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Lateral epicondylopathy (LE) is the most common cause of elbow pain, and the natural course of the disorder can be exasperating.  Twenty percent of untreated patients demonstrate no improvement after one year.  (1) However, a new systematic review in the Journal of Hand Therapy has shown “compelling evidence” that elbow mobilization and manipulation can significantly improve pain, grip strength, and functional outcomes. (2) Watch the following video demonstration of three potent mobilization/ manipulation techniques validated by this study.

 

LE affects between 1 and 3% of the general population each year.  (3) The condition occurs predominantly in the fourth or fifth decade and affects men and women equally.  (4) LE strikes the dominant arm in 75% of cases.  (4) The pathogenesis of LE entails repetitive wrist extension causing micro-tearing of the common extensor tendon, ultimately leading to a failed healing response and degeneration.  (5,6) The primary site of injury is the extensor carpi radialis brevis (ECRB) tendon, 1-2 cm distal to its attachment on the lateral epicondyle.  (5,7,8) While acute inflammation may accompany the earliest phase of tendon disease, it is unlikely to last more than a few days.  (9) In chronic cases, inflammatory cells are absent.  (9-12) Researchers now recognize that repetitive microtrauma does not cause inflammation but rather a failure of the natural healing process; resulting in a disorganized pathological degeneration of the tendon called angioblastic degeneration.  (9,10,12-16) Since LE is primarily a degenerative condition rather than a chronic inflammatory process as once hypothesized, the term “tendinitis” has been replaced with “tendinosis” or “tendinopathy”.  (9,12-15) True chronic tendinitis is rare compared to tendinopathy. A degenerated tendon may be predisposed to partial or full thickness tears as a result of ongoing strain, particularly rapid eccentric overload. IASTM is thought to help mobilize scar tissue and increase pliability by re-initiating an inflammatory process through controlled microtrauma.  (19,20) The use of IASTM has demonstrated “significantly better” outcomes than exercise alone – with 57% resolution of complaints after one month of care, and 78% resolution after two months.  (21) Anecdotal evidence suggests that dry needling may be a useful alternative for recalcitrant cases. The previously referenced Journal of Hand Therapy study compared elbow Mobilization with Movement (MWM), Mill’s Manipulation (MM), and Regional Mobilizations (RM) for managing LE. The study found a mean effect of:

  • 47% for Mill’s manipulation (MM) on improving pain rating
  • Mill’s manipulation (MM) did not improve pain-free grip strength
  • 43% for Mobilization with Movement (MWM) on improving pain rating
  • 31% for Mobilization with Movement (MWM) on improving grip strength (2)

Manipulation of the cervical and cervicothoracic region has been shown to decrease pain and disability in LE patients.  (22-24) Other studies suggest that mobilization or manipulation of the wrist may be as effective as conventional local treatment for LE.  (25,26)

*Want to learn more about the most effective spinal and extremity manipulation techniques?

Click here to access the Motion Palpation Institute schedule of practical, evidence-based classes from our profession’s leading experts.

STM and stretching exercises should be directed at the wrist extensors and supinator muscle. Resistance training may begin isometrically and advance to eccentric exercise. All outcome measures for the treatment of LE show improvement with the addition of eccentric wrist extensor strengthening.  (27) Eccentric strengthening is thought to stimulate collagen metabolism and synthesis. (27,28) The “Tyler Twist” exercise, utilizing a Theraband Flexbar® is a novel approach to eccentric strengthening that has shown significant pain reduction and excellent outcomes in limited trials. (29,30)

The ChiroUp lateral epicondylopathy protocol has already been updated to reflect this latest information. Subscribers may review detailed video demonstrations of each manipulation and mobilization technique. The default LE home exercises have also been modified to include home mobilization with movement. You can practice with confidence knowing that you are truly delivering up-to-date best practices to your patients.

Click here to review a sample ChiroUp condition report for LE.

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References

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  2. Lucado AM. et. al. Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. J. Hand Therapy 2018 Apr 25 [Epub ahead of print]
  3. Hong QN, Durand MJ, Loisel P. Treatment of lateral epicondylitis: where is the evidence? Joint Bone Spine. 2004;71(5):369–373
  4. Ollivere CO, Nirschl RP. Tennis elbow:current concepts and rehabilitation. Sports Med. 1996;22(2):133–139
  5. Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. Aug 2008;27(8):1015-9.
  6. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: Pathogenesis, imaging, and treatment. RadioGraphics. 2010;(30):167-183.
  7. Conway JE. Clinical evaluation of elbow injuries in the athlete. J Musculoskeletal Med. 1998;15(10):43–52.
  8. Rettig AC. Elbow, forearm, and wrist injuries in the athlete. Sports Med. 1998;25(2):115–130.
  9. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth. BMJ. 2002;324(7338):626–627.
  10. Boyer MI, Hastings H. Lateral tennis elbow: “Is there any science out there? J Shoulder Elbow Surg. 1999;8(5):481–491.
  11. Regan W, Wold LE, Conrad R, Morrey BF. Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med. 1992;20:746.
  12.  Kraushaar BS, Nirschl RP. Tendonosis of the elbow (Tennis Elbow). Clinical features and finding of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81:259–278.
  13. Ollivere CO, Nirschl RP. Tennis elbow:current concepts and rehabilitation. Sports Med. 1996;22(2):133–139.
  14. Nirschl RP. Elbow tendonosis/tennis elbow. Clin Sports Med. 1992;11:851–870.
  15. Bishai SK, Plancher KD. The basic science of lateral epicondylosis: Update for the future. Techniques in Orthopaedics. 2006;21(4):250-255.
  16. Khan, K.M., Cook, J.L., Taunton, J.E., et al., 2000. Overuse tendinosis, not tendonitis. Part 1: a new paradigm for a difficult clinical problem. Physics and Sportsmedicine 28, 38–48.
  17. Hammer WI. The effect of mechanical load on degenerated soft tissue. Journal of bodywork and movement therapies 08/2008; 12(3):246-56.
  18. Blanchette MA, Normand MC. Augmented soft tissue mobilization vs natural history in the treatment of lateral epicondylitis: a pilot study.
  19. Stover S, Sevier T, Helfst R, Jansen CWS. The effectiveness of the ASTYM system in improving treatment outcomes in patients with lateral epicondylitis: a single-blinded randomized trial. Joint #1. Presented at the Joint Annual ASSH/ASHT Meeting. Sept. 22-24, 2005. San Antonio.
  20. Cleland JA, Flynn TW, Palmer JA. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. J Man Manip Ther 2005;13:143-51.
  21. Cleland JA, Whitman JM, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis. J Orthop Sports Phys Ther 2004;34:713-22.
  22. Josué Fernández-Carnero, Cesar Fernández-de-las-Peñas, Joshua A. Cleland, Immediate Hypoalgesic and Motor Effects After a Single Cervical Spine Manipulation in Subjects With Lateral Epicondylalgia Journal of Manipulative and Physiological Therapeutics Volume 31, Issue 9, November–December 2008, Pages 675–681
  23. Manchanda Geetu, Lecturer, Grover Deepak  Effectiveness of movement with mobilization compared with manipulation of wrist in case of lateral epicondylitis. Indian Journal of Physiotherapy and Occupational Therapy – An International Journal, 2008, Volume : 2, Issue : 1 16-25
  24. Peter AA Struijs, Pieter-Jan Damen, Eric WP Bakker, Leendert Blankevoort, Willem JJ Assendelft and C Niek van Dijk Manipulation of the Wrist for Management of Lateral Epicondylitis: A Randomized Pilot Study Physical Therapy July 2003 vol. 83 no. 7 608-616
  25. Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: Current concepts. J Am Acad Ortho Surg .2008;(16):19-29
  26. Langberg, H., Ellingsgaard, H., Madsen, T., et al., 2007. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scandinavian Journal of Medicine and Science in Sports 17, 61–66
  27. Page P. A New Exercise For Tennis Elbow That Works! N Am J Sports Phys Ther. Sep 2010; 5(3): 189–193.
  28. Tyler T.F., et al. , Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial. J Shoulder Elbow Surg. 2010; 19(6):917–922

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman

DC, CCSP, DACO

Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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