Posts tagged lateral elbow pain
Manual Therapy Improves Outcomes In Patients With Tennis Elbow
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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
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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.  

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Lateral Elbow Pain and Physical Therapy Solutions
lateral elbow pain, tennis elbow, boulder physical therapy

Elbow pain on the outside of the elbow is most common in individuals’ aged 30-50 y.o. and effects 1-3% of the general population (Shiri et al. 2006).  Risk factors for this condition include blue collar workers utilizing repetitive gripping and manipulation in the work place, smokers, and tennis athletes.  This condition has previously been described as tennis elbow or tendonitis.  The first term is a non specific umbrella term and the second has been proven to be incorrect based on our current understanding of the pathophysiology behind this condition.  Tissue sampling of the wrist and finger tendons running along the outside of the tendon has failed to show any inflammatory cells making the term lateral epicondylosis, epicondylalgia, or lateral elbow tendinopathy more appropriate. 

These terms suggest a more degenerative condition consistent with increased cellular and collagen formation (Cook et al. 2009).  Our previous blog post detailed the ineffectiveness of anti-inflammatory treatments, including NSAIDs and corticosteroid injections, for the long term management of lateral elbow pain.  In fact, corticosteroid and platelet rich plasma (PRP) injections have been shown to have poor long-term outcomes and the highest rates of recurrence among conservative treatments (Coombes et al. 2013).  Recent evidence advocates for early diagnosis and management based on an individual’s unique presentation (Coombes et al. 2015).  Differences in the clinical presentation of this condition are normal and our examination and treatment must be based on the patient’s presentation.

Clinical examination involving pain at a patient’s lateral elbow, and pain with gripping or finger and wrist extension is consistent with lateral elbow pain.  Caution is advised to rule out competing diagnoses including referral from the neck, nerve entrapment, ligament tears, and elbow instability.  Clinicians should examine surrounding areas of the body to determine their impact on pain processing and/or   

Patients with higher levels of baseline pain and disability require early interventions due to the poor long-term prognosis associated with this presentation (Smidt et al. 2006).   This patient population may also present with greater symptoms at rest including night pain interfering with sleep patterns.  Another factor often associated in patients with lateral elbow pain includes concomitant musculoskeletal complaints in the neck and shoulder.   A treatment plan aimed at treating impairments in the upper quarter, in addition to the elbow, may accelerate recovery and reduce future recurrence (Cleland et al. 2005).

manual therapy, lateral elbow pain, physical therapy

Conservative treatment remains a hallmark of lateral elbow tendinopathy.  The vast majorities of patients treated conservatively with either a wait and see approach or with Physical Therapy demonstrate improvements in pain and function at one year (Bisset et al. 2006).  The difference among treatment groups is secondary to the speed of recovery and economic impact seen in groups assigned to Physical Therapy.  Physical Therapy groups undergo a rapid improvement in the short term while the wait and see group takes up to 26 weeks to reach the same level of improvement.  This rapid improvement in symptoms leads to decreased costs due to decreased utilization of health care resources in the coming year.   The key question in the literature is what treatment should patients be provided with once they enter Physical Therapy. 

Manual therapy including spinal and extremity joint mobilization and manipulation has been shown to reduce pain processing and improve pain and function.  Pain free grip strength has immediately increased in response to these elbow interventions.  These techniques are designed to reduce pain and allow a faster transition to an exercise program. 

Exercise is one of the most important components of a treatment programs.  Upper quarter exercises have been shown to reduce time off work and future medical costs, as well as, improve work and ADL tolerance (Pienimaki et al. 1998).  Programs should gradually load the wrist extensors to restore coordination and strength to the tendon.  A more irritable patient will benefit from isometric exercise whereas a more chronic, less irritable condition will benefit from eccentric exercises.  Progression of the exercises should involve multi joint and functional movements to restore function in the upper quarter.

A recent review article suggests sub grouping patients based on their presenting signs and symptoms to best determine how to allocate these PT interventions (Coombes et al. 2015).  These authors suggest advice, NSAIDs, and a wait and see approach for patients without risk factors for long term disabiilty, low pain severity and disability.   Conversely, moderate and high risk patients with risk factors for long term disability, high pain and disability scores are most appropriate for pain medication and physical therapy interventions. 

Physical Therapy sub groups, lateral elbow pain

In conclusion, lateral elbow pain is not a homogenous condition and should be examined and treated based on an individual’s presentation for optimal outcomes.