Tennis Elbow – making a difference?

Tennis Elbow is one of those conditions where cautious prognosis is wise until we see the response to treatment over one or two reviews.  The propensity for chronicity in this area is well known to both therapists and patients alike.  Associated with this resistance to treatment is a wide variety of treatment techniques employed (always a warning sign).  One of the biggest challenges clinically is demonstrating improved pain response during individual treatment session’s.

Specific clinical markers for tennis elbow

Resisted wrist extension

Resisted supination,

Resisted elbow flexion

Resisted finger extension

Grip strength

all provide a cluster of easily quantifiable measures to determine improvements in function or reductions in elbow sensitivity.

Of course the first important issue to recognise is that not all lateral epicodylitis is the same phenomena and in reality spans a spectrum from …

Pathological Spectrum

Common extensor tendon insertion pain

Myofascial irritation of the forearm supinators and wrist extensors

Radioulnar joint dysfunction

Peripheral entrapment neuropathies at the lateral elbow

Biceps insertion

Tendenopathies

Elbow joint pathology.

This spectrum of pathologies is likely associated with the variations in provocation testing which we observe clinically but nonetheless does give us direct feedback on the effectiveness of our interventions.

Treatment Strategies

Using anti-inflammatory modalities such as ultrasound, interferential, laser and TENS rarely produce an objective improvement in measurable function within a treatment session.  Whilst the merits of employing anti-inflammatory measures as part of the management strategy seem reasonable, their merits are usually not directly measurable but would fit in the category of “useful things” to include in the management.

commonly utilised around the area of irritation can sometimes induce a local analgesic effect resulting in measurable change in objective measures.  Experience suggests a variable response, often indirectly measured over time rather than within sessions and  with significant potential for causing irritability in the presence of a neural component to symptom patterns.

Manual therapy – anteroposterior mobilisation of the radial head, elbow extension and medial glide of the olecranon are accessory joint motions which should be routinely assessed both for mechanical characteristics and symptom provocation.  When these are contributory factors one can generally expect an observable change on test re-test within a treatment session.

Neural mobilisation – this is a large topic in its own right but in the presence of neural sensitivity direct nerve mobilisation techniques have an important role in desensitisation.  The clinical challenge of course is actually producing a nerve desensitising effect from mechanical treatments.  There is the potential to produce increased neural sensitivity particularly if the mechanical aspects of the nerve interface throughout the length of the upper limb have not been adequately screened and addressed.

SNAGS

Brian Mulligan’s work has been pioneering in this regard and seat belt gliding techniques to produce lateral distraction around the elbow give very direct and immediate feedback with regard to reduction of symptoms – particularly if grip test is used as the provocation measure.

In recent years my preference has been to use a grip dynamometer as an objective measure, apart from the obvious benefit of providing a numerical scale of feedback it appears that patients who still have symptoms on grip strength do find it difficult to quantify improvement just simply by arbitrarily clenching a fist.  Therefore the numerical scale can be quantified in relation to maximum pain tolerance and therefore would give fairly indisputable feedback with regard to response to treatment.

Invasive Management

Of course the alternative is steroid infiltration which would also appear relatively arbitrary if Cochrane Reviews are considered. It’s  many years since I have seen surgical interventions in this area but would be interested to know if any of our readers have had experience -positive or negative with this approach?

Let us know by leaving a comment.

Enjoy the clinical challenge.

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