Chronic Lateral Elbow Pain
By
Martin Meyer
Sports Physiotherapist
My background
Graduated in 1996 from Curtin
Completed Masters in Sports Physio
in 2000
Last 2 years in Calgary, Canada
Elbows, elbows, elbows.
Aims
Briefly look at elbow anatomy
Possible pathogenisis and pathoanatomy of chronic elbow pain
Physiotherapy techniques
Manual Techniques
Therapeutic Exercise
Taping
Practical Session
Elbow Anatomy
Arthrology
Multifaceted articulation
Humeroradial articulation
Humeroulnar articulation
Radioulnar
(Reid 1993)
Ligamentous Anatomy
Ligamentous Anatomy
Ulnar collateral
Radial Collateral
Annular Ligament
(Reid 1993)
Muscular Anatomy
Supinator C5-C6
Brachioradialis C5-C6
ECRL C6-C7
ECRB C6-C7
Extensor Digitorum Longus
Triceps C7-C8
Anconeus C7-C8
C6-C8
(Travell and Simons 1983)
Neural Anatomy
Radial Nerve Between lateral and medial Triceps
heads
Divides prox to elbow
Under fascial connections of ECRB
Pierces supinator head and continues to
supply extenor musculature
Peyto Lake, Jasper
Lateral Elbow Pain
Terminology - Tennis Elbow Vs
Lateral Epicondilytis Vs Lateral
Epicondylalgia
Approximately 3% of population
Accounts for 5-7/1000 GP visits
45% of elite tennis players
Age- 35-50 years
Males=Females
Etiology
Becomes evident with repetitive
loaded tasks
Tennis
Golf
Baseball
Presents also with repetetive
unloaded tasks
Sweeping
Computer workers ie desk jokeys
Common Symptoms
Pain over lateral epicondyle radiating
into forarm
Pain on activities using the hands
Weakness of grip strength
Occasional night pain
Possible soreness in the am
May worsen thru the day
Sources contributing to Lateral
Epicondylalgia
1.
2.
3.
4.
5.
6.
7.
Common Extensor Tendon
Myofascial
Radio-humeral joint
Cervical and Neural Involvement
Central Sensitization
Elbow joint arthritis
Ligamentous
Common Extensor Tendon
Tendinitis vs tendinopathy
No findings of inflammatory cells
Macroscopically Tendon is dull, brown and soft
Microscopically-
Findings of disrupted collagen fibers
Increased cellularity-myofibroblasts but not
inflam. cells
Neovascularization
Poorly organized collagen
Focal necrosis
Nirschl and Ashman 2003
Histology
Normal Tendon
Tendinosis
Khan et al 2000
Imaging
MRI
Increases in signal in
affected tendons
Ultrasound
Increase in hypo-echoic
area in tendon
Khan and Cook 2004
Importance??
Effect of medical anti-inflammatory
treatments
NSAIDS
Cortisone injections
Effect of physical anti-inflammatory
treatments
Outcome of injury
Time frames for rehabilitation
3-6 months
Myofascial
Travell and Simons
Active trigger points through elbow
musculature as causes of pain
Trigger points
What are they?
Palpable tight and tender bands within muscle
substance
Are normally found in muscle
When excessive can cause pain with referral
Why are they??
Ca channel blockages
Tetonic muscular contraction
Avascular portion of muscle
Why they develop?
Overuse
Repetitive action ie postural
Due to lack of local/deep muscle activity
Protective response
neural system
Neural driven
Radiculopathies
Psychological
Nutrition
Sleep disturbances
Evaluation
Palpation of active trigger points
through elbow musculature
Palpate for active triggers through
cervical and scapular musculature
Common trigger points involved in
Lateral Epicondylalgia
Brachioradialis
Supinator
Extensor Digitorum Longus
ECRL
ECRB
Triceps
Anconeus
Supinator
Brachioradialis
(Travell and Simons 1983)
Forearm Extensors
(Travell and Simons 1983)
Triceps
Long head(1) and lateral Medial
Head(2)
Triceps
Lateral Head(3) and Deep Medial
Head(4)
(Travell and Simons 1983)
Anconeus
(Travell and Simons 1983)
Radio-humeral joint
Radial head
subluxes in pronation
reduces in supination
In sustained pronation postures, head of
radius may sublux increasing load on CEO
(Mack ??)
Due to:
Lack of supination range
Poor eccentric control of supinator
Evaluate
Joint play
Especially into supination
Lateral Glide
Accessory movement (Vincenzino 2003)
Only 20% of patients may have articular signs
(Yaxley and Jull, 1993)
Muscular control of supinator
Deep stabiliser of radiohumeral joint
(Stroyan and Wilk 1993)
Neural and Cervical Involvement
Most commonly C6-C7 spinal
segments
Upper limb neurodynamics altered
ULTT IIb-radial nerve
Evaluate
Cervical Spine
PPIVMS- hyper vs hypo
PAIVMS
Possible direct referral to elbow
Neural
ANT for radial nerve- ULTT IIb
Reactivity and tenderness on radial
nerve palpation
Central Sensitization
Secondary hyperalgesia
Represents disordered neural processing
and central sensitisation
(Wright et al 1992)
Examination of CEO Increased levels of glutamate, mediator
in pain
Reduced levels of prostaglandin P2
(Alfredson, 2000)
Changes in sensory-motor system
Reduction in reaction time, speed of
movement and co-ordination
Changes also evident in unaffected side
(Pienimaki 1997a)
Abnormal postures and muscle activation
Studied in tennis players (Kelly 1994)
Clinically seen as poor scapulohumeral stability
and poor postural positions
Evaluation
Postural position
Scapulohumeral stabilty and rhythm
Statically
Resting posture
Dynamically
Open kinetic movement
Close kinetic loading tests
Functional
Scapular slide tests
Putting it all together
Jasper National Park
How does it come together..
Altered Central
Processes
Altered Cervical
Function
Altered cervical
and scapular
control
Altered Neural
Function
Tendinopathy
Altered R/H Function
Lateral Epicondylalgia
Altered myofascial system
Aims of Physiotherapy
Lake Louise
Banff National park
Identify causative systems
Use manual treatment techniques
Therapeutic Exercise
Progress above into functional tasks
Physiotherapy and Lateral Epicondylalgia
Jasper National Park
Treatment for Tendinosis
Not a lot of supporting evidence for physical therapy
modalities
Ultrasound
IFT
ICE
Frictions
Best physiotherapy intervention
Eccentric wrist extensors exercise
Curwin and Standish type protocol
Braces and taping
Unload forces in tendon
Tapings
UNLOADING and
RADIAL HEAD SUPPORT
MCCONNELL UNLOADING TAPE
Treatment for altered
Myofascial System
Release active trigger points
Soft tissue techniques
Spray and stretch
Ice release
Stretching
Trigger point injections
IMS- similar to dry needling, most effective
Correct causative factors
Travell and Simons, 1983
Dry needling
Most effective and least painful
ECRL
Brachioradialis
Supinator
Lateral head of triceps
Painful
Anconeus
Extensor digitorum
Treatment for altered radiohumeral function
Manipulation
Radio-humeral joint mobilisations
p/a to improve supination
MWM lateral glide of elbow
Manual treatment
Home treatment
(Mulligan 1999)
Therapeutic Exercise
Eccentric Supinator control
Hammer
Theraband
Into ranges of elbow flexion
Progress to functional
Manipulation
- High velocity thrust
- Force in line with joint
- No muscle spasm
MWM elbow
- Sustained lateral glide
- Gripping
- Progress into elbow ext
and pronation
- Pain free
MWM self treatment
Altered cervical and neural function
and central processing
Cervical manual therapy
Mobilisation
Manipulation
Spinal/Neural manual therapy
Elvey approach
Lateral glides +/- neural tension
(Elvey 1986)
Mulligan approach
MWM cervical spine- lateral glide or A/P
Elvey lateral glide
Stabilising hand
- Lateral glide to segment
- Oscillatory technique
- Progress into ANT
Stabilising hand
MWM with a/p glide
- Sustained a/p glide
- Gripping
- Progress into elbow ext
pronation and ANT
- Pain free
Effects may be more neurological
than physiological
Pathology Education- explain pain
Butler
(Vicenzino 2003, Abbott 2001)
I FEEL GREAT!!
A guide for the use of
Manual Therapy (Vicenzino 2003)
Sunshine Village, Banff
1.
2.
3.
4.
5.
Grip pain >> Palpation
MWM elbow and self treatment
Elbow manipulation
p/a radial mobilisations
Palpation>> Grip pain
Cervical lateral glide
MWM cervical spine- lateral and a/p
Grip pain=Palpation
Try 1 first
May need to move then to 2
Past history of Cx dysfunction
Try 2
Night pain
As long as it is mechanical, use taping
A Guide to Therapeutic Exercise
Winter, Lake Louise
Eccentric Exercise
Wrist extensors
Supinator
Scapular Stability
Low traps
Serratus Anterior
Upper Traps??
Cervical Stability
Deep neck Flexors
Global Upper limb conditioning
Rotator cuff
Triceps
Isolated and Functionally
Neuromuscular Connection
Stability
Dynamic
Functional
(OSullivan 2000)
Practical Session
MWM
Elbow lateral glide
Cervical a/p
Elvey Lateral Glide
Taping
Tennis elbow taping
McConnell Unloading
Thank you
Three Sisters, Canmore
