This is to:
Assess and begin manual therapy and exercises
Teach you how to treat and tape yourself at home
Teach you how to do exercises and stretches at home to help your arm strength
Your physiotherapist will then need to see you for 1 session every week/fortnight
This is to:
Review your exercises and self-treatment to make sure you are doing them correctly
Progress your exercises and stretches as you get better
Make sure you are actually doing your exercises
Your physiotherapist will not use:
Ultrasound, Laser or any other machines
Massage or “frictions”
Voltaren or Feldene gel
Research has proven that these treatments DO NOT HELP your condition.
It is important to understand that during the programme, there should be no pain !
Please tell your physiotherapist if you are getting pain during treatment and they will stop.
When you do your self-treatment at home, you SHOULD NOT get pain – Stop if you do !
When you do your exercises at home, you SHOULD NOT get pain – Stop if you do !
It is important to understand that you will feel good during and after your treatment and self-treatment at home but the pain will come back for about 3 weeks.
THIS IS NORMAL !!
STICK WITH THE PROGRAMME !!
Research shows that this programme will be effective in gaining a long-term solution to your pain
It is important to follow the exercise programme your physiotherapist gives you.
You will see stable strength improvements within 3-6 weeks.
You should avoid:
Picking up objects with your palm facing down
Any activity that aggravates your symptoms
You should do:
Your exercises
Your stretches
All activities that do not aggravate your symptoms
Listen to your physiotherapist !!

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