Regional Interdependence In Treatment Of The Elbow

 Regional Interdependence of manipulation on elbow pain[edit | edit source]

Definition:  [edit | edit source]

  • Treatment directed at one area of the body to elicit changes in another
  • In addition to treatment directed at the elbow, patients with elbow pain may benefit from treatment directed at the cervical or thoracic spine, elbow, and/or wrist.

Treatment Techniques[edit | edit source]

        Cervical (link to spot within this page) (Patients - Treatments - Video - References)

        CT  (Patients - Treaments - Video - References)

        Thoracic (Patients - Treatments - Video - References)

        Wrist (Patients - Treatments - Video - References)

        Carpal Mobilization (Patients - Treatments - Video - References)

        Median and Radial Nerve mobilization (Patients - Treatments - Video - References)

Outcomes
[edit | edit source]


 Pain

Pain free Grip strength

Pressure pain threshold Disability Perception of change Global improvement Max grip force Carpal mobility Elbow flexion test
Cervical X X
CT X X X X
Throacic X

Wrist 

 X X X X X
Carpal mobilization X X X
Medain/Radial Nerve Mob X X


Cervical Thrust Manipulation for Lateral Epicondylagia[edit | edit source]

  • Patient supine with neck in nuetral
  • Physical therapist positions neck into rotation and contralateral flexion
  • High velocity low amplitude (HVLA) thrust manipulation directed superior and medial towards contralateral eye

Cervical Thrust Manip Video

Cervico-Thoracic Mobilization for Lateral Epicondylagia[edit | edit source]

  • Non-thrust grade III and IV PPIVM and PAIVM directed at impaired segment

Done in combination with the following:  

  • Stretching of wrist extensors, strengthening of wrist and forearm, and mobilizations of elbow/wrist

CT Manip Video

Thoracic Manipulation for Lateral Epicondylagia
[edit | edit source]

  • Patient is supine with arms across their chest
  • PT places stabilizing hand just under restricted segment
  • Other hand is used to stabilize neck, head, and upper thoracic spine
  • PT performs gentle flexion to targeted segment
  • High-velocity, low amplitude thrust in downward, cephalad direction

Wrist Manipulation for Lateral Epicondylagia
[edit | edit source]

  • Therapist grips patient's scaphoid between thumb and index finger
  • Place other hand over same landmarks for stabilization
  • Extend patient's wrist while manipulating scaphoid ventrally

Carpal Mobilization for Cubital Tunnel Syndrome[edit | edit source]

  • Patient seated
  • Physical Therapist stabilizes patient's hamate palmarly
  • Dorsally Physical therapist palpates triquetral bone with thumbs stacked on one another
  • Patient instructed to lean back to provide traction on carpals
  • Wrist flexion maintained and HVLA thrust to triquetral palmarly

Nerve Mobilization for Radial or Medial Nerve Entrapment[edit | edit source]

  • Patient supine, placed in ULTT positions for radial or median nerve
  • Flex/Extend patients elbow while in test positions
  • Extend elbow about 2 seconds into range
  • Tension felt/ no pain
  • Flex elbow to point of no tension
  • Repeat 6-7 times

• 4. Treating Cubital Tunnel Syndrome 5
• Carpal manipulation
• Presentation
Insidious medial elbow pain, 2-6 out of 10 on VAS scale
Parathesia in ulnar distribution
Aggravating movements: pushing and pulling with R arm, lifting her children, holding phone to her ear, using a computer
Denied neck, shoulder, or radicular pain
• Examination
Cervical stability tests
Selective tissue tension test (STTT) for the upper extremity
AROM, PROM w/ OP and strength assessment at wrist and elbow
Cervical compression and distraction
Sensory testing: deep tendon reflexes C5-C8, sensory testing dermatones C5-T1, strength testing of muscle in C5-C8 myotomes
Elbow and wrist ligamentous testing
Elbow flexion test for Cubital Tunnel Syndrome
Upper Limb Tension Test (ULTT)
Joint passive mobility
• Intervention Strategy
With the patient seated comfortably, the therapist grasps the patient’s wrist with both hands. On the palmar side, the therapist stabilizes the patient’s hamate with both index fingers, one on top of the other. On the dorsal side, the therapist palpates the triquetral with both thumbs. To assess the patient’s tolerance to the mobilization a pre manipulation hold was implemented by pushing down palmarly through the triquetral while stabilizing the hamate. If tolerated, the therapist proceded to have the patient lean back to provide a little traction on the carpals and then while maintaining some wrist flexion, the therapist performed a downward HVLA thrust to the triquetral in a palmar direction. Immediately following manipulation the patient was asked to move the elbow, without pain, in the new unrestricted ROM: Elbow flexion, elbow supination, wrist extension, and ulnar deviation.


• Follow up
Patient returned 3 more times to the clinic at 2 days, 1 week, 2 week, and 4 weeks after the initial visit.
Negative ULTT with ulnar nerve bias 2 days later and normal carpal mobility both maintained until discharge.
Less provocative elbow flexion test at 2 days which resolved at 1 week, returned at 2 weeks, and had resolved by discharge.
At 2 weeks patient was manipulated with same procedure
At 4 weeks all positive tests were now negative and pain was 0/10
SOURCEMEDICAL DIAGNOSIS OF CUBITAL TUNNEL SYNDROME AMELIORATED WITH THRUST MANIPULATION OF THE ELBOW AND CARPALS- KEARNS, WANG[edit | edit source]


• 5. Treating Radial Tunnel Syndrome
Entrapment of the deep radial nerve/Radial Tunnel Syndrome: (ekstrom)
• Clinical Presentation:
o Right lateral elbow pain for four months
o Decreased joint prom during neural tension testing
o Burning pain over lateral epicondyle
o 4/5 Strength on right wrist, finger and thumb extensors
• Tests performed: neural tension testing of median and radial nerve
o Cervical ROM/Special tests
o Median nerve test:
 Shoulder girdle depression with elbow flexed to 90 degrees
 Shoulder abduction with the elbow flexed to 90 degrees
 Shoulder lateral rotation
 Wrist and finger extension with forearm supinated
 Elbow extension
o Radial nerve test:
 Shoulder girdle depression with elbow flexed to 90 degrees
 Forearm pronation
 Elbow extension
 Wrist and finger flexion
 Shoulder abduction
o Palpation for abnormal tenderness over the radial tunnel.
o Resisted supination
o Pronation
o Grip[edit | edit source]

• Interventions:
o Patient was placed into similar positions used for the tensioning tests then the mobilization was performed by flexing and extending the elbow.
o The mobilization were performed gently, extending the elbow for about 2 seconds just into the range where patient felt tension but no pain and then flexing the elbow to the point where the patient felt no tension.
o Six to seven mobilizations were done emphasizing the median nerve, followed by 6 to 7 mobilizations emphasizing the radial nerve. The patient’s response dictated the degree of elbow extension during mobilization.
o If pain or discomfort or any signs, such as tingling in the hand, were produced, the range of elbow extension was reduced.
Link to video: http://www.youtube.com/watch?v=ts1vBavU4kI&feature=youtu.be
• Outcome:
• Minimal tenderness or pain with palpation over the lateral epicodyle, the radial tunnel, and muscle bellies of the extensor carpi radialis longus and brevis muscle.
• Follow up:
o After first week of intervention, ROM in the right upper extremity increased
 Grip strength increased from 14 to 20 kg
 Slight decrease in tenderness and pain over lateral epicondyle and radial tunnel
o After ten weeks of intervention grip strength increased to 39 kg
o Minimal tenderness with palpation over the lateral epicondyle , the radial tunnel
o Pain free 70%-80% of the time and only had an aching pain when performing activities that would normally aggravate the elbow.[edit | edit source]


•
Pain can refer down the forearm and into the hand
B. Indications[edit | edit source]

C. Contraindications[edit | edit source]

a. Symptoms in cervical spine
b. Bilateral presentation
c. Cervical disc disruption
d. Previous whiplash
e. Cervical surgery[edit | edit source]


o
D. Reassessment[edit | edit source]

E. 11 Physical Therapy Management in addition to manipulation….[edit | edit source]

F. 14 Clinical Bottom Line (conclusion)[edit | edit source]

• Manipulation of the wrist in those with lateral epicondylitis might have additional treatment effects short term compared with ultrasound, friction massage, and muscle strengthening and stretching
• Incorporating manual therapy directed at the cervicothoracic spine may provide additional benefits over treatment directed only at the elbow.[edit | edit source]

G. 16 References[edit | edit source]


Search terms:
LE and Radial tunnel syndrome
MT and radial nerve
Manipulation and radial nerve
Posterior interoussens nerve syndrome
1. Fernández-Carnero J, Fernández-de-las-Peñas C, Cleland J. Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. Journal Of Manipulative & Physiological Therapeutics. November 2008;31(9):675-681.[edit | edit source]

2. Fernández-Carnero J, Cleland J, Touche. Examination of Motor and Hypoalgesic Effects of Cervical vs Thoracic Spine Manipulation in Patients With Lateral Epicondylalgia: A Clinical Trial. Journal Of Manipulative & Physiological Therapeutics [serial online]. September 2011;34(7):432-440.[edit | edit source]

3. Cleland J, Flynn T, Palmer J. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. Journal Of Manual & Manipulative Therapy (Journal Of Manual & Manipulative Therapy). September 2005;13(3):143-151.[edit | edit source]

4. Struijs P, Damen P, Bakker E, Blankevoort L, Assendelft W, van Dijk C. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Physical Therapy. July 2003;83(7):608-616.[edit | edit source]

5. Kearns G. Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals. Journal Of Manual & Manipulative Therapy (Maney Publishing). December 2010;18(4):228.
[edit | edit source]

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