5 It cannot be overstated that elbow symptoms may arise from local structures such as the humeroulnar joint, as well as remote structures such as the cervical and thoracic spine. The potential for spine involvement in elbow pain has long been reported ( Berglund et al. 2008, DeFranca & Levine 1995, Haker 1993, Noteboom et al. 1994, Yung et al. 2011). Failure to address remote structure involvement is likely to reduce treatment effectiveness or prolong therapy. There is some evidence to indicate that manual therapy applied to remote structures can influence elbow symptoms. For example, in subjects with lateral epicondylalgia, Vicenzino et al. (1996) demonstrated that a cervical lateral glide technique, when compared to a control and placebo condition, had immediate positive effects on pain, pain-free grip strength, elbow pressure pain thresholds, and the neurodynamics of the upper limb. Furthermore, it has been shown that for lateral epicondylalgia, local elbow management together with treatment directed at the spine achieved a successful long-term outcome in significantly fewer visits than local elbow management alone ( Cleland et al. 2004). Difficulty arises when trying to identify from where pain may originate ( Curatolo et al. 2006). For example, people who suffer with chronic lateral epicondylalgia demonstrate widespread areas of proximal and distal referred pain ( Slater et al. 2005), a hallmark feature of central sensitization. The presence of central sensitization distorts the clinical picture, making a definitive diagnosis difficult ( Curatolo et al. 2006). In addition, there may be referred pain from proximal structures, particularly the spine. Berglund et al. (2008) compared a cohort of factory workers with and without lateral epicondylalgia. They reported a much higher frequency of cervical and thoracic spine pain (70%) in subjects with elbow pain than those without (16%). They also found a much higher incidence of positive findings to upper limb neurodynamic testing and pain provocation tests of the spine in subjects with elbow pain. The presence of spine pain together with pain in the elbow region does not definitively indicate the cause of the elbow symptoms will be the proximal structures. However, this evidence indicates the importance of careful subjective and physical examination in patients presenting with elbow pain. Particular care should be given to identifying symptoms throughout the upper limb, as well as the spine. Patients with elbow pain will often have more than one pain. On careful questioning, it may be possible to identify a difference for each pain with respect to movement-related behaviour. Consequently, each pain may have different origins and may need treating in different ways. The superior radioulnar joint is concerned primarily with the movement of pronation and supination. The articular surfaces include the convex, cylindrical-shaped rim of the radial head and the reciprocally shaped osseofibrous concavity created by the radial notch of the ulna and the annular ligament. Normal range (age 20–44) for pronation is reported as 82° for females and 77° for males; supination is 91° for females and 85° for males respectively ( Soucie et al. 2010). Pronation range increases in extension, and vice versa for supination ( Shaaban et al. 2008). Range is also inversely related to age. The humeroulnar joint is a uniaxial hinge joint formed between the trochlear notch of the ulna and the trochlea of the humerus. The joint surfaces are saddle-shaped, being concave in the sagittal plane, and convex in the frontal plane ( Standring 2008). The axis of movement for flexion and extension is asymmetrical, which accounts for the carrying angle in the terminal range of extension with the forearm supinated. The carrying angle in this position is 17°, with no significant difference between men and women according to a recent large-scale survey ( Kumar et al. 2010). Consideration of the carrying angle is important, particularly when mobilizing the elbow in the end-range of extension and supination. The primary active movements available at the humeroulnar joint are flexion and extension with a small range of pronation and supination. For people aged 20 to 44, normal range for flexion in females is 150° and in males 145°; extension is 5° for females and 1° for males ( Soucie et al. 2010). The asymmetry and saddle-shaped nature of the humeroulnar joint surfaces allow small range of internal and external rotation around the long axis of the ulna ( Lockard, 2006). Hence, rotation of the ulna can contribute towards forearm pronation and supination. Coupled internal and external rotation of the ulnar also occurs during flexion and extension ( Armstrong et al. 2000): external rotation during flexion in supination; internal rotation during flexion in pronation ( Bryce & Armstrong 2008). Altered ulnar rotation may account for pain and/or limitation of elbow extension (particularly in chronic and recurrent elbow pain disorders, such as throwing injuries). Altered rotation may alter the trochlea articular contact area during movement. In this way, the olecranon moving on the humerus can be likened to the patella moving on the femur. Just as altered patellofemoral dynamics is a commonly postulated cause of anterior knee pain, so altered dynamics of ulnar rotation may also be a common cause of pain and movement limitation at the elbow. In the Mulligan Concept ( Mulligan 2010), subtly altering ulnar rotation through mobilization with movement (MWM) can be a potent treatment option to manage some elbow movement disorders. The radiohumeral articulation is a triaxial ball and socket joint, which lies between the convex-shaped capitulum of the humerus and the concave-shaped radial head. Movements occurring at this joint are flexion and extension as well as pronation and supination. The axis of pronation and supination lies approximately about a line drawn from the centre of the humeral head to the distal head of the ulnar ( Bryce & Armstrong 2008). This joint may be dysfunctional in movement-related joint disorders inducing pain in the lateral elbow. Although the elbow is not typically considered a weight-bearing joint, there are significant compressive and shear forces at the elbow during certain movements. For example, performing a simple press-up induces a compression force of 45% of body weight across the elbow joint ( An et al. 1992). Greater force is transmitted through the radiohumeral joint, with only 43% borne by the ulna ( Bryce & Armstrong 2008). Hence, weight-bearing function may need to be considered in some patients with elbow pain. Various nerve trunks pass across the elbow joint, and may be susceptible to abnormal compression loading, or repetitive micro-trauma invoking inflammatory change, at a number of vulnerable sites ( Hariri & McAdams 2010). For example, the posterior interosseous nerve is a branch of the radial nerve, which is vulnerable to stress in the radial tunnel, but is most commonly affected as it passes through the tendinous arcade of Frohse on the proximal edge of the supinator muscle ( Clavert et al. 2009). The ulnar nerve may be compressed, inflamed or irritated in the cubital tunnel. The ulnar collateral ligament, the medial edge of the trochlea, and the medial epicondylar groove form the boundaries of the cubital tunnel, with the roof formed by the arcuate ligament complex. A further four sites of ulna nerve compression have been reported in the elbow region ( Hariri & McAdams 2010). The median nerve may be compressed at four sites ( Hariri & McAdams 2010): the ligament of Struthers (originates at the supracondylar process and inserts on the medial epicondyle), the bicipital aponeurosis, the pronator teres muscle, and the proximal arch of the flexor digitorum superficialis. The most frequent cause of median nerve compression is dynamic compression of the nerve between the two heads of the pronator teres muscle, exacerbated by forearm pronation and elbow extension. There are a large number of muscles arising from the elbow, whose main function is to control movement of the wrist and hand. Many muscles merge to attach to the medial and lateral epicondyles, through common tendinous attachments. These structures are susceptible to overload and degeneration that frequently result in pain. Lateral epicondylalgia is reported as up to four to seven times more common than medial epicondylalgia, or golfer’s elbow ( Rineer & Ruch 2009). The higher prevalence of lateral elbow pain may be due to a number of factors, including differences in forces generated by the extensor muscles as well as differences in size of the tendons area of insertion. The first questions the therapist should ask the patient are: ‘what is your main problem?’; ‘what do you think will happen to you?’; ‘what do you think therapy can do for you?’; and ‘do you fear harm from physical activity?’. Knowing the patient’s attitudes and beliefs towards their problem frequently directs the rest of the examination. These simple questions may alert the astute therapist to the possibility of yellow flags, or psychosocial issues, which require further questions and ultimately to more formal psychosocial screening instruments. Psychosocial factors of a feeling of low job control and low social support are associated with symptoms of lateral epicondylalgia ( van Rijn et al. 2009). Further more significant anxiety and depression were detected in 55% and 36% of patients with chronic lateral epicondylalgia, respectively ( Alizadehkhaiyat et al. 2007a). Physiotherapists have been shown to have difficulty in detecting intuitively psychological risk factors such as fear avoidance ( Calley et al. 2010). In contrast a simple question such as ‘Are you afraid physical activity will cause an increase in your pain?’ has been shown to be helpful in identifying people with fear avoidance and catastrophization ( Calley et al. 2010). Failure to identify these issues is likely to lead to treatment failure, as is the case in other musculoskeletal disorders such as low back pain. A detailed body chart is an important first step to identify the potential source of the patient’s symptoms. The nature of the symptoms and their location may help the therapist to decide which pain mechanisms are predominant (nociceptive, peripheral neuropathic, central mechanisms) ( Smart et al. 2010). In the previous edition of this book ( Hengeveld & Banks 2005), it has been suggested that local sources are more likely to be the origin of the symptoms if the symptoms are collectively: 1. Consistent (predictable pain response to activity) 2. Familiar (described as being a joint-like ache) 3. Specific (easily localized in areas of recognizable neuromusculoskeletal structures). In contrast, referred pain from remote sources will be vague, and more difficult to localize, with spread proximally. Symptoms should follow a predictable response to activity involving the spine or shoulder. Pain with a dominance of central mechanisms may be suspected ( Smart et al. 2010) if the symptoms are collectively: 1. Inconsistent and activity provokes exaggerated responses 2. Diffuse, non-specific, widespread and spreading to other body regions outside the upper limb affected In addition to the words the patient uses to describe the symptoms, non-verbal cues may also enhance the physiotherapist’s hypothesis about the disorder. For example, the patient may point precisely to the location of the pain or may use the whole hand to describe a broad area of symptoms or one finger may follow the course of a peripheral nerve. These nonverbal cues may provide further evidence for a local or remote structure as the pain source. It may be possible for the patient to determine the depth of symptoms. Deep pain over a particular joint line may give indication about structural involvement. Superficial pain over a muscle belly or tendon may be one factor in determining a structural diagnosis. Pain arising from sensitized neural tissue is felt deep, probably because the axons that become mechanosensitized are those that supply deep structures ( Bove et al. 2003, 2005). While it is tempting to believe that physiotherapists can identify the pain source from detailed questioning, the validity of these assumptions has not been tested. Certain areas of symptoms are quite common to specific local elbow structures and are described in Table 5.1. Table 5.1 Elbow symptoms associated with local structures Where possible the level of functional impairment that the patient is experiencing must be quantified. This information is invaluable in determining the level of disability at the outset of the treatment programme and serves as a measure of change or treatment progress. There have been at least five patient self-rated questionnaires described to evaluate elbow disability; however, not all have been validated ( Longo et al. 2008). Useful questionnaires include the Disabilities of Arm, Shoulder, and Hand (DASH) and Patient Specific Functional Scale (PSFS). The PSFS is not specific to the elbow and can be used for any body region, and is therefore easy to remember and easy to score. Construct validity has been demonstrated for the DASH scale ( Gummesson et al. 2003, Slobogean et al. 2010). Likewise the PSFS has been shown to be a valid and reliable measure of disability and has been shown to be more sensitive to change following treatment than other measures of disability, pain and physical impairment ( Donnelly & Carswell 2002, Pengel et al. 2004). The minimal clinically important change for the PSFS has been reported as 2.0 ( Cleland et al. 2006). For the DASH questionnaire the minimal detectable change is 10.5 and the minimal clinically important change is 10.2, where full function is 100.0 ( Roy et al. 2009). A short form of the DASH questionnaire has been developed which is more useful than the long form, in the rush of daily clinical practice ( Angst et al. 2009). • In standing, ask the patient to make a fist with the arm by the side, then with the arm in 90° shoulder abduction and internal shoulder rotation, followed by contralateral cervical flexion and scapula depression. Successive changes in arm position increases the stress on the neural structures in the upper limb, in particular the radial nerve. If the symptoms increase with the concomitant increase in stress applied to the neural system then peripheral nerve sensitization may be postulated and further examination should focus on this ( Hall & Elvey 2011). • In a supine lying position, push the radius cephalad, so that the head of the radius is compressed against the capitulum. If this manoeuvre increases the symptoms significantly, the radiohumeral joint may be considered for further examination. • If the only factor which alters the patient’s symptoms is the strength of the grip and pain is only reproduced on active contraction of the extensor muscles, and during palpation of the common extensor origin, the most likely source of impairment will be of the extensor muscle apparatus. Pain and stiffness produced in the elbow primarily with a flexion or extension movement would suggest further investigation of the radiohumeral and humeroulnar joints in particular. Pain and stiffness with activities involving pronation or supination suggest that further investigation of the radiohumeral, and radioulnar joints is warranted. There are numerous and varied causes for the onset of elbow symptoms. For example, traumatic intra-articular fractures or osteochondral defects cause immediate pain and disability, but may also alter the geometry of the elbow joint, leading to long-term pain and joint stiffness ( Nandi et al. 2009). Alternatively, degenerative arthropathies or tendinopathies may result in recurrent episodes of pain, which usually recover over a period of time. Episodes of elbow pain and dysfunction may also follow unusual, prolonged, repetitive or forceful activity such as throwing a ball for the first time, repeatedly or with excessive force. Overuse of the wrist and hand, such as in industrial or repetitive manual tasks, may explain proximal forearm and elbow symptoms ( Silcock & Rivett 2004). A previous history of upper limb injury or pain, not just in the elbow, may explain why the elbow has become symptomatic in individual cases. As is the situation with other musculoskeletal pain disorders, in the majority of cases of elbow pain, the cause of the problem is not specific and there is no recognizable pathology. If symptoms are prolonged or there is recurrence with little evidence of mechanical or stressful triggers, then the identification of the actual and potential barriers to recovery should be considered. Potential barriers to the recovery of severe pain include work-related disease, length of history of the disease, ergonomic risk exposure, job stress, level of job support and pain-coping style ( Feuerstein et al. 2000). Other reports of barriers to recovery also include the psychological status of the patient. Alizadehkhaiyat et al. (2007a) found elevated levels of depression in 55% and anxiety in 36% of people suffering from lateral epicondylalgia. Hence, it is important to view elbow problems as a biopsychosocial disorder, rather than a purely biological dysfunction. The psychological status of the patient must be considered. In addition to the psychosocial status, there may be the potential for prolonged symptoms due to a number of related physical issues, which detailed examinations may identify. The presence of neural symptoms in the arm and cervical joint signs has been associated with poor short–term outcome following local elbow treatment for lateral epicondylalgia ( Waugh et al. 2004). Hence, examination of the spine including the rib cage, is important at least in the management of lateral epicondylalgia ( Cleland et al. 2004). Altered posture of the upper limb and abnormal patterns of motor control may be risk factors for the development of pain and maybe involved in prolonging recovery. Kelley et al. (1994) identified in subjects with lateral epicondylalgia marked dysfunction of forearm muscle activation, especially of the extensor carpi radialis muscles, along with qualitatively determined altered kinematics of the upper limb when compared with healthy controls. Quantitative evidence of altered postural and motor control in lateral epicondylalgia has also recently been demonstrated ( Bisset et al. 2006b). Routine special questions provide information about the potential for serious pathology and should be included in the screening of the patient’s condition. Of interest are the patient’s recent general health status, related weight loss, the medication they have been prescribed and any medical imaging procedures that have been undertaken. Further information regarding special questions is given in Chapter 1. Manual therapy for the elbow consists of a wide range of different mobilization or manipulation techniques (MWM), as well as taping procedures and exercise. Although no studies have directly investigated the efficacy of the Maitland Concept for the management of elbow pain disorders, a number of studies have investigated other forms of manual therapy. Lateral epicondylalgia is the most common elbow condition in adults ( Hong et al. 2004) affecting up to 3% of the general population, with higher incidence in manual occupations ( Shiri et al. 2006). It is not surprising that this condition has been most commonly investigated for manual therapy interventions, probably in part due to the ease in identifying subjects for study inclusion. Mulligan MWM is the most frequently studied manual therapy intervention for lateral epicondylalgia ( Herd & Meserve 2008). These studies had the highest quality research methodology rating scores (PEDro score 6.2/10) when compared to studies investigating other forms of manual therapy ( Herd & Meserve 2008). Pagorek (2009) reviewed the evidence for MWM and found overall that there was strong evidence that MWM reduces pain and increases grip and other muscle strength parameters in people who suffer from lateral epicondylalgia. This review was limited to studies published between 2001 and 2008. From a database search the author identified two randomized controlled trials, one cohort study and two case series meeting the inclusion criteria. Not included in this review was a randomized controlled trial comparing MWM with exercise, to therapeutic ultrasound with exercise and to a control group ( Kochar & Dogra 2002). The MWM group showed significantly greater improvement than both the ultrasound group and the control group on pain, weight-lift test, and grip strength. The MWM group showed improvement on most parameters from the first week onwards. An additional investigation compared the effect of MWM combined with Mulligan taping techniques to traditional forms of treatment ( Amro et al. 2010). Consistent with previous investigations, this study revealed significantly greater improvement in pain and grip strength in subjects who received the Mulligan approach. Evidence is available to support beneficial effects of cervical mobilization and manipulation for the treatment of lateral epicondylalgia. Two studies have demonstrated (Vicenzino et al. 1996, 1998) that a cervical mobilization has immediate positive effects on pain-free grip strength, pressure pain threshold and neurodynamics. In addition, it has been reported ( Fernandez-Carnero et al. 2008) that a single application of a cervical high velocity thrust had similar effects. However, no long-term follow-up assessment was included. One study ( Cleland et al. 2004) of high methodological quality ( Herd & Meserve 2008) demonstrated that the addition of cervical spine mobilization to a treatment regimen including manual therapy and exercise directed at the elbow and wrist resulted in significant improvements in pain-free grip, pain, disability, and patient-rated treatment satisfaction when compared with local treatment to the elbow. Outcomes for the cervical mobilization group were found to be superior both at discharge and at six-month follow-up. Thus, the inclusion of the cervical spine in management of lateral epicondylalgia is supported. Evidence is also available to support the use of manipulative techniques at the wrist for managing lateral epicondylalgia (see Fig. 5.65). Struijs et al. (2003) examined the effectiveness of wrist manipulation compared to local elbow management consisting of friction massage, ultrasound and exercise. This study’s findings supported the use of wrist manipulation in management, with significant benefits demonstrated for at least six weeks following treatment. In terms of manual therapy directed to the elbow region, one study, rated as only fair methodological quality ( Herd & Meserve 2008), examined the effectiveness of neural mobilization combined with radial head mobilizations when compared to standard treatment for lateral epicondylalgia ( Drechsler et al. 1997). AP radial head mobilization was carried out in a degree of neural provocation for the radial nerve (in elbow extension with shoulder internal rotation and abduction). Results favoured the combined treatment over standard treatment at discharge and up to three months’ follow-up. Exercise has also been shown to be beneficial for lateral epicondylalgia ( Bisset et al. 2005). The primary physical impairment is a deconditioning response to pain ( Vicenzino 2003). Hence, general strengthening exercises should be considered for the whole upper limb. At least exercises should include strengthening of the forearm muscles controlling wrist/finger flexion and extension, as well as supination/pronation and radial/ulnar deviation. Furthermore, stretching exercises for the muscles around the forearm should be considered, in addition to re-education of motor control of the wrist during gripping activities ( Bissett & Vicenzino 2011). An eight-week exercise programme provided positive benefits in a chronic population, who had failed other conservative treatments, including corticosteroid injection ( Pienimaki et al. 1996). Similarly researchers found that, compared with an ultrasound treatment, exercise resulted in fewer medical consultations, less surgery and fewer sick days ( Pienimaki et al. 1998). Likewise, a randomized controlled trial revealed that a supervised exercise programme brought about the largest reduction of pain and improvement in function through a six-month follow-up period, compared with Bioptron light therapy and Cyriax physiotherapy techniques ( Stasinopoulos & Stasinopoulos 2006). Recently it has been shown that pain accounts for between 41–66% of the variability in disability following elbow trauma ( Doornberg et al. 2005, Lindenhovius et al. 2008). In contrast, physical impairment in elbow movement only accounts for between 17–35% ( Doornberg et al. 2005, Lindenhovius et al. 2008). This evidence strengthens the case for a multisystem biopsychosocial approach to the examination and management of elbow disorders. Clinical evaluation should encompass evaluation of pain, disability, psychosocial barriers to recovery, as well as a detailed physical examination. Physical examination includes the elbow joints accessory, physiological and combined movements. In addition, evaluation should encompass upper quarter dynamic postural and motor control, as well as simple tests of elbow muscle function. Including detailed examination of the cervical and thoracic spine, upper limb neurodynamic tests and neurological function will only serve to enhance the diagnostic, treatment and management role of manual therapy in elbow disorders.
Management of elbow disorders
Introduction
Anatomical and biomechanical considerations
Subjective examination
Body chart
Elbow symptoms
Local structures
Medial part of the lateral epicondyle
Common extensor origin
Radiohumeral joint line/posterior aspect of the head of radius
Radiohumeral joint, annular ligament, radioannular joint
Band of pain across the elbow
Radiohumeral, humeroulnar joints
Deep anterior pain
Radiohumeral, humeroulnar, superior
radioulnar and median or radial nerves
Surface anterior
Anterior capsule, biceps
Medial epicondyle
Common flexor origin
Ulnar notch
Ulnar nerve
Behaviour of symptoms
History (present episode and its progression since onset and past episodes and their natural histories)
Special questions
Evidence-based practice with reference to manual therapy
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