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Re: Tennis Elbow (well I guess)
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Re: Tennis Elbow (well I guess) - April 3, 2007 5:39:00 AM
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PTupdate.com
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Usually the posterior mobes are sore just due to the soft tissue and manner of force. I do it more to loosen up the joint than anything. If no "pop", it may be firmly seated, or they just did not elicit a strong enough biceps contraction....I make them push like they are trying to lift one of my college dates off the barn floor
As far as IFC...I'll even use a TENS with high rate/high width in modulated mode. I just go until I get a good muscle contraction and twitch, with a fair amount of physical discomfort for endorphin response
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Re: Tennis Elbow (well I guess) - April 3, 2007 5:59:00 AM
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Chocco
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One thing i hae tried in the past but havent done recently ( because i havent seen tennis elbow in a year, darn OT's)is to mobilize the radial head, then tape proximal plus distal radial ulnar joints to maintain mobilization. Added with TFM plus us or ice massage for patient comfort. I like to test for cervical involvement with snags to c-spine and reproducing aggravating activity. I could maybe more thourough with that after reading this thread. Also some people swear by mulligan Tennis elbow mobes with the belt,I like the above better(matter of preference).
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Re: Tennis Elbow (well I guess) - April 3, 2007 9:59:00 AM
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ragempt
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From: linden, michigan
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chocco, the mulligan mob is just a lateral proximal ulna mob with a belt right? i tried that with my last 3 patients and one said it feels better but just temp. gains. what do you think?
duffy, im not against IFC. i will try if you have had good luck. i have the modalities here i just dont use them. i have this sweet estim. machine. im going to have to get a student PT to teach me how to use it though.
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Re: Tennis Elbow (well I guess) - April 3, 2007 1:25:00 PM
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Chocco
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For the mulligan mobe you need to make sure you are having the patient perform the aggravating activity while you are mobilizing ( grip, Wrist , finger ext). There is a simmilar elbow ext mobe with the belt that does work good. Mulligan mobes are great but they are just mobilizations to correct positional faults, if they are not combined with some sort of exercise, taping or selfmobilization at home symptoms can return, especially with chronic conditions.
FYI if you try taping both distal and proximal radialulnar joints you need to tape them in opposite directions. ex( post. proximal radius and ant. distal radius taping.)
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Re: Tennis Elbow (well I guess) - April 3, 2007 2:48:00 PM
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ragempt
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Chocco, so your using the squeezing to reproduce the pain to find out what way to mobilize them? ok that seems logical. i will try the tapping. obviously you have had luck with this?
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Re: Tennis Elbow (well I guess) - April 3, 2007 3:49:00 PM
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clydesdale6
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I can tell you what is now working for the vast majority of our CHRONIC tennis elbow patients. It is something that I learned on this site about 1.5 yrs ago. I injured myself stabilizing a heavy wheel barrow. More aggressive strengthening. I now measure their grip when they enter, give them aggressive strengthening, with a focus on eccentrics, and then re-measure grip. Our results are way better than they used to be. We used to do light strenthening and modalities. We probably had a 50% success rate. We must be in the 80% + zone now. I understand the value of clearing the spine and making sure you have true tennis elbow. But I was astounded how comlicated some members wanted to make my case of tennis elbow. Once we kicked up the strengthening, I saw a major improvement in the first week. I thank the members of this forum for that. I work in a clinic of 8 full time PTs and this is now how we tx tennis elbow and it works great.
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Re: Tennis Elbow (well I guess) - April 3, 2007 4:57:00 PM
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Chocco
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Clyde I agree with the strengthening but i feel the mobes and taping allow for 1)improved early results with pain and mobility 2) Decreased pain during treatment plus HEP. Pts are more compliant with exercises without pain than with pain.
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Re: Tennis Elbow (well I guess) - April 3, 2007 5:06:00 PM
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clydesdale6
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Please further explain the taping idea. I would like to try that. I have tried enough mobs, I have given up on them in this application. You might have more luck than I do with them. For our clinic of 8 full timers, we have had almost no beneficial LONG TERM benefit with mobs. But please tell me about the tape.
As far as the pain goes. I tell them that it will hurt. I tell them what to expect, they accept it and are willing to push into it a little. Then the tissue "remodels" and they simply get better. The key is they know what to expect. Plus I get them away from focusing on pain and to start focusing on the dynamometer. The numbers go up quickly and steadily. I learned it on here and it works friggin awesome.
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Re: Tennis Elbow (well I guess) - April 3, 2007 5:36:00 PM
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PTupdate.com
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As Clydesdale indicates, the pain will occur, and they need to stick with it. I just abstracted an article on eccentrics for Achilles tendinosis (just finished a series on treatments for this problem), and pain can increase for up to one month using this route. I think many PT's are afraid and reluctant to try this, as the results can take so long, and if a patient only gets one month of PT, the reputation becomes "the guy that makes them all worse after a month"
And rage...if you want to see a GOOD argument, check out the labrum thread on myphysicaltherapyspace.com, in the ortho section. It's quite large, but Barrett Dorko phrased it right when that thread should be cut and framed and placed in every PT department
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) - April 4, 2007 6:56:00 AM
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ragempt
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clyde, can you get into more detail about the exact exercises you give your patients?
duffy, the patient said she had a great day after we did the mob you prescribed. damb you! i did it again with greater contraction, still no pop but the results are what counts in my book. cant see it being a long term fix but i am striking out with her.
wonder why nobody commented on increased MMTs yet no functional improvement.
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Re: Tennis Elbow (well I guess) - April 4, 2007 7:00:00 AM
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ragempt
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sorry, a little more with regards to the incresed MMTs after cervical mobilization (mckenzie chin tucks). they were changes from 3+/5 to 5/5 with shoulder flexion, triceps and wrist extensors.... that was wrist extensors/ flexion?? any ideas why this did not carry over to function?
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Re: Tennis Elbow (well I guess) - April 4, 2007 7:37:00 AM
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ptim
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Have you tried Retraction with extension?
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Re: Tennis Elbow (well I guess) - April 4, 2007 8:59:00 AM
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ragempt
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ptim, yes actually rep/ext supine gave her the best return of her MMTs with some short term funtional gains but nothing great happened with home exercise program. so far mobilization has gave her the best gains as of right now. so far "50%" better
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Re: Tennis Elbow (well I guess) - April 4, 2007 9:37:00 AM
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clydesdale6
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They are simple exercises:
1. wrist extension at 90 elbow flex, 45 flex and full ext. I do one set of each
2. wrist extension- heavier- 3 sets of 10 at full ext
3. wrist ext with a plyo ball 3 sets of 10
4. digiflex grips- holding 6 seconds- 3 sets of 10
Of course you can then add or subtract depending on how they react. But, I give them the dynamometer before and after. Very often they are stronger after each tx. The 3 sets of wrist ext at full ext, with emphasis on the eccentrics is the meat of the program. That and the ball, which throws finger ext. into it. This program flat out works. We have given up on mulligan's mob. Not that it doesn't work, but this seems to work better and the patient can repeat it at home.
For HEP, I have them do wrist ext at full elbow ext every 2 hrs, 1 set of 10. Very simple, very effective.
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Re: Tennis Elbow (well I guess) - April 4, 2007 9:55:00 AM
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ragempt
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thanks clyd, i will try
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Re: Tennis Elbow (well I guess) - April 4, 2007 10:28:00 AM
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Chocco
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Wow a lot of action on this topic since last night.
I agree that strengthening is an important part of tendinosis treatments. I am very familiar with Dr Khan's approach to treating tendon injuries and we use it frequently in our clinic. I feel that people are too quick to dismiss positional faults and begin strengthening with pain without trying to minimize the patients symptoms while performing these exercises. Mobes and taping aren't going to help everyone but in my experience they help to give some patients relief early on in treatment and provide less pain durring strengthening. McConnell taping for the knees with patellar "tedinitis" patients. Mulligan ankle taping with achilles "tendinitis" are other methods of taping I do along WITH strengthening. They are not typically mentioned as part Dr. Khan's treatment, But I have found them to be effective.
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Re: Tennis Elbow (well I guess) - April 4, 2007 10:34:00 AM
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Chocco
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For the fun of it on your next couple of Tennis elboy patients while they are squeezing the Dynamometer hold the distal radius posterior and the distal ulna anterior and check the patient's pain and strength, if no improvement then recheck with the opposite mobilization. It won't work with all patients but I used to use it as a screening tool. The pateints that felt improvement would typically do better with taping.
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Re: Tennis Elbow (well I guess) - May 4, 2007 6:28:00 PM
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RSBMPT
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Just wondering if you have done specific selective tissue tension testing to identify what is at fault with respect to the elbow. I do agree with others that poor proximal stability can lead to tennis elbow and correction of this would be of great help, as well as addressing any length and strength imbalances identified in the forearm. I have found that addressing proximal weakness, TFM and Ice (initially), rest and avoidance of offending activity and progressive strengthening including eccentrics at some level (encouraging collagen remodelling along the correct lines of force) is usually successful. Counterforce bracing is some times necessary. Have you tried a Mill's Manipulation?
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Re: Tennis Elbow (well I guess) - May 5, 2007 9:23:00 PM
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baysic
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Clydes, I'm interested in your strengthening approach, but am curious if you have used Mulligans self MWM for tennis elbow. I noticed that you like the strengthening program because there is a home component. I have found the self MWM to be very effective, given that there is likely a propioceptive component that needs to be worked on more than three times a week in a PT clinic. I am just wondering if not utilizing a self MWM or taping is a reason for you abandoning Mulligan's mobs?
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Re: Tennis Elbow (well I guess) - May 19, 2007 5:15:00 PM
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srcase
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From: Michigan
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Hi Rodger,
In regards to changes in MMT, but not function, there is a big difference between muscle strength and motor control. The patient is probably using faulty movement patterns repetitively throughout her day, and thus undoing anything gained by your treatments. I agree with Ryan Bonilla, that we need to find ways to unload the overused structures, but first, we have to figure out what those structures are. Taping, bracing, and modalities are all ways to calm the tissues down, depending on the level of irritability. So is the correct movement. Have you given her alternative ways to move? I would focus on neuromuscular reeducation with this patient. If someone's strength goes from 3+ to 5 in a short period of time, that is not muscle hypertrophy...it's neuromuscular. Don't discount the neurodynamics so quickly, maybe you just haven't diagnosed the problem as specifically as you could. Try reading Michael Shacklock's Clinical Neurodynamics...it will shed a new light on neuromuscular problems.
Good luck!
Sarah
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