Elbow Treatment 1.0
Lateral elbow pain (lateral epicondylitis, AKA tennis elbow, radial nerve entrapment syndromes) is a frequent presentation in our clinic March-May as folks who started a weight routine for a New Year’s resolution begin to ‘crash and burn’ as poor form leads to tissue failure in the extensor tendons for the wrist. Nirschl described a surgical technique in the 1970s which was highly effective at relieving this condition. Common current wisdom is that the putative cause of pain is related to the commonly observed granulation tissue associated with the ‘mobile wad of 3’ extensor tendons. Co-morbidity we frequently see in clinic may include entrapment neuropathies and Miller and Reinus, in 2010 provided a nice review of those. While this is interesting from a structural perspective and helps to inform manual therapies addressing this condition, it is not the thrust of this article. Let’s examine lateral elbow pain from a functional point of view.
Elbow Treatment 2.0
Borrowing a page from the Joint by Joint approach, the elbow is a hinge joint somewhat analogous to the knee. The literature suggests that many of the maladies of the knee can be addressed by working on strength and mobility around the hip. Similarly with the elbow, we see a stable joint complex surrounded by comparatively more mobile shoulder and wrist joints. Consistent with Joint by Joint, poor mobility in the inherently mobile joint structures will lead to the body “asking for” more mobility in a stable joint complex, in this case the elbow. Often using this approach and working through shoulder mobility and stability we can have a great impact on the long-term function of the elbow. In the last several years this approach has been quite useful in reducing treatment time and improving outcomes in this condition in our clinic. Typically we would focus on improving scapular mobility often using Stecco’s manual therapies to assure appropriate scapular retraction and protraction. Upper thoracic joint mobilization or manipulation was also quite helpful in improving overall shoulder mechanics by improving mobility in the scapular thoracic articulation and in the thoracic spine in order to spare the glenohumeral articulation. A patient in our clinic today provided an excellent example of an even more modern approach integrating DNS principles with the joint by joint and manual therapy methodology.
Elbow Treatment 3.0
SR, a 35-year-old public safety officer, presented with left lateral elbow pain which began insidiously over the past several weeks. Eight weeks before he had started a self-improvement project involving weightlifting using a four day split. Prior to that it had been several years since he had engaged in regular weightlifting. Significant prior history included several incidents of shoulder injury and near dislocations on the affected side. Painful ADLs included reaching for the milk in the back of the refrigerator, lifting a coffee cup, opening a heavy door or gripping the handlebars of his mountain bike. In the gym, patient found benchpress, and overhead pushing and pulling exercises to be provocative.
In standing, left arm was inwardly rotated and the humerus was palpated in an anteriorly displaced position in the glenoid. Shoulder abduction, external rotation and extension were painlessly limited in active range of motion. Palpation over the left lateral epicondyle of the humerus, passive left wrist flexion, resisted left wrist extension, and strong handshake all produced pain at CC. Strong handshake produced 6/10 severe pain. Intra-abdominal pressure (IAP) assessment revealed rib flare, apical breathing pattern and poor ability to pressurize the thoraco-pelvic canister. Spinal segmental extension restrictions were noted in the thoracic spine. ULNNTs were negative and Spurling’s suggested no radicular involvement.
A structural diagnosis of lateral epicondylitis was rendered with functional contributors including:
- poor IAP/respiratory pattern per DNS protocols,
- poor shoulder mobility leading to overuse of the stability-loving joint complex per Joint by Joint approach.
We decided to begin with DNS-informed protocols first to see if patient would be able to correct most of his own condition utilizing functional corrective exercise. We decided that afterward we would address joint and myofascial components as deemed necessary.
Patient was instructed in diaphragmatic breathing while maintaining rib tuck position and long spine. That pattern formed the basis for all subsequent exercises. We then trialed dead bug, wall bug and foam roll progressions and the latter 2 were within patient’s functional pain free range. In short as Dr. Craig Liebenson would put it, they were the most difficult exercises the patient could perform excellently. To see Dr. Liebenson apply this approach you can check out this video. To assist with thoracic extension while providing a closed chain weight-bearing position for the affected joint complexes patient was coached in modified Sphinx exercise. Before manual therapy was applied, a mid-treatment audit was performed as a handshake test. With firm grip patient smiled widely and noted that he only had 1/10 severe pain in the lateral elbow. Objectively, the strength of the grip was quite a bit more robust.
Subscribers to MyRehabExercise.com may view the above videos by clicking on the images.
Manual therapy included prone manipulation of the T4 segment into extension as well as prone combo manipulations of the upper ribs. Glenohumeral rotation mobilizations were provided in internal and external vectors through abduction and flexion ranges of motion to aid in joint capsule mobility. Graston technique was provided using gua sha type rapid stroke movements proximal to distal to improve blood flow and oxygenation of the extensor muscles. This concluded the treatment portion of the first encounter. Total amount of contact time for this established patient with new presentation was 30 minutes. A posttreatment audit was performed as strong handshake and patient had 0/10 severe pain in the lateral elbow and his grip strength was markedly improved. He received emailed exercise prescription follow-up of all of these exercises from MyRehabExercise.com. He was scheduled for a return visit in one week which will likely consist of manual therapies per Stecco protocols to improve scapulothoracic mobility and joint centration of the glenohumeral articulation. typical follow-up exercise at that time will likely be closed chain DNS exercises such as Tripod Sit and Bear Crawling and Therabar Eccentrics.
Previous blog posts here outlined the rationale for addressing the deep spine stabilization system and respiratory pattern in this case. Below is the graphic that shows how those dominoes stack up.
According to DNS theory, the hypertonic upper trapezius represents an adaptational motor program for shoulder stabilization. In the absence of an adequate punctum fixum with a well functioning deep spine stabilization system, lower trapezius and serratus anterior are unable to stabilize the scapula against the chest wall. The upper trapezius is then placed into a primary role to stabilize the shoulder girdle by “plugging it in” to the cervicothoracic area. The resultant alteration in biomechanics pitches scapula upwards and forwards in the shortening of the pectoralis minor and internal rotators. The hypertonicty in these muscles in turn de-centrates the humeral head in the glenoid. While the clinician and manual therapist can positively impact the course of care with manual method alone, adding this kind of foundational corrective exercise dramatically decreases the treatment time and improves the overall musculoskeletal health of the patient. Much of this exercise work can also be provided by a heads up personal trainer who has learned these techniques, but the trainer should have a DC or PT help on the pain management end. Better yet, those trainers who are familiar with DNS assessment techniques for their work, can help avoid having their clients on the disabled list where they can’t train at all.
I will try to follow up with this patient on the blog in future posts. In the meantime, consider MyRehabExercise.com for excellent patient/client oriented videos for the correctives shown above as well as many more to help with your functional exercise instruction. Click on the link below to learn more!
Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979 Sep;61(6A):832-9. PubMed PMID: 479229.
Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist. AJR Am J Roentgenol. 2010 Sep;195(3):585-94. doi: 10.2214/AJR.10.4817. Review. PubMed PMID: 20729434.
Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010 Feb;40(2):42-51. doi: 10.2519/jospt.2010.3337. Review. PubMed PMID: 20118526.
Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17(4):230-6. PubMed PMID: 20140154; PubMed Central PMCID: PMC2813499.
Our 2nd installment to this area of the blog focuses on medial collapse of the knee. Many of the most common running-related injuries stem from this excessive aberrant motion (Milner, et al, 2010; Ferber, et al, 2010). Interestingly, in runners at least, the root of this problem is more software related than hardware related. Early studies investigating anterior and lateral knee pain in runners, found excessive hip adduction and tibial torsion during gait analysis to be positively correlated with pain in the knee. (Dierks, et al, 2008; Souza et al, 2009) It was theorized that runners with knee pain would exhibit gluteal weakness and that was born out in subsequent studies. However, follow-up studies attempting to treat by strengthening the glutes showed that despite improvement in gluteal strength after training, these runners still had knee pain when they ran.(Blønd, et al, 1998) It wasn’t until 2011, that significant success was found in these runners when they received real-time coaching + biofeedback to correct the valgus collapse. (Noehren et al, 2011) My feeling over the years has been that a glute strengthening program that targeted functional movement on 1 leg and, coupled with the verbal cues for gluteal integration while running, would improve outcomes in runners with knee pain. Some recent studies have born that out and we’ve also seen good effect with that approach.(Earl et al, 2011; Dolak et al, 2011) Below is a good example.
Bryan, 21 year old college XC runner, presented with chronic, episodic left anterolateral knee pain while running. Pain began in his freshman year of high school and usually became more noticeable each year toward the end of the XC season. He felt that the pain, while not severe enough to place him on the injured list, was sufficient enough to limit his performance by limiting his high intensity training. He had had extensive physical therapy, which he attributed with keeping him able to run, but not to run pain-free. He had limited experience with weight training, but had done bodyweight core training in the past 2 years and found some benefit in his pain incidence after. He arrives between seasons on the advice of his coach, and only experiences knee pain on his long days when mileage exceeds 12-13 miles. He had no prior direct trauma to the knee.
On ortho assessment, Ober’s and Nobles test confirmed shortened and painful ITB on the involved side. Hip adductors were shortened and Thomas-Gaenslen’s indicated shortening of the hip flexors. Palpation over the distal 1/3 of the ITB and medial and lateral peripatellar retinaculum reproduced CC pain. No patellar malalignment was noted on static exam. On movement exam, deep squat was painful in the medial patellar region and showed quad dominance and slight valgus collapse. With manual cueing to activate the glutes, he squatted without pain. Squat depth was markedly improved with a 2/4 “cheater board”. Dorsiflexion of the ankle was limited bilaterally. Lunge also produced slight pain, marked crepitus and valgus collapse. Seated slump test produced no nerve tension signs, SLR was 80 deg bilaterally. Structural diagnosis of patellofemoral syndrome was rendered and the functional exam to shed light on the cause was initiated.
Functional assessment findings were as follows:
Stecco Movement Verification: Given mobility issues raised in the ortho exam, we started here and found painful Centers of Coordination at ante-genu, media-genu, lateral-genu, lateral coxa, media-coxa and ante-coxa.
Janda Key Movement Assessment: Hip extension was delayed in glute max activation and strength was +4/5 on the involved side. Hip abduction revealed hip flexor dominance and +4/5 glute med strength on manual challenge.
Mag 7: 1 leg stand was normal on time bilaterally, but demonstrated ankle eversion on the involved side and lateral pelvic tilting. 1 leg squat was painful
with valgus collapse of the knee and again showed lateral pelvic tilt. Wall Angel revealed T4 mobility deficits.
At this point, I felt comfortable enough with the findings to render a functional cause of the PFS as shortening of the hip flexors and adductors with resultant gluteal inhibition…lower crossed syndrome. We performed PIR and Fascial Manipulation to the hip flexors (AN-PV) and re-tested the hip extension KMP and found better strength in the glute max and improved firing order. Repeat of the painful lunge pattern was still painful though. Fascial manipulation to AN-GE resulted in ability to lunge painlessly. Time constraints forced us to end this first session, so patient was briefly shown lunge stretches and goblet squats for hip mobility. However, patient’s T4 mobility deficits forced a peel back to tactical frogs for hip mobility. He was referred to MyRehabExercise.com for follow up tutorial videos on those exercises.
At the next visit, Bryan reported slightly less pain during runs the previous week. We addressed the collapse at the distal end of the kinetic chain with the Vele’s Lean + Short Foot exercise and patient was instructed to perform prior to runs along with dynamic stretching of the hip flexors and adductors. We also tested the previously observed lateral pelvic tilt in single leg positions with static side plank and patient showed endurance values of 80/95 sec on the involved side and 70/99 on the contralateral side. QL was tender to palpation on the contralateral side and patient recalled that he ofter felt fatigue in that area on very long days. no pelvic obliquity was noted on exam. For manual therapy, I made a judgement call based on previous experience, and performed Graston Technique soft tissue manipulation to the tender peripatellar retinaculae. While I don’t generally go directly to the painful area, I’ve found that with PFS of such longstanding history, the painful scarring of that tissue sometimes represents a space occupying lesion that may need to be addressed. HVLA manipulation of the T4 area into extension was also performed as well as hip long axis distraction manipulation. Bryan was able to squat and lunge without pain after.
At next visit, patient only had knee pain on the long runs and reported decreased severity when it occurred. We had no provocative movements to assess in the clinic and were left with ADLs and objective movement quality measures. Single leg squat was not painful but demonstrated valgus collapse. Patient was shown Bulgarian split squats to replace the lunges and was now able to perform Goblet squats which replaced the tactical frogs. RNT challenge was added to the Bulgarians. We also repeated Graston to the peripatellar retinaculae, which were less painful during treatment. T4 extension manipulation was once again performed.
The following visit, Bryan reported he was now able to run 13 miles without knee pain. With ADLs and clinical provocative tests now painless, we turned toward longer term training to be done at home. Patient was shown progression pattern for adding weight to the Bulgarians, and was shown single leg deadlift using cross body pattern. He was also shown single leg Pallof presses to integrate the anti-rotation training of the digital flexors. We discussed findings of previous studies in distance runners involving heavy weight half squats and he was given copy of one study to share with the trainer at school. This allowed this patient who was naive to weight training to integrate this training under supervision. Lumbar FCE was performed and patient was WNL on all quadrants in the core test.
Bryan was seen a few more times during the course of the following season, but only to address neck and shoulder stiffness around exams. He ran painlessly for the first season in his running career that year and PR’d twice. He was chosen for the XC team that competed at NCAA nationals a goal he had not been able to accomplish previously. Note that we intentionally did not attempt to take the patient into deep squats and to “correct” the ankle dorsiflexion deficits. This was a judgement call given the research the shows inverse correlation between ankle dorsiflexion ROM and performance in elite distance runners. This patient was seen only 5X to get resolution of his longstanding complaint, by using a functional approach. Removing the energy leaks in his gait by stabilizing the core, and improving transverse plane control via the foot and hip allowed him to balance his musculoskeletal system to train with higher volume and intensity. This allowed him to not only run injury free for the first season in his life, but also to run faster than before.
The exercises featured here are part of the membership-only area of MyRehabExercise.com. Members can use the extensive library of functional exercise tutorials to help improve patient care and to reduce time necessary to train patients. The service is only $9.99 monthly, and those interested may trial the service risk-free for 30 days for only $1. Click on the link below for more info.
Milner CE, Hamill J, Davis IS. Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture. J Orthop Sports Phys Ther. 2010 Feb;40(2):59-66.
Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Orthop Sports Phys Ther. 2010 Feb;40(2):52-8.
Dierks TA, Manal KT, Hamill J, Davis IS. Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run. J Orthop Sports Phys Ther. 2008 Aug;38(8):448-56. Epub 2008 Aug 1.
Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther 2009;39:12–19.
Blønd L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7-year retro- spective follow-up study of 250 athletes. Acta Orthop Belg 1998;64:393–400.
Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. Br J Sports Med. 2011 Jul;45(9):691-6. Epub 2010 Jun 28.
Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011 Jan;39(1):154-63. Epub 2010 Oct 7.
Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip Strengthening Prior to Functional Exercises Reduces Pain Sooner Than Quadriceps Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2011 Jun 7.
Let’s kick off a regular installment here on the blog. Periodically, we’ll discuss case studies and case conceptualizations based on a functional rehab approach. Case studies were always one of my favorite ways to learn in school. Some of these will be straight up cases that we see in the clinic, some will be composites of several commonly presenting complaints somewhat like the vignettes we all knew and loved from board exams. It’s my hope that this will help those of us with a bit more familiarity with these methods provide a more direct path for learning to the newer adoptees of functional rehab. There are of course, many “Roads to Rome”, so some of the therapies applied don’t matter as much as how they are applied in the big picture. Let’s start with Mike, a recent patient in our with shoulder pain.
Mike, a 38 y.o. carpenter, presented on referral from his wife, with complaint of chronic left anterior shoulder pain of 4 months duration after lifting a heavy door by himself. He said he bent down with left arm straight under the bottom side of the door, right hand grasping the top of the door and stood up. He walked for a ways and had difficulty turning a corner. He thinks he might have felt a pulling sensation in the shoulder at that time. He continued his work day and noticed pain at rest in the shoulder the next day, and marked pain on left arm flexion, abduction and extension when putting his shirt on the in morning. After a week of pain, he saw his PCP, who prescribed OTC NSAIDs. PCP also offered steroid injection which patient says he denied because of fear of needles. Pain at rest improved over the subsequent weeks but movement related pain remained at a slightly lower level. He also found it impossible to lay down on either side and was not sleeping well as a result.
Exam revealed a sitting and standing posture with head and shoulders forward, with inwardly rotated arms. Ortho eval revealed painful arc in the left arm between 90-120 degrees. Neer’s, Yocum’s and Hawkins-Kennedy were all positive for external, anterosuperior rotator cuff impingement. Supine external rotation was limited with report of anterior tightness over the shoulder, relocation of the humerus anteriorly did not affect the pain with external rotation, making internal impingement unlikely. Active internal rotation and abduction were primary painful movement vectors. Motion palpation of the thoracic and cervical spine revealed restricted motion in extension and rotation in both areas.
- Janda Key Movement Patterns: Scapulohumeral dyskinesis with early hiking of the left shoulder on abduction. Supine neck raise revealed chin jutting and head shaking after 12/30 seconds.
- Stecco Movement verification screen implicated following Centers of Coordination: ante-scapula, ante-humerus, ante-cubitus; retro-scapula, retro-thoracic; lateral-scapula, lateral-humerus, lateral-cubitus; intra-scapula, intra-humerus; extra-humerus.
- Selective Functional Movement Assessment (SFMA): DN for MS rotation and extension. DP for squat, UE MRE/LRF bilateral, C-sp rotation and extension.
- Dynamic Neuromuscular Stabilization (DNS): Apical breathing pattern observed and patient showed insufficient activation of diaphragm/core with Diaphragm Test and Intra-Abdominal Pressure test.
Structural diagnosis of external impingement syndrome was rendered, with a functional dx of Upper Crossed Syndrome per Janda. Presumed pre-existing postural habitus contributed to the poor healing of the acute injury and resultant impingement syndrome.
Initial treatment consisted of Stecco Fascial Manipulation over AN-SC, RE-SC, IR-HU. Mid-treatment re-assessment after manual therapy revealed improved painful active abduction of the left arm to near 120 degrees before pain and perhaps 30-40% improvement in internal rotation. Thoracic extension was improved but still painful. HVLA manipulation to the T4, T6 and R1 segments allowed for painless thoracic extension.
Exercise instruction consisted of neck ups, home self mobilization using lacrosse ball with focus on mid-scap area and pecs, and Sidelying Thoracic Extension and Rotation peeled back to painless abduction to around 110-115 degrees. After the latter exercise, Mike reported a big sense of opening in his chest and upper back. He was emailed tutorial videos of the 3 exercises from MyRehabExercise.com for reference with HEP.
In subsequent follow up treatments, we worked on the areas implicated in the Stecco movement verification screen with Fascial Manipulation and continued exercise prescription, progressing from kettlebell armbars and screwdrivers, to TGU to the high hip position. Breathing/stabilization faults were addressed with Dead Bug variations incorporating diaphragmatic breathing and “sternal crunch”. He was then progressed to full TGU and early soft rolling patterns. Patient was released after having met his treatment goals after 6 treatments in 6 weeks.
COMMENT: This treatment method of assessing movement quality to determine functional deficits, applying manual therapy and re-assessing after treatment, and finding painfree multisegmental movement pattern-based exercises to build on is what marks the functional rehab approach. With every manual therapy applied in the clinic, patient was shown ways to try to accomplish similar results at home to reduce dependency on the caregiver. Exercise played a role in the treatment from Day 1. An excellent overview of this approach from one of the pioneers in functional rehab is at http://www.craigliebenson.com/?p=1595.
These multi-joint functional exercises are a bit more difficult to teach patients how to do, and having the video tutorial back up at MyRehabExercise.com helped groove those movements and allow the patient to make more headway at home. The methods of manual therapy are interchangeable, all will have some benefit. The particular exercises may differ dependent on the ability of the patient to perform them painlessly. This offers a way out of the sterotypical boxes of our respective professions. Gone are the endless chiropractic visits consisting of heat/stim and manipulation. Gone are the endless physical therapy visits of ASTYM/Graston, iontophoresis and ultrasound. Gone are the weekly spa massage treatments that help for a few days. Gone are the single joint bicep curls and leg extensions in the corporate gym environments that push unbalanced clients to injury and one of the aforementioned treatment scenarios. So let’s all of us look around our communities and find the experts in our respective fields and work together for the benefit of our patients and clients. Folks need us out there.
I would be interested to hear your respective comments and experiences, so chime in.
Also, if you’d like to see what the functional rehab video tutorial library looks like at MyRehabExercise.com, you can trial it for $1 for 30 days risk free. After that, the cost is only $9.99 per month. Click on the link below to start the trial!