Posts tagged elbow pain
Manual Therapy Improves Outcomes In Patients With Tennis Elbow
lateral-elbow-pain-tennis-elbow-treatment

Manual therapy, including joint mobilization and manipulation, is a Physical Therapy intervention designed to reduce pain and improve mobility.  These interventions have been shown to accelerate a patient's recovery compared to usual care or exercise alone.  Although mechanisms behind its' effectiveness are still being researched, manual therapy unique ability to reduce pain allows an individual to exercise at a higher intensity.  Greater loading of the injured tendon accelerates a patient's recovery and return to work and sport.  A recent review of the literature highlights the benefits of manual therapy for patients with lateral elbow pain.

Lucado and colleagues reviewed 20 studies on the effectiveness of manual therapy applied either locally to the elbow or globally to the upper quarter in patients with lateral elbow pain (J Hand Ther. 2018).  These techniques included mobilizations, mobilizations with movement, and manipulation.  The authors found local elbow manual therapy treatments reduced pain and improved pain free grip strength in the short term.  Regional manual therapy techniques applied to the upper quarter improved pain, grip strength, and function.  The authors concluded there is compelling evidence for the utilization of manual therapy by Physical Therapists at all time points in a patient's recovery from lateral elbow tendinopathies.

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Shoulder Stabilization Improves Pain and Function in Patients with Elbow Pain
Shoulder-stabilization-lateral-elbow-pain-treatment

Lateral elbow pain, tennis elbow, is a limiting condition causing pain with repetitive movements including gripping.  This condition was previously though to occur secondary to inflammation within the wrist and fingers tendons insertion into the arm, but current researchers have not found inflammatory cells in patients with this condition.  Instead, cells of the injured tendons display degeneration and disorganization consistent with the healing process.  Gradual loading of these injured tendons with exercise has been shown to accelerate the recovery process and tendon remodeling.

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Loading of the injured tendon through exercise is critical to its' healing.  Both over loading and under loading are equally detrimental to the recovery of the tendon.  New research demonstrates utilizing shoulder strengthening reduces pain and improves arm function in patients with lateral elbow pain.  Lee and colleagues randomized patients to either elbow or shoulder strengthening groups (J PT Sci. 2018).  Authors reported both groups improved grip strength, pain, and tenderness after the completion of the strengthening program.  No differences were noted between groups indicating loading of the injured tendons can be done specifically at the elbow or globally through the shoulder.  The key is loading based on the tissue tolerance of the injured tendon.  

To learn more on how to successfully manage your tendon pain contact the experts at MEND

No Difference Between Surgery and Placebo Surgery For Tennis Elbow
elbow-pain-tennis-elbow-treatment

Tennis elbow or lateral epicondylalgia is a painful condition affecting the wrist and finger extensor tendons as they attach into the arm.  Breakdown of the tendon at its' insertion and weakness in the forearm muscles lead to pain and reduced tolerance for gripping and hand movements.  Physical Therapy treatments including manual therapy to the spine and extremity joints has been shown to accelerate recovery and lead to reduced healthcare utilization over the long term.  Importantly, manual therapy improves a patient's tolerance for strength training exercises which allow for long term relief.  Patient's who do not improve with conservative treatments may opt for surgical debridement of the injured tendon and muscle.  

A recent double blinded, randomized controlled trial compared the effectiveness of surgery to a sham or placebo surgery in patients with chronic tennis elbow pain (Krosiak et al. Am J Sports Med. 2018).  Patients were randomized to either a sham/placebo group (skin excision and exposure of the tendon) or a surgical debridement and excision of the affected tissue.  Interestingly, both groups improved pain and function at 6 month follow up but there were no significant differences between groups.  Authors stopped the study early due to the lack of differences between the surgical and placebo groups.  The authors reported no additional benefit of surgery over placebo for patients with chronic elbow pain.

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Imaging's Role in Youth Baseball

In our previous blog posts we have written on the limitations of MRI for many injuries and conditions.  In general, these expensive tests have high rates of false positives where patients without pain often have positive results including ligament/labrum tears or tendon changes.  The incidence of false of positives increases in athletes with the majority of major league baseball players, regardless of symptoms, demonstrating rotator cuff tears or labrum injury.   It appears these changes are no different in our little leaguers.  

An article in the Journal of Bone and Joint Surgery examined 10-13 year old little league baseball players.  Each player underwent an MRI on both elbows at the start of the season.   The authors found many of the players with or without pain had imaging findings in their elbow.  Adding to our existing data that many athletes have positive MRI findings without pain or injury.  Two factors were associated with a positive MRI and elbow pain including year round baseball play and working with a private pitching coach.  

Athletes are encouraged to work with a local Physical Therapist to treat their elbow pain and reduce their risk of throwing injuries. 

Shoulder Range of Motion and Risk of Injury in Professional Baseball Players

Shoulder and elbow injuries are on the rise among youth and professional baseball players.  Our previous post on baseball injuries detailed the risk of future injury if an athlete has lost range of motion in his shoulder prior to the season.  In particular, emphasis has been placed on the amount of internal rotation (hand behind lower back) in an athlete's throwing shoulder.  A common adaptation in a thrower's shoulder is to develop additional external rotation (cocking phase of throwing) and lose internal rotation (Figure A).  An important point is the athlete should maintain the same total range of motion from side to side given this adaptation (Figure B).  An at risk shoulder would have an total range of motion less than the uninvolved side.  

A recent prospective study in the American Journal of Sports Medicine examined the impact of a Professional thrower's range of motion on their injury incidence during the season.  Wilk et al. examined 296 professional pitchers for range of motion and followed these players through the upcoming season.  As expected, the authors noted significant side to side differences in their shoulder range of motion.  51 pitchers reported 75 shoulder injuries for a total of 5570 days on the disabled list and 20 surgeries were performed.  The authors found <5 degrees greater external range of motion in the throwing shoulder of pitchers made them 2 and 4 times as likely to become placed on the disabled list or undergo surgery during the season.  

A thrower requires a greater degree of shoulder external rotation than another athlete, if this adaptation is not present it may be a sign of further problems.  In particular, the total range of motion should be measured and be equal between the throwing and non throwing shoulders.  For more injury prevention information or to address risk factors for your sport contact the experts and Mend Physical Therapy. 

Lateral Elbow Pain (tennis elbow) and Physical Therapy Treatments
Lateral elbow pain and boulder physical therapy treatments

Lateral Elbow Pain and Lateral Epicondylalgia

Lateral epicondylalgia, also known as tennis elbow, is an overuse injury involving the common origin tendon of the wrist and finger extensors. Patients with this condition often report pain in the lateral elbow exacerbated by gripping, lifting, or manipu- lating objects with their hands.

Previously thought to be a condition of inflammation (lateral epicondylitis), new research shows a lack of inflammatory cells in this condition. Instead, lateral epicondylalgia is considered a degenerative condition and one of dysfunctional, immature healing of the tendon(5,6). Tendons have been shown to remodel and heal along the lines of stress from exercise and appropriate loading(7).

4-7 cases per 1000 patients experience the condition and lateral epicondylalgia has a 1-3% incidence within the general population(1,2).

The condition primarily effects the dominant arm of individuals between 35-54 years old1. Amateur tennis players, patients with poor posture, frequent computer use, and manual tasks involv- ing force and repetition are at greater risk for the condition(2).

The majority of patients reports resolution of their symptoms by 1 year but may range up to 24 months(1).

Physical Therapy interventions have been shown to accelerate this recovery process and have been shown to be more cost effective than a wait and see approach or a corticosteroid injection(9). 

Elbow Pain and Physical Therapy Treatments

elbow pain, manual physical therapy, treatments

Review articles do not support the use of Physical Therapy modalities including ultrasound and iontophoresis in the treatment of lateral epicondylalgia(4).

Corticosteroid injections have been advocated for short term relief by many studies. While experiencing early relief, patients undergoing corticosteroid injections have a higher recurrence rate (72%) compared to a wait and see (10%) or Physical Therapy treatments (4%). (3)

Recent systematic report strong evidence against the utilization of platelet rich plasma (PRP) injections in patients with lateral elbow tendinopathy(12).

Evidence reviews on the topic of lateral elbow pain advocate for a multimodal Physical Therapy treatment model including spinal and extremity joint manipulation/ mobilization, soft tissue treatments, and strengthening exercises(4,13). 

boulder manual physical therapy, elbow pain, mobilization with movement

Physical Therapy Evidence

A manual physical therapy approach combined with exercise has been shown to accelerate a patient’s recovery by reducing pain and disability in the short term. Medical evidence has also shown patients receiving this treatment approach have the lowest recur- rence rate of pain and medication use(10,11).

Conversely, poorer long term outcomes and higher recurrence rates have been documented in patients receiving corticosteroid injections(10).

Bisset et al. reported the utilization of manual therapy and exercise is superior to wait and see and corticosteroid injection at short-term follow up11. It appears PT helps accelerate recovery and is superior to a wait and see approach.

Evidence suggests treatment of the upper quarter including the cervical, thoracic, elbow, and wrist regions may provide positive effects on patient’s pain and function(14). 

physical therapy, wait and see, injection for elbow pain

When to Seek Physical Therapy Care

Patient’s with lateral elbow pain exacerbated by gripping or manipulation of the hand and wrist should be treated with a multimodal Physical Therapy treatment plan to reduce pain and disability. 

References

1. Smidt N, Lewis M, Van Der Windt DA, et al. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol 2006;33:2053–9.

2. Shiri R, Viikari-Juntura E, Varonen H, et al. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol 2006;164:1065–74.

3. Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939.

4. Coombes, B. et al. A new integrative model of lateral epicondylalgia. Br J Sports Med 2009;43:252–258

5. Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports 2008;18:3–15.

6. Alfredson H, Ljung BO, Thorsen K, et al. In vivo investiga- tion of ECRB tendons with microdialysis technique--no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand 2000;71:475–9.

7. Riley G. Chronic tendon pathology: molecular basis and therapeutic implications. Expert Rev Mol Med 2005;7:1- 25.

8. Smidt N, Assendelft WJ, van der Windt DA, et al. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain 2002;96:23–40.

9. Coombes, B. et al. Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. Br J Sp Med. 2015.

10. Coombes, B. Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia A Randomized Controlled Trial. JAMA. 2013. 309(5):461-469.

11. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corti- costeroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.

12. De Vos, R. et al. Strong evidence against PRP injections for chronic lateral elbow tendinopathy. A systematic review. Br J Sp Med. 2014.

13. Fernandez-Carnero, J. et al. EXAMINATION OF MOTOR AND HYPOALGESIC EFFECTS OF CERVICAL VS THORACIC SPINE MANIPULATION IN PATIENTS WITH LATERAL EPICONDYLALGIA: A CLINICAL TRIAL. J Manipulative Ther Phys. 2011. 34(7):432-440.

14. Vicenzino, B. et al. Joint manipulation in the management of lateral epicondylalgia. A clinical commentary. JMMT. 2007. 15(1):50-56.