PHYSIOTHERAPY
TREATMENT APPROACHES
FOR TENNIS ELBOW
Vicente Lloret
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KEY WORDS:
- Clinical picture ≠ Diagnosis
- Subclassification
- Pain ≠ Damage
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CLINICAL PICTURE
What are we talking about when we talk about...?
PFG: Pain Free Grip
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1. Pain does not provide a measure of the
state of the tissues
2. Pain is modulated by many factors:
somatic, psychological and social
3. Relationship between pain and the state
of the tissues is less predictable as pain
persist
4. Conscious correlate of the implicit
perception that tissue is in danger.
PAIN ≠ DAMAGE
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1. Pain does not provide a measure of the
state of the tissues
2. Pain is modulated by many factors:
somatic, psychological and social
3. Relationship between pain and the state
of the tissues is less predictable as pain
persist
4. Conscious correlate of the implicit
perception that tissue is in danger.
Moseley GL. Reconceptualising Pain. Physical
Therapy Reviews. 2007 Aug 25;3(12):169-78.
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SUBCLASSIFICATION
...low level evidence...
...need of further research...
EVIDENCE BASED PHYSIOTHERAPY
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COMPLAINS OF
- Limited range of movement
- Pain
- Limited range of movement associated with pain
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COMPLAINS OF
- Limited range of movement
- Pain
- Limited range of movement associated with pain
Movement disfunction
{
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Pain
system(s)
changes
Local
tendon
pathology
MANAGEMENT
Motor
system
impairments
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Bisset L, Russell, Ha B, Bradley S,Vicenzino B (2006)
Bilateral sensorimotor abnormalities in unilateral epicondylalgia.
Arch Phys Med Rehabil. 87:490-5.
Motor system impairments
150
175
250
225
250
275
300
325
350
375
Tiempodereacción(mseg)
Control Epicondilalgia
RT1
RT2
80
90
100
120
130
Velocidaddelmovimiento
Control Epicondilalgia
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Motor system impairments
PienimakiT, Kauranen K,Vanharanta H (1997) Bilaterally decreased
motor performance of arms in patients with CLE,
Archives Phys Med Rehab 78 (10): 1092-5
Results: Compared to normal the patient had:
-19-36% slower reaction times for both arms
-31-32% slower speed of movement for both arms
- There was no difference between affected and unaffected arm.
Conclusión:
- Unclear mechanims at play.
- What comes first the pain of tennis elbow or motor
control deficit?
- May be indicative of altered central processing
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Kelly JD, Lombardo SJ, Pink M, Perry J, Giangarra CE (1994)
EMG and cinematographic analysis of elbow function in tennis players with LE,
AJSM 22:359-63
0
10
20
30
40
50
60
70
80
90
100
Normal
Lesionado
PREPARATION
1º 2º
ACCELERATION
BALL
IMPACT
FOLLOW-THOUGH
1º 2º
Motor system impairments
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Motor
system
impairments
morphological deficits
sensori-motor (bilateral)
strength imbalance
global changes
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Pain systems changes
Slater H,Arendt-Nielsen L,Wright A, Graven-NielsenT (2004)
Sensory and motor effects of experimental muscle pain in patients
with LE and controls with DOMS. Pain 114:118:30
Pain was quicker in onset and over larger areas bilaterally.
Indicative of involvement of central sensitization
A number of interacting neurophys mechanisms:
facilitation of quiescent or latent synapsis
expansion of receptive fields
activation of mor WDR neurons
Pain lasted longer in sore arm of patients.
Bilateral hyperalgesia
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Pain systems changes
Alfredson H, Ljung BO,Thorsen K, Lorentz R (2000) In vivo investigation of ECRB tendons with
microdyalysis technique - no signs of inflammation but high amounts of glutamate in tennis
elbow.Acta Orthop Scand 71(5):475-9
- 4 patients with chronic pain ECRB origin & 4 control
- Microdyalysis under LA and resting conditions over 2 hour
period (15 min samplings)
- Sampled glutamate and prostablandin E2 (PGE2)
- Glutamate higher in patients
- PGE2 no different
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Pain
system(s)
changes
Pain systems changes
mechanical hyperalgesia
deep tissue sensitivity
central sensitization
local neurotransmitters
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Local tendon pathology
Zezig E, Ohberg L,Alfredson H. Extensor origin vascularity related to pain in patients withTE.
Knee Surg SportsTraumatol Arthrosc (2006) 14:659-63
- 17 patient: 22 elbows (5 bilateral) v 11 controls
- US + Doppler study
Neovessels closely related to neural structures
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Local tendon pathology
Local
tendon
pathology
collagen fibrils disarray
Neovascularisation
increased matrix protein
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Management
Pain
system(s)
changes
Motor
system
impairments
Local
tendon
pathology
morphological deficits
sensori-motor (bilateral)
strength imbalance
global changes
mechanical hyperalgesia
deep tissue sensitivity
central sensitization
local neurotransmitters
collagen fibrils disarray
Neovascularisation
increased matrix protein
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Exercise, Prolotherapy, Polydocinal
Exercise,Exercise,Exercise
MW
M,gradedmotorimagery
Management
Motor
system
impairments
Pain
system(s)
changes
Local
tendon
pathology
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Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, and BillVicenzino
Mobilisation with movement and exercise, corticosteroid injection, or wait and see for
tennis elbow: randomised trial
BMJ Nov 2006; 333: 939
Physical treatment
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NNT=3
NNT=2
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Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, and BillVicenzino
Mobilisation with movement and exercise, corticosteroid injection, or wait and see for
tennis elbow: randomised trial
BMJ Nov 2006; 333: 939
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¿What is a MWM?
- MWM = hypoalgesia and rapidly function recovery
Vicenzino B.Wright A. Effects of a novel manipulative physiotherapy technique on tennis
elbow: a single case study. ManualTherapy 1995; 1(1):30-5.
Abbott JH, Patla CE, Jensen RH.The initial effects of an elbow mobilization with movement
technique on grip strength in subjects with lateral epicondylalgia. ManualTherapy 2001;
6(3):163-9.
Positional fault =
biomechanical correction?
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Observación clínica:
Patient presents with Pain & Disability Pain free & recovered
Observation 1:
Retrospective interpretation of clinical observations:
Observation 2:
Observation 3:
The Mobilisation exerts a force to a joint that glides joint surgaces.
The force needs to be specific for the technique to be effective.
The MWM reverses a positional fault.
Inferred clinical aplication
Antecedent event:
Traumatic (injury) or Non-
traumatic (postural, overuse)
Positional Fault
Patient experiences
Pain & Disability
Identification of positional
fault by practitioner
MWM applied to reverse
positional fault
MWM reverses
positional fault
MWM
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Hsieh C-Y,Vicenzino B,Yang C-H, Hu M-H,Yang C. Mulligan ́s mobilization with movement for the
thumb: a single case report using magnetic resonance imaging to evaluate the positional fault
hypothesis. ManualTherapy 2002; 7(1):44-9.
Gal et al. Movements of vertebrae during manipulative thrust to unembalmed human cadavers..
1997 J of Manipulative PhysTher 20:30-40.
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Hsieh C-Y,Vicenzino B,Yang C-H, Hu M-H,Yang C. Mulligan ́s mobilization with movement for the
thumb: a single case report using magnetic resonance imaging to evaluate the positional fault
hypothesis. ManualTherapy 2002; 7(1):44-9.
Gal et al. Movements of vertebrae during manipulative thrust to unembalmed human cadavers..
1997 J of Manipulative PhysTher 20:30-40.
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MWM
Transient change
in bone position &
increase ROM
NEUROPHYSIOLOGIC
Pain effects
Associated systems &
modeling
Sensory motor system
Initial non-opioid
hypo-algesia:
DPIS-PAG mediated?
Sensorimotor integration
BIOMECHANICS
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Motor
system
impairments
Pain
system(s)
changes
Local
tendon
pathology
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THANK YOU!
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