Regional Interdependence In Treatment Of The Elbow

Regional Interdependence

• 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

• Lateral epicondylitis

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

        CT Mobilization (Patients - Treaments - Video - References)

        Thoracic Manipulation(Patients - Treatments - Video - References)

        Wrist Manipulation (Patients - Treatments - Video - References)

• Cubital tunnel

        Carpal Manipulation (Patients - Treatments - Video - References)

• Radial Nerve entrapment

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

Outcomes

	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

• 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

• 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

• Patient supine with arms crossed over chest
• Physical therapist localizes thoracic segment using “pistol grip”
• Physical therapist flexes thoracic spine and stabilizes neck and head
• Physical therapist performs high-velocity, low amplitude manipulation in a cephalad direction.

Wrist Manipulation for Lateral Epicondylagia

• 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

• 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

• 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

Clinical Bottom Line (conclusion)

• 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.

References

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.

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.

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.

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.

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.

Search terms

• LE and Radial tunnel syndrome
  

  MT and radial nerve
  

  Manipulation and radial nerve
  

  Posterior interoussens nerve syndrome