Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary
Bill Vicenzino, PT, PhD,
Joshua A. Cleland, PT, PhD, OCS, FAAOMPT, and
Leanne Bisset, PT, MPhty (Sports)
This article has been
cited by other articles in PMC.
Lateral epicondylalgia (LE), epicondylitis, or tennis elbow is a musculoskeletal disorder often encountered by healthcare practitioners, such as physical therapists, and is characterized by pain over the lateral elbow that is typically aggravated by gripping activities1. The syndrome is most prevalent (35–64% of all cases) in jobs requiring repetitive manual tasks, it results in restricted function, and it is one of the more costly of all work-related illnesses2–4. The peak incidence of this condition occurs between the ages of 35 and 50 and usually affects the dominant arm5.
Formerly called lateral epicondylitis, lateral epicondylalgia or epicondylar tendinopathy are more appropriate terms considering that numerous studies6–9 have shown the absence of inflammatory cells in this disorder. It has, therefore, been suggested that the term epicondylitis be abandoned in favor of ‘epicondylalgia1,10,11. Recent evidence suggests that the symptoms associated with LE might be related to a constellation of changes in the extensor carpi radialis brevis and common extensor tendon mechanism. These have been reported to include signs of neurogenic involvement12 as a result of chemical mediators of pain located in myelinated sensory fibers (e.g., substance P and calcitonin gene-related peptide)12,13 and increased levels of glutamate (an excitatory amino acid)14, neovascularisation15, and changes in muscle fiber morphology (e.g., fiber necrosis, higher percentage of fast twitch oxidative fibers, and moth eaten fibers)16. Impairments in the sympathetic nervous system (e.g., absent vasomotor response)17 and the presence of mechanical but not thermal hyperalgesia further point to the involvement of the pain and/or sensory systems in this condition18,19.
Currently, no general consensus exists as to the most appropriate management strategy for LE, even though several systematic reviews have been published. A review conducted by Bisset et al20 identified evidence for the use of elbow manipulation21–22 and therapeutic exercise23 in the short term and recommended that the long-term effects of joint manipulation be studied. Other limitations with the current literature include poor methodological quality (i.e., lack of experimental rigor), a finding that has changed little since an earlier systematic review by Labelle24.
Interestingly, in a recent commentary on management of LE, Ashe et al25 listed a number of treatment approaches that included patient education, splinting, modalities (e.g., ice, LASER, and high-voltage galvanic stimulation), strengthening, and stretching. Noteworthy was the omission of joint manipulation from their list. Perhaps this may be related to the fact that LE has long been conceptualized as a musculotendinous disorder and the traditional focus of joint manipulation has been the direct influence upon joint structures rather than musculotendinous tissues26.
Since the last clinical commentary on a manual therapist’s perspective on LE27, a significant number of studies21,22,28–44 have investigated the effects of joint manipulation of the elbow and wrist as well as of the cervical and thoracic spines. The purpose of this paper is to comment on current research investigating the effects of joint manipulation, to elaborate on the hypothesized physiological mechanisms contributing to these clinical effects, and to present a clinical reasoning process to the technique selection that is based on the patient’s clinical presentation. The commentary will provide clinicians with a rationale to refine decision-making regarding the incorporation of joint manipulation for the management of LE.
Conclusion
The literature, and in particular that reporting research of joint manipulation techniques in LE, has greatly increased over the 20 years. This growth in the literature provides an opportunity for practitioners to base clinical decisions on data that is more advanced in its inferential capabilities. For example, practitioners may approach the application of joint manipulations to the spine and peripheral joints with greater confidence of at least deriving short-term effects in pain-free grip force and pressure pain thresholds. The physiological rationale for these effects has also progressed and can now be more plausibly used in explaining clinically observable effects. Despite these advances, there remains much to be studied before there is solid evidence to support the use of joint manipulations in the treatment of LE. Until such data becomes available, we propose that practitioners base clinical decisions on a sound clinical examination and evidence from the literature as presented herein.
What does this Mean?
CORE Physical Therapy in Omaha Explains…
By Dr. Mark Rathjen PT DPT CSCS
The above article overall is very interesting and well developing into the examination of manual therapy and tennis elbow pain/condition management. Other article have studied various strengthening aspects and range deficits, other on manual interventions and post radial head mobilizations. The emerging research early on is very positive though harder to test. Testing becomes hard with manual techniques as provides vary in technique use and implementation. Used with appropriate clinical reasoning, it can decrease the patient visit per episode and visits per diagnosis.
At CORE Physical Therapy in Omaha, we utilize various manual expertise. We also use trigger point dry needling to restore motion and normal tissue kinematics. At that time, overall then the athletes is ready for strengthening and return to sports protocol. Research is paramount in training and retaining our athletes to get the fullest performance in Omaha, and the best results for injury prevention.
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