Lateral Epicondylalgia

1. Lateral Epicondylalgia How can physical therapy help your patients with this painful condition? Group Delta

2. Lateral Epicondylalgia (LE) • This condition affects 1.3% of the population and 15% of workers who work in situations that require repeated gripping maneuvers. • Conservative treatment is generally the recommended approach, although this condition can be difficult to treat. • LE can be recurrent in nature, although most will experience resolution of symptoms within 6 to 24 months even without treatment.

3. Lateral Epicondylalgia (LE) • Formerly known as “tennis elbow” or “lateral epicondylitis” • LE has recently been demonstrated to be a degenerative process • Characterized by a dense population of fibroblasts, disorganized and immature collagen, and an absence of an inflammatory process. • The affected tendon is most commonly the extensor carpi radialisbrevis (ECRB). Waugh EJ. Lateral epicondylalgia or epicondylitis: What’s in a name? JOSPT. 2005; 35(4): 200-202.

4. Physical Therapy Treatments for LE • Joint mobilization at the elbow • Strengthening exercises • Flexibility/stretching • Acupressure • Spine mobilization • Kinesiotaping • Dry needling • Iontophoresis

5. Joint Mobilization at the Elbow • Mobilization with Movement (MWM) Non-thrust mobilization technique performed with the elbow extended and pronated. • The therapist applies a lateral glide to the elbow while the patient performs a painful activity (usually a gripping motion or grip dynamometer). • While sustaining the glide, have the patient repeat the isometric gripping action. Repeat 6-10 times in a session. • VicenzinoB, Cleland J, Bisset L. Joint Manipulation in the Management of lateral Epicondylalgia: A Clinical Commentary. The Journal of Manual & Manipulative TherapyVol. 15 No. 1 (2007), 50–56 • Vicenzo B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Manual Therapy (2003) 8(2), 66–79.

6. MWM • MWM continued • MWM and exercise demonstrated a significantly improved pain-free grip ratio, severity rating, and global improvement at 6 weeks compared to control group following 8 treatments. • Demonstrated to be significantly better than corticosteroid injection at 52 week follow-up. • Subjects also had significantly fewer recurrences (5) than did the injection group (47). • Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, Bill Vicenzino. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ, doi:10.1136/bmj.38961.584653.AE (published 29 September 2006).

7. MWM • MWM continued • MWM combined with taping demonstrated significantly greater improvements in pain rating and outcome scores in 34 subjects when compared to traditional treatment (thermal treatment, massage, US, strengthening, stretching). • CPR developed for subjects more likely to respond to MWM and exercise including age <49, pain-free grip strength of >112 N on affected side, and pain-free grip strength of <336 N on the unaffected side. • AkramA., Diener I, Bdair W, Hameda I, Shalabi A, Ilyyan D. The effects of Mulligan mobilization with movement and taping techniques on pain grip strength, and function in patients with lateral epicondylitis. Hong Kong Physiotherapy Journal (2010) 28, 19-23. • Bill Vicenzino, Dugal Smith, Joshua Cleland, Leanne Bisset. Development of a clinical prediction rule to identify initial responders to mobilisation with movement and exercise for lateral epicondylalgia. Manual Therapy 14 (2009) 550–554.

8. Wrist Manipulation High velocity low amplitude thrust technique performed at the scaphoid bone for lateral epicondylalgia

9. Wrist Manipulation • Patient’s involved forearm is rested on a table with the palmer side down. The therapist sits at a right angle and grips the scaphoid bone with the thumb and index finger. The therapist then extends the patient’s wrist dorsally and the scaphoid bone is manipulated ventrally at the same time. • In a study of 31 subjects, scaphoid manipulation resulted in significant improvements in pain during the day compared to multimodal treatment approach (US, friction massage, strengthening exercises) after 9 treatments over a 6 week period. • Struijs P, Damen P, Bakker E, Blankevoort L, Assendelft W, Niek van Dijk C. Manipulation of the Wrist for Management of Lateral Epicondylitis: A Randomized Pilot Study. Physical Therapy . Volume 83 . Number 7 . July 2003.

10. Elbow Manipulation • Mills Manipulation • High Velocity Low Amplitude thrust performed at the end of elbow extension while the wrist and hand are flexed

11. Spine Mobilization • Spinal segmental dysfunction may contribute to pain in the elbow region. Concomitant neck pain has been shown to be one of the strongest contributors to persistent elbow pain. Studies examining the effects of treatment of the cervical and thoracic spine have noted the following: • 70% of subjects with lateral elbow pain reported pain also in the cervical or thoracic spine as compared to 16% in a control group. • Cervical flexion and extension range of motion was significantly lower in the lateral elbow pain group as compared to the control group. • Provocation tests of the cervical and thoracic spine were significantly higher in the lateral elbow pain group as compared to controls. • 90% of subjects with lateral elbow pain presented with segmental hypomobility in the lower cervical spine.

12. Spine Mobilization • Manual physical therapy techniques directed at the spine include passive accessory and physiological intervertebral mobilization, manipulation, and muscle energy techniques. These manual techniques result in: • Immediate decreases in pressure pain thresholds around the elbow joint. • Immediate improvement in neurodynamics. • Possible reductions in abnormal afferent input. • Fewer physical therapy visits needed to achieve reduction in pain.

13. Strengthening Exercises • Patients with LE demonstrated statistically significant improvement in grip strength following isotonic exercises as compared to control groups. • A supervised eccentric strengthening program performed over the course of four weeks reduces pain (VAS), improves function, and improves pain-free grip strength at 28 week follow-up as compared to Cyriax therapy and bioptronlight. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylitis – A systematic review. J Hand Ther. 2012; 25: 5-26.

14. Strengthening • Isometric strengthening (home exercise program consisting of four sets of 50 repetitions daily) early in the course of lateral epicondylalgia produced clinically significant improvement in pain and function (measured by the Modified Nirschl/Pettrone score) at one-month follow-up. • Minimal difference between immediate physical therapy and delayed physical therapy (exercises beginning following 4 weeks of oral NSAID treatment) at 12 month follow-up. Park JY, Park HK, Choi JH, et al. Prospective evaluation of the effectiveness of a home-based program of isometric strengthening exercises: 12 month follow-up. Clinics of Orthopedic Surgery. 2010; 2: 173-178.

15. Strengthening • In a chronic lateral epicondylalgia population, an isokinetic eccentric exercise program for the forearm supinators and wrist extensors was performed and found to be beneficial. • Beginning at low load (30% maximal intensity) with progressive increase in velocity and intensity resulted in decreased pain (VAS), and improved function as compared to control group (ice, analgesic TENS, ultrasound, deep friction massage, and stretching). Croisier JL, Foidart-Dessalle M, Tinant F, et al. An isokinetic eccentric programme for the management of chronic lateral epicondylartendinopathy. Br J Sports Med. 2007; 41: 269-275.

16. Flexibility/Stretching • Flexibility exercises to stretch the wrist extensor muscles are commonly used in PT practice. • These exercises are designed to decrease the downward pressure on the bone from where these muscles originate and the site of primary pain. • These are done with the elbow in full extension and the wrist in full flexion. • The opposite hand grabs the flexed wrist and stretches it further downward--stretching the tight wrist extensor muscles. The stretch is held for 10 seconds and repeated throughout the day.

17. Wrist Extensor Stretch

18. Acupressure • Acupressure to the upper forearm: This site is located approximately 1.5inches below and towards the thumb from the primary bony pain site of the elbow. • This is a trigger point over a very deep nerve and requires deep and constant pressure for approximately 15 seconds at a time and significantly helps reduce the tightness in the wrist extensor muscles which provides relief of the severe pain in the elbow. • Your therapist will identify this pressure point for you so that you can administer the pressure yourself throughout the day.

19. Kinesiotaping • Kinesiotape and kinesiotaping (KT) method were founded by Dr.kenzoKase in 1973 in Japan. • Physiological effects of KT: • Stimulates sensory receptors which are required for normalization of tone and eliciting desired muscle response. • Affects all layers of the body and improves fascia mobility. • Decreases inflammation/swelling/pressure on mechanical receptors resulting indecreased pain and spasm. • Maintains homeostasis. • Increases space beneath skin and increases fluid exchange between tissue layers. • Reduces edema and increases healing process and assists tissue recovery. • Decreases pain, improves ROM and reduces fatigue. • Facilitates ligament and tendon function.

20. Kinesiotaping • The treatment for lateral epicondylalgia falls under two corrective techniques: • Fascia Correction • This method utilizes “Y” strip with tension on tails. In this method we gather fascia to align tissue by using 15-25% stretch. Position to be maintained is elbow in extension, forearm pronation, wrist ulnar deviation. Tape can be applied at radial styloid area and tails surround the tissue end above the lateral epicondyle.There should be no tension at the ends and then we activate the glue. • Space Correction • This method is called a Donut Hole. We cut I strip, fold tape, cut a hole on the fold and slit the ends. We position the arm in extension, tear paper in the center, apply a stretch of 25-50% and splay the ends.

21. Kinesiotaping

22. Benefits of Kinesiotaping • Analgesic effect • Creates space for area of pain and inflammation • Increases lymph drainage from the area via increased subcutaneous space • Correct Misalignments • Aligns fascial tissues

23. Dry Needling • Muscle trigger points may contribute to pain in the elbow region. A trigger point is a hyperirritable contracture knot located within a taut band of muscle that, when pressed upon, reproduces the pain that a person is experiencing. Trigger points may develop from muscle overload, such as: • Prolonged postural demands (as seen in computer workers, dentists, musicians) • Unaccustomed or prolonged eccentric activity (e.g. manual labor, engaging in sports such as weight-lifting, tennis) • Direct trauma

24. Dry Needling Trigger points involved in elbow pain may be located in muscles surrounding the elbow (triceps brachii, brachioradialis, supinator, extensor carpi radialislongus and brevis, and extensor digitorumcommunis) or in muscles distant from the elbow, such as the infraspinatus and supraspinatus. Several studies examined the prevalence of trigger points in patients presenting with complaints of elbow pain. They found that these patients had significantly more muscle trigger points when compared to their non-painful elbow and when compared to normal controls.

25. Dry Needling Dry needling is a treatment approach in which a thin filament, or needle, is inserted into the trigger point. The needle is directed in and out of the trigger point until a local twitch response occurs, signaling a release of the contracture knot and corresponding increases in blood flow, restoration of normal muscle length-tension, and decreases in pain. These changes are immediate and lasting.

26. Iontophoresis • A recent study found that for the treatment of lateral epicondylalgia, iontophoresis using dexamethasone is more effective than cortisone injection. • All patients in the study were treated with hand therapy consisting of three phases: rest, mobility (stretching to increase ROM), and strengthening (to increase strength and overall function). • Patients were also randomized into groups receiving dexamethasone via iontophoresis (maximum of two treatments), intramuscular/intratendinous dexamethasone injection, and intramuscular/intratendinous triamcinolone injection. Stefanou A, Marshall N, Holdan W, et al. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg. 2012; 37A: 104-109.

27. Iontophoresis • Outcome measures (grip strength, and patient-rated tennis elbow evaluation which assessed pain and function) were taken at baseline, completion of treatment, and six month after treatment. A secondary outcome of work status was also assessed (no work restrictions, work with restrictions, unable to work) • This study found more statistically significant improvement in grip strength and unrestricted return to work in the iontophoresis group than in the two injection groups • Hypothesis for this finding is that once the analgesic effect of the intramuscular medication wears off, the degenerative pathology of lateral epicondylalgia remains unchanged. In contrast, iontophoresis is non-invasive and may help to reduce acute pain while not blocking the release of cytokines in the degenerated tissue. Stefanou A, Marshall N, Holdan W, et al. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg. 2012; 37A: 104-109.

28. Referral Patients with lateral epicondylalgiademonstrate improvements in pain, grip strength, and function when referred to a licensed Physical Therapist.

29. Additional References Spine Mobilization: Gunn, C., Milbrandt, W.; 1976; Tennis elbow and the cervical spine; Can Med Assn J; 114: 803-809. Vicenzino, B., et al; 1996; The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylaglia; Pain; 68:69-74. Vicenzino, B., et al; 2007; Joint manipulation in the management of lateral epicondylalgia: a clinical commentary; J of Manual & Manipulative Therapy; vol. 15; no. 1; 50-56. Berglund, K.M., et al; 2008; Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain; Manual Therapy; 13: 295-299. Cleland, J., et al; 2004; Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis; JOSPT; vol. 34; no. 11; 713-723. Fernandez-Carnero, J., et al; 2008; Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia; J of Manipulative and Physiological Therapeutics; 31(9): 675-681. Smidt, N., et al; 2006; Lateral epicondylitis in general practice: course and prognostic indicators of outcome; J Rheumatol; 33: 1-7.

30. Additional References Kinesiotaping: Liu, Y.H., Chen, S.M., Lin, C.Y., Huang, C.I., and Sun, Y.N. (2007). Motion tracking on elbow tissue from ultrasonic image sequence for patients with lateral epicondylitis. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference 2007, 95-98.

31. Additional References Dry Needling: Fernandez-Carnero, J., et al; 2007; Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia; Clin J Pain; vol. 23; no. 4; 353-359. Fernandez-Carnero, J., et al; 2008; Bilateral myofascial trigger points in the forearm muscles in patients with chronic unilateral lateral eipcondylalgia: a blinded, controlled study; Clin J Pain; vol. 24; 802-807. Simons, D.G., Travell, J.G., Simons, L.S.; 1999; Travell & Simons’ Myofascial pain and dysfunction: the trigger point manual, vol. 1. Second ed. Lippincott William & Wilkins, Baltimore, pp. 278-307. Shah, J., Gilliams, E.; 2008; Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofasical pain syndrome; J Bodywork and Movement Therapies; vol. 12; 371-384.