A beaut topical review on tennis elbow (lateral epicondylagia or LE) emerged in the recent Journal of Physiotherapy (Bissett and Vicenzino 2015, Physiotherapy management of lateral epicondylalgia, open access). I think it’s the best review of the status of our LE knowledge. Importantly, it reminds us that LE is “not self limiting and it’s associated with ongoing pain and disability in a substantial proportion of sufferers”. This suggests to me that people experiencing lateral elbow pain deserve a bit of attention and shouldn’t be shunted to the outside courts to wait it out. The authors of the review suggest that “sensitisation of the nervous system” is “one plausible reason for persistent pain in LE”.
As an old clinician I think I, and the patients I was treating over the years, have tried most of the interventions that are reviewed in the paper – exercise, manual therapy/manipulation, orthoses, laser, ultrasound, acupuncture, shock wave therapy and multimodal therapy, and I agree with the general consensus that not much helps. Although, the authors do state that “mobilisation with movement, and exercise” are likely to be superior to “wait and see”.
But, consider that most of these interventions do not target (or even consider) “sensitisation of the nervous system”. Perhaps the poor, equivocal outcomes are understandable?
The clip below presents my current thinking and some techniques for approaching lateral elbow pain – they’re all very much related to a sensitive nervous system. Maybe there are more in this group than we realise?
[youtube https://www.youtube.com/watch?v=ExaLbUdF-hw&w=560&h=315]
Thoughts, comments and your own experiences with lateral epicondylagia welcome in the comments below.
–David Butler
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The magic ingredient – Imaginability!
An excellent clip and beautiful to observe the ongoing evolution of knowledge and application.
You’ve just got to love the shirt !!!😍
DB
London 👍👍👍
What David said 🙂
Thanks for highlighting our recent paper in Journal of Physiotherapy. The u-tube video was instructive on many levels – notably exemplar on the clinician-patient interaction/communication, but especially so for the emphasis placed on non-threatening exercises that the patient can self perform. The importance of patients being able to self-treat with mobilization techniques cannot be understated. It is one of the reasons I was drawn to the MWM techniques for this condition, with my clinical observations convincing me that patients gained confidence with performing previously provocative tasks in non-painful ways. A defining feature of TE is pain on gripping and a widely agreed intervention is progressive resistance exercise (shown to prevent recurrence). If on assessment the MWM is indicated, it is a nice way to encourage pain free gripping and allow exercise (usually to restore strength and endurance capacity of the forearm muscles) in a non-threatening and pain free manner. There are data that support the lateral glide MWM of the elbow for TE to ‘desensitize’ the sensitive nervous system and so address sensitization reported to exist in chronic TE. The critical point is that the MWM for the elbow are ones that the patient can self perform quite effectively, which ties in nicely with David’s emphasis on the patient performance of non-threatening exercises.
I would like to suggest that the statement that “…‘mobilisation with movement, and exercise’ are likely to be superior to ‘wait and see’…” is understating the reported effect of MWM+exercise in our clinical trials[1,2]. In our clinical trials we have shown MWM+exercise to speed up recovery (by over twofold*) and being superior to wait and see and similar to corticosteroid injection in the early stages, but not having the deleterious effect on recovery and high recurrences of the injection over the longer term. The relative benefit of MWM+exercise over wait and see was brought sharply into focus when we discovered that patients in the wait and see and injection groups sought out over twice as many other treatments than did those in the MWM+exercise group.
Finally, my comment here is not about MWM v Neural techniques, but rather that for the same reasons David explains that the neural mobilizing techniques are beneficial. That is, there is merit in mobilization techniques, which can be self-applied (in-context), to encourage and motivate the patient to move the injured limb in non-threatening and therapeutically beneficial ways.
1. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 3;333(7575):939.
2. Coombes B, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of Corticosteroid Injection, Physiotheray, or Both on Clinical Outcomes in Patients with Unilateral Lateral Epicondylalgia. JAMA: 2013 309(5):461–9.
* Modeled in house by statistician
Thank you Dave for writing this NOInote and creating the video and thanks Bill for making your remarks. It is a great honour how we (physios in the developing world) can learn from the clinical discussions from experts in the field.
Tennis elbow (TE) has been a big clinical problem here for physios in Nepal. TE is the most commonly asked questions by my junior physiotherapists working in other facilities. Most ask me over a text message after their frustrations in failing to treat TE. The most common ways how I am asked are, “Please tell me the EXACT treatment of TE?”, “what is the CORRECT treatment for TE?” etc.
My perspective from a developing world where physiotherapy is fairly new but the practice style is ancient. These problems exist because of the way physios are trained. In India (most physios in Nepal are trained in India), a teacher generally lists out all the treatments that may work in a clinical condition. For example, a teacher would mention, stretching, strengthening, manual therapy, taping etc works for TE. The training does not incorporate clinical reasoning behind — why, when and how these treatments work for that particular condition. Also, the undergraduate course does not introduce evidence based practice. So, after the course, physios have no idea where and how to look for recent knowledge in a topic. Also, if they discover, they do not understand what the article is saying and for majority, a research paper looks “scary”.
As a physiotherapist, with the opportunity to learn the techniques, I have used both Neural mobilization and MWM in tennis elbow successfully. However, most PTs here fail to manage TE successfully is the way they use “correct” treatment techniques during the “wrong” time of course of TE. An example is, a PT fails to identify peripheral sensitization due to nervous system, and he/she incorporates static stretching for wrist extensors (with elbow extended and pronated) to stretch extensors for over 30 seconds for a highly irritable case. He/she fails to realize what might go wrong in the neural structure due to this maneuver and he/she worsens the condition. Then, physio really gets frustrated thinking, stretching helped “that case” and worsened “this case”.
Another example is, in presence of central sensitization dominating the problem, where the complain does not really correlate with any of the features/ tests of TE, aggravating and alleviating factors are inconsistent. PTs only focus on the local tissues with all they can —— ultrasound, TENS, IFT, taping, soft tissue mobilization, mobilization of superior radioulnar joint for a lateral elbow pain. However, they fail to acknowledge the psychosocial aspects of the pain.
So, I think, the problem in management of a clinical problem such as TE in developing world (may be true in other places too) lies on lack of clinical reasoning among the PTs mostly. It would be helpful if expert clinicians and researchers such as Dave and Bill write a paper (or talk over a youtube video) to novice PTs that the management approach lined up in the systematic review or narrative reviews do not fit for all the TEs or at least not for all the stages of a condition.
It was great to read this blog and I am looking forward to more interesting discussions in future.
Regards from Nepal,
Saurab
Reblogged this on jointhedotssite and commented:
Wonderful gentle pain free exercises for tennis elbow. Non threatening and fun. Do them with your favourite music perhaps !
Reblogged this on saurabsharma's Blog and commented:
A comprehensive review by Bisset and Vicenzino and an expert remarks by David Butler. You will also get to see the video by Butler with variety of fun exercises for radial nerve mobilization for lateral epicondyalalgia !!
This article came at such an opportune time for me, as I have recently had some patients with very clear UE neural mechanosensitivity issues, causing severe pain. I have had a lot greater success than previously, managing these conditions with a few approaches I’ve gleaned from Noijam and references Ive used from different posts.
I started using some of the techniques from the video, with success, but found I needed more. What I found to be really effective was a combo of the protocol used in this 2011 study, published in ‘Contemporary Clinical Trials.’
A novel protocol to develop a prediction model that identifies patients with
nerve-related neck and arm pain who benefit from the early introduction of
neural tissue management
Robert J. Nee, Bill Vicenzino, Gwendolen A. Jull, Joshua A. Cleland, Michel W. Coppieters
And lastly, I’ve been addind in some Specific Traction to the cervical nerve roots corresponding to the most involved distribution in the UE.
The results have been somewhat unbelievable.
Thanks for the great resource!