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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[ginger]

Can't help but wonder which outdated text book this was lifted from james.

[alophysio]

Hi Ginger,

Not lifted my dear but referenced.

I hadn't put the thorax or cervical assessment on there as there isn't a research base for it. This protocol can be used with confidence knowing there is research to back it up. In this environment where insurance companies don't understand that Level 3/4/5 evidence is still evidence based practice, it is helpful.

In reality, you would assess the articular, myofascial, neural, visceral and emotional systems of the patient for each region (Lee and Lee 2007).

However, knowing that you live in the articular system, you will still get neurophysiological effects and inhibition of the myofascial system from your mobilisations to the cervical spine. Kind of like a shotgun.

Still, as you know, i still would prefer your manual therapy to electrotherapy any day

Cheers

[ginger]

not sure with whom I'm responding to here , it is either a james in pakastan who has lifted a piece from a text book , or an aussie who responds as if he had done so. I'm sure all will be revealed. I had trouble reading the last post after the piece from alophysio where he claims to pay attention to " visceral and emotional systems ". haven't had a bigger laugh all day.

[alophysio]

Thanks Ginger, glad to help you add some humour to your day.

To clarify, the original post listed a protocol i had posted upon request in a different thread. If you had properly read the original post (just scroll higher and you can see it clearly), my name is there and i listed the sources where i got my information from.

In context, the protocol is a practical summary of information provided by people who research in the field of lateral epicondylitis.

Next, just because you lack the skill of knowing how to assess someone's viscera doesn't mean that everyone else who does is a joke...

Also, if you don't pay attention to your patient's pyschosocial issues, you would be a very cold physio indeed - and ignoring the biopsychosocial model that has been thrust upon us. Actually i am sure that you do since you claim such high rates of success for your CM.

If the information is outdated (the paper was from 2003 by the way so it can be considered a little outdated), then what is your "up-to-date" information to contribute to the discussion? What are your intelligent remarks (smirks not required...) and arguments as to why the above is not valid?

Derision is not an attractive look for you. I appreciate that not all people think/believe that everything can be cured by your "continuous mobilisations" to the spine for all problems. The fact that you have devotees out there should counter your claim that research is impossible because you lack the time or the energy (perhaps sore from so many thumb breaking mobilisations?). Sometimes physiotherapy is an art - which i am sure you appreciate - so what is the harm in finding out how other therapists are helping people?? Are you that arrogant that other ways actually exist?

Lastly, your way is not the only way otherwise someone earlier in life would have discovered it. In fact, your continuous mobilisations are simply Maitland mobilisations practiced by thousands around the world. It doesn't actually sound hard.

In fact, i could probably sum up most of your posts - "use CMs".

Respect is somethinig i have always paid to you. You claim to be happy to answer questions about CMs but then when i do, you direct me sites where other physios also question you and you don't reply to the questions.

Still, i suppose we need all types of people out there. It is truly a shame that your method of communication is one of arrogance, lack of research-informed comments, single-minded in nature (CMs fix everything), and just plain abrasive.

I haven't felt so sorry for someone in ages...i pity you.

[physiobob]

not sure with whom I'm responding to here , it is either a james in pakastan who has lifted a piece from a text book , or an aussie who responds as if he had done so. I'm sure all will be revealed. I had trouble reading the last post after the piece from alophysio where he claims to pay attention to " visceral and emotional systems ". haven't had a bigger laugh all day.

I think that the first post was in relation to something published by alophysio, who is a regular and widely read contributor to this forum. I think the first poster lifted it just for some reference material on which others could comment. Perhaps specific discussion of what should/should not/could be included etc. in this list would be more constructive than personal bickering.

Everyone likes to "have a good laugh" but it would be great for those who do to put their words where their comments are.

[alophysio]

Apologies for the rant...i should be more respectful.

[ginger]

alophysio , you deserve my apology for seeming abrasive derisive and unwilling to prop my responses with further considered details. I find myself more and more disillusioned with the general state of the physiotherapy community, at least those represented by the majority of posters on MSK matters. The real possibilities that may lie in improving the understanding of MSK problems by physios , are at the undergrad level. It seems those whose reference points and methods are derived from outdated models , find a paradigm shift just too hard. I do find it difficult though to lurk and not respond where seemingly rational discussion occurs with the blinkers still on about referred events. AS to your comments , I take responsibility for your umbrage and will refrain from offering comment without sufficient detail to fill in the blanks.

[alophysio]

Hi Ginger,

Thank you - no hard feelings. I too share your frustration.

I am a little cynical at the undergrad level though because students are focused on passing, not healing at that stage - they haven't had the experience of actually helping someone significantly change their life due to manual therapy.

But hopefully by putting credible alternatives out there will help others consider the possibilities, maybe even feel the difference!

Cheers

[Marty10]

To Jamesmayur and those who have stated that there is no inflammation in lateral epicndy"litis":
I am aware of the research that says that there are no inflammatory cells, but some patients seem to respond well (although temporarily) to NSAIDS and injections. Do you agree? If so, how would you explain this?Thanks!

[alophysio]

Hi Marty10,

NSAIDs and injections...

...well, if there are signs of inflammation, treat them - heat, swelling, pain, redness, loss of function...

As for injections, i am fairly confident there is research that suggests a short term benefit in terms of pain but longer term results in the same group leading to decreased improvement overall.

If you were treating someone who strained their elbow on the weekend, you are probably looking at some form of inflammation. If you are treating someone with a 6 month history of elbow pain, you are probably treating something that is not inflammation.

In the end, we are trying to break a cycle and gradually expose the injury to load to assist in repair - i am fairly pragmatic about such things...especially having suffered from LE myself...i only ask that the patients know about WHY they are getting a treatment etc.

Cheers

[mulberry]

bill vicenzino missed one thing in his assessment; the myofascial assessment developed from physiotherapist luigi stecco and his wife carla stecco who is an orthopaedic surgeon. the technique is called myofascial manipulation and is based on the meridain channels of traditional chinese medicine. luigi refers to painful sites and centres of perception; arease that your are aware of pain and states the lesions of the myofascial meridian; meridian channel, usually are juxtapositioned near the centre of perception (CP), the lesion site is called the centre of coodination (CC) and usuallu is found where the monarticular and polyarticular muscles converge there line of tension along the myofascial plane.

for example;

lateral epicondylagia is the centre of perception of the elbow. to identify the centre of coordination look at the muscles attached to the lateral epicondyle.
the monoarticular muscles is the aconeus and supinator and brachialus
polyarticular muscles are the wrist extensors/ thumb extensors abductors and the muscles that attach onto the lateral intermuscular septum such as triceps and biceps brachii
the centre of coodination will be the area of convergence of the tension of monarticular and polyarticular muscles either proximally or distally from the area.
the distal site of supinator over the interosseous membrane and the origin of thumb extensor / abductor. also beneath the wirst extensors.

or

the distal site of aconeus and the interface between brachioradialus

or the origin of brachialus and the interface between triceps or biceps brachii

the CC wil be tender on palpation and refer pain like a active trigger point.

i also quickly run along the path of the affected myofascial meridian to identify lesions; active and latent trigger points then treat the active trigger point and re asssess. if there is still residual weakness i then will treat the latent trigger pint as well if still there after the release of the active trigger point. 90 percent of the time the latent trigger point will resolve with active trigger point trreatment

for example

the large intestine meridian is made up of the soft tissue that passes over the lateral epicondyle. i will palpate over the length of the large intestine and its opposite the heart meridian to identify lesions to treat in the segments juxta positioned to the painful site; active trigger points, if there are no active trigger points i will then assess the next segment above or below until i find the active trigger point along the length of the myofascial meridians; large intestine and heart

[estherderu]

Hi Mulberry,

very interesting.
Can you give us some references to read about this technique you speak of?
You might know I have spoken about the meridians in relation to musculoskeletal problems and epicondylitis before (from the bindegewebs/meridian corner) and am always interested in knowing more, especially regarding the science behind any given method or technique.

Thanking you in advance.

Esther