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Tennis Elbow (well I guess)
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Tennis Elbow (well I guess) - March 31, 2007 11:44:00 AM
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rodgere
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From: Linden
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Does anyone have any reasoning why roughly 50% of my tennis elbow people complain of pain with active elbow extension? I understand that this should signify neuro involvement but neuro mobilizations usually do not help my traditional tennis elbow people. I usually spend 15 minutes evaluating central problems before looking at the elbow or shoulder. Man, I am having a tough time fixing these elbows lately. Any help would be nice.
Treatments I have tried on my 3 tennis elbows include:
Neuro Butler stuff
Mckenzie cervical protocol
Radial head mobs, in directions that give temporary gains (“wow that feels better”)
PAs
ASTYM
There MMTs have increased and their less tender to palpation but complaints are still the same.
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Re: Tennis Elbow (well I guess) - March 31, 2007 12:29:00 PM
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treybien
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I wonder at times if it is anconeous that is causing this problem. Because it is a weak extensor and it is a stablizer in pronation which is the position that most tennis elbow flare up occurs (overhand grip and overhand with wrist extension.) I try then to treat aconeous. I am an ART practitioner so I use this most often but whatever STM technique you may want to use should be fine.
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Re: Tennis Elbow (well I guess) - March 31, 2007 2:54:00 PM
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PTupdate.com
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With the ECRB attaching to the deep fascia, perhaps the anconius or even triceps causes a pull, and thus pain. Plus, it also attaches to the radial collateral ligament, so the movement into extension, and thus the radius moving, may irritate it as well. With the other wrist extensors also attaching at the humerus, perhaps they are attempting to perform some elbow extension as well.
I noted that you are not doing any actual exercise to the tissue itself, nor any modalities. Also, neural mobilizations are not going to help those "traditional" tennis elbow persons, but rather those with issues that are acting like tennis elbow, or precipitating some extensor dysfunction that leads to the tennis elbow.
Considering the fact that you see temporary relief with the radial head mobilizatons, consider trying this muscle energy technique:
1. Apply posterior mobilizations to the radial head for a few minutes
2. Flex elbow to 90 degrees, and then block any more flexion as the person attempts a maximal biceps contraction. Odds are you will feel/hear a loud clunk or crunch like biting into celery
The theory behind this is radial head malposition, perhaps posterior, causes pressure under the extensor origin and the ECRB. This may also explain the lack of elbow extension often seen in this patient population. The repositioning usually really helps my patients, and also facilitates greater elbow extension as well. At that point, I barrage them with my shock-and-awe treatment, and its rare that we do not resolve anybody with this problem
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
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www.PTupdate.com
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Re: Tennis Elbow (well I guess) - March 31, 2007 10:53:00 PM
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ginger
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From: Melbourne Victoria
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Mr Evans , PA's to what?
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The Grand Pediculator
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Re: Tennis Elbow (well I guess) - April 1, 2007 5:38:00 PM
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ragempt
Posts: 111
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From: linden, michigan
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thanks Duffy i will try your treatment tech Monday. thats exactly what i wanted, some ideas. i dont use modalities and have tried basic eccentrics exercises with them
Ginger, sorry i usually try PAs to cervical levels C4-T2 and then test comparable signs. sometimes good results but striking out lately.
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Re: Tennis Elbow (well I guess) - April 1, 2007 6:14:00 PM
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ginger
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Rage, levels are appropriate of course, just wondering if you follow the CM protocol, as described by me in the manual therapies section.
Ap's work well . With the added benefit of often reproducing the pain as felt at the elbow, which can be monitored with continuing mobilisation as it goes away.
C7 is often undertreated, difficult to get through traps , so I find approaching it with thumb directed underneath traps works better, ie into the root of the neck, more anteromedially.
Good luck.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Tennis Elbow (well I guess) - April 1, 2007 6:35:00 PM
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Marc Bronson
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Check for deficits in ipsilateral shoulder external rotation. This deficit in ROM, hence power, means that the wrist must extend with greater magnitude and velocity to compensate.
Check for passive insuffiency of the major internal rotators of the shoulder, subscap, teres major, lat dorsi and pecs. Lengthen those, work on proper motor control of the external rotators and make sure there's no scapular dyskinesis. Exercise for serratus anterior (wall slide) and lower traps will improve GH and scapular function.
Consider DDx radial tunnel syndrome and work on the supinator as well. Perhaps the forearm flexors are weak eccentrically too. By treating the neuromuscular imbalances along the entire upper extremity kinetic chain you're more likely to bust through this plateau and get to the source of the problem which may lie proximally.
Best,
Marc.
PS: SNAGs/glides/mobs/manips might also be complementary as per Gingers suggestion.
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BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: Tennis Elbow (well I guess) - April 2, 2007 1:52:00 AM
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PTupdate.com
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Rage: Have you ever had tennis elbow yourself?
Duffy
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Re: Tennis Elbow (well I guess) - April 2, 2007 2:31:00 AM
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Shill
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Roger,
A no brainer, but dont forget relative rest from the aggravating task(s). No matter how good you and your programs are, your patients can mess it up by not stopping and/or modifying the things that make them consistently worse. This can often (inadvertently) be de-emphasized.
Steve
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Re: Tennis Elbow (well I guess) - April 2, 2007 3:58:00 AM
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PTupdate.com
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Steve is abosolutely right....most patients are the cause of their own failure in PT...and the PT often does not recognize that. All the PT, meds, injections and fancy scans cannot cure something that is just getting banged every single day.
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Tennis Elbow (well I guess) - April 2, 2007 4:18:00 AM
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ragempt
Posts: 111
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From: linden, michigan
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Thanks everyone. going to try Duffys tech.
Ginger is that a straight posterior/anterior mob? i have read your section before, i will read it again. are you useing maitland grade 2 or 3. I like your ideas regarding central problems. Are you a Mckenzie fan? wondering if you have a main teacher or you have learned from experience
Shill, yes she makes jewlry for a living. twisting that cable recreates comparible signs. this has been D/C for right now
Duffy, no never had tennis elbow. were you going somewhere with that? going to try your treatment today
Marc, great ides, never even thought of that. on day one i always check AROM of shoulders. it was WNL. but I will check passive.
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Re: Tennis Elbow (well I guess) - April 2, 2007 5:43:00 AM
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ragempt
Posts: 111
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Duffy tried your tech. she said "its better" but i have heard this from her before. I will contiue. I also followed Marc and gave her a shoulder flexibility program b/c it did apear that her shoulder IR was tight.
On 2 ocassions she said "my shoulder hurts today" and not the elbow. this leads me to belive her pain may be referred from somewhere other than the neck.
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Re: Tennis Elbow (well I guess) - April 2, 2007 6:19:00 AM
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FLAOrthoPT
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proximal shoulder stabilizer weakness will lead to compensation and overuse of distal parts, consider the shoulder stabilizers as possibly being weak
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Re: Tennis Elbow (well I guess) - April 2, 2007 6:57:00 AM
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fisiovilaca
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Thanks for discussing Tennis Elbow in this forum. I have treated many patients unsuccessfully and this forum will help to achieve better way to evaluate its cause.
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Re: Tennis Elbow (well I guess) - April 2, 2007 11:25:00 AM
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ginger
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From: Melbourne Victoria
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Rage , the indicators for cervical referred events just got a lot better with her description of occasions of shoulder pain. I have no Guru or teacher as such . I've developed the methods I describe here myself. The CM protocol is not maitland in style or sensitivity, or results. You will note from the piece in the Manual therapies section , that CM is a sensitive continuous conversation between joint, paravertebral muscle and therapists thumb. Not grade anything. Sometimes the appropriate 'grade'to use a maitland term will be close to #1, others at #4. It is whatever works best, monitored by therapists sense of tone and tone changes, aided by patient's pain and pain improvements.
As is often true of results gained by decreasing unusual tone in skeletal muscle ( when protective events like this woman has are still active ), there will be usefull reductions in referred pain ( such as the shoulder and elbow in this case ), but these will be temporary. This is untill or unless the central cause is adressed. Muscle tone reductions are certainly useful , as marc and Duffy suggest, but only in the context of a clean up after the central pain causing mechanism has been dealt with.
I say this because, by dealing with the relevant facet joint behaviours and normalising them, an immediate normalisation in paravertebral and skeletal muscle behaviour will occur. The skeletal muscle behaviour ( tightness ) can then be seen in the light of hindsight to have been a referred event, like the elbow pain and the shoulder pain.
Keep at it. Your hands are your best instruments, I look forward to further comments and results.
Cheers
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Tennis Elbow (well I guess) - April 2, 2007 3:24:00 PM
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PTupdate.com
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Ragempt: I brought the question up regarding your own history, as sometimes what we do on ourselves when we suffer an ailment can help when we treat the patient.
I noticed that you indicated you do not use modalities. Why not?
I've had lateral epicondylitis on the left, and nasty medial on the right. Both from lifting (thus the reason for the elbow poll on this site posted last year) I always felt best, and noticed the best improvement when I bombarded my problem, ala the "shock and awe" technique.
I'd start with heat and IFC..enough to get the wrist extensors pumping and twitching, followed by TFM, strengthening, stretch, pulsed US over the focal point (one of the problems I insist on using this modality for and we can all argue this later) and ionto/ice. When I did this, and consistently, I had the most improvement
Often, as PT's, we begin hunting all over the body when the problem was right at home all along, and we just weren't treating it appropriately.
Did you get the "pop" when you did the MET?
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Tennis Elbow (well I guess) - April 2, 2007 3:31:00 PM
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ginger
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From: Melbourne Victoria
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How are your arms now Duffy?
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Tennis Elbow (well I guess) - April 3, 2007 1:22:00 AM
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PTupdate.com
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Pretty **** good.
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Tennis Elbow (well I guess) - April 3, 2007 2:13:00 AM
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ptim
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Is it just active extension that is painful, or is passive also painful?
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Re: Tennis Elbow (well I guess) - April 3, 2007 4:05:00 AM
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ragempt
Posts: 111
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From: linden, michigan
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Ginger and Duffy you PTs are so funny. I love when you go at it. I’m serious b/c both of you have good arguments.
Duffy, although I am more of a central believer, I will give you props she did walk out saying “it feels better” nodding her head yes. I also think its overall a good thing to have the patient walk out with a smile on her face. I did not hear a pop and will try again when I see her tomorrow. Oh I did the mob post. Like you said and she said it was worse so then I did it anterior and she was happy. Wouldn’t anterior be a better combination with resisted elbow flexion considering both promote radial head anterior displacement? Tell me about your parameters with IFC?
Ginger yes I understand where you’re going. Treating the elbow directly is like changing the tire on a care that has poor alignment. Ultimately it leads to changing more tires. I am going to read your CM post at lunch again. So you’re not Maitland? You sound like one of those down under therapist. I often get changes with patients MMTs with cervical spine mobilization but Dammit I cant get their functional complaints to improve. Even if I improve their MMTs long-term their compliant is the same. This frustrates me regarding central treatments.
Ptim, only active elbow extension especially with active pronation
FlaOrtho, agreed I started her on a JC band program and swiss ball isometrics in supine after Marcs comment
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