Ep 199. Lateral Elbow Tendinopathy: What the Evidence Says with Dr. Leanne Bisset

Are you confident in how you are assessing and treating lateral elbow pain or are you missing key pieces of the puzzle? Today we are exploring the clinical and research evidence behind lateral elbow and genopathy from diagnostic labels and differential diagnosis to exercise prescription manual therapy techniques and when physiotherapy outperforms the other treatment options. Our guest is Dr. Leigh Ann Bissett and associate professor at Griffith University and most post-calato physiotherapist with extensive clinical and research expertise in MSK health and persistent pain. She is a recognized leader in elbow and genopathy research and education. I am a renauptiarche physical therapist and this SPT protocol where leading clinicians share practical insights to elevate your practice. By the end of this episode you have a clear framework for assessing and managing lateral elbow pain with confidence. Now let's dive into today's discussion. PtProtox is only possible with the support of the fellow looking and innovative companies like Sarah Health. Remote therapeutic monitoring sounds great but also difficult. Sarah Health makes RTM simple and easy for your patients and providers. Check out S-A-R-A Health.com/PtProtox for a special offer. Hi Leigh Ann, welcome to PtProtox. How are you? Well thanks Mariana, nice to meet you. Awesome, very nice to meet you and excited to have you here. So let's get started just talking a little bit about yourself in your background. Okay so my name is Leigh Ann Bissett. I am an associate professor at Griffith University in the School of Allied Health, Sport and Social Work. I teach into the Physiotherapy program but my area of research and clinical interest lies in up-align musculoskeletal conditions and in particular around the elbow. So that's where a lot of my work has focused on over the last 20 or so years. I want you to quickly share something with you. I built a new home exercise program platform designed to make the whole process easier for clinicians. You can upload your own videos, customize plans without generating new links and send everything through one simple link. No apps are logins for patients. You can also track when patients open their exercises and copy descriptions straight into your documentation. If you want to try it out, I'm offering a 30-day free trial. Just visit hunnehael.net/hep and use the code 30dayfree when you sign up for the standard plan. And now back to the show. Very good. So we are going to talk about lateral elbow pain and my first question is just how clinicians should think about those different diagnostic labels, the tenis elbow, the tenginopathy. So what are all those names and you know, does it matter why we call it? Yeah, look, I think it does matter. I think tenis elbow means something to our patients, to our clients. That's what is often just that general lay term given to patients if they go and see their doctor, oh, you have tenis elbow. And you'll see that a lot in the media as well. So oftentimes I will still use that term because it's familiar to my patients. Theitis, so lateral epicondylitis, has been around for a long time. And that's probably what has changed over the decades. Originally, of course, tenginopathy was considered inflammatory in nature in terms of the pathophysiology. So theitis, suffix was relevant back then. But over the years, we know that tenginopathy involves more than it can be inflammatory, but more than that, it's often degenerative. So if you get somebody, I think it's worth, it's worthwhile being precise. Don't use iters unless you've got somebody who's got an acute presentation and you seriously think or realistically think in terms of tissue healing and repair timelines that there is an acute inflammatory phase. If it's not that acute inflammatory phase, then we should be using tenginopathy. It's changed over time. We've gone through lateral epicondylalja because that suggests a pain presentation. And we know that with lateral epicondylalja, there are a lot of systems involved, not just tissue pathology. So epicondylalja was used quite a bit, but tenginopathy probably brings us more in line with all of the tendon disorders where there's sort of a common theme in terms of the pathophysiology. It's just the complexity that changes, I think, between body regions. No, absolutely. And they're like, what are some differential diagnosis that we should be aware on that same area? So I think when your, when a patient comes to your clinic and you're looking at what is going on near differential diagnosis, I like to think muscle, muscle/tendon, killer system, so the joint system and then the nervous system. So if you think about them in those three broad categories, under the muscle/tendon system, with obviously the primary hypothesis or the most common diagnosis you'll see with your patients is tendonopathy, particularly if there in that demographic age range between 35 and 65, so the working population in particular, men and women, they don't, the job, their occupation or their activity doesn't necessarily define the inclusion or exclusion of tendonopathy because people get it if they're office workers, if they're housewives or if they're manual workers like builders and concreters and people like that. So there's a broad range in terms of the type of person or the occupation of the person, but that age group is typically a tendonopathy diagnosis. The joint pathologies, I think, are commonly missed. And I think that the differential diagnosis there is tricky because their pain often presents very much like elbow tendonopathy. So if we're sticking with lateral elbow pain, their pain will still be around that precise lateral elbow region, it'll be pinpointed there, but what's probably slightly different with these people is they may have some subtle clicking that they feel or that they're aware of, they're the type of activities that aggravate them are often weight bearing activities. So when they're under load and for example, supernated, under load, like doing pushups and things like that because that tends to, we're talking about instability, so lateral, lateral, ligament, lateral, oner, collateral ligament involvement, which may present as that articular joint type of pain, but it's related to instability, supination drives radial head posteriorly. So weight bearing positions where there's joint, added joint compression or subtle instability that moves that radial head. I'm not talking Frank gross instability following a dislocation that can happen too, but we're talking more these chronic, insidious type presentations because they're probably the hardest ones or they present commonly like tendonopathy. So instability joint, also older demographic if you're talking away, but often the joints may also be present, think about it if they've got a history, especially childhood history of gymnastics or throwing sports. They can also of course have present with more chronic long-term joint pathology, degenerative changes and things like that related to their, to their sport. And then if we think neural, I think these ones are a little bit different. These ones have more spreading pain and neural, of course, you can get ridiculopathy, always think about your higher, you know, your nerve root impairments that can present as arm pain, but I'm talking about here peripheral neuropathy. So there's this really close relationship between the radial nerve and that common extensit tendon and muscle group where the radial nerve passes the anterior to the elbow joint on that lateral side passes back underneath that common extensor muscle group and tendon and and of course bifurcated. indicates into a primary motor and primary sensory nerve, but that motor nerve can become, I think, hypothetically compressed and irritated, particularly in the presence of tendonopathy where you've got pathology and a tendon means that you've got increased cross-sectional area of the tendon, so it's space occupying. And then you load at contraction, like muscle contraction, gripping activities, things like that. Again, have this potential with a sicker tendon to compress that nerve that's got that relationship, that anatomical relationship underneath the tendon, and there's a bony floor underneath the nerve, so it's really got nowhere to go when that compression happens. It's a dynamic compression, so, and because that's mainly a motor nerve, you don't always get that pins and needles and numbness. So I guess one of my key take home messages to people listening here is radiating pain, down the forearm, into the back of the hand, above the elbow, so something that follows that radial nerve pathway, that can be an indicator, think about it being a neural component. The absence of pins and needles and numbness does not exclude a nerve involvement, particularly when it's primary motor. So the pain we're getting in these conditions, I think is more no-see-septive. It's more the fact that the innovation of the fascia within a nerve is generating that pain. Okay, and let me see if I got it right. So in the joint one, you said it's more with way bearing, and you referenced the ligament, and then some joint, the generation according to this poor, if you did a long term. So that would be mainly the two cases that you envision, like in the joint aspect. Mostly, yeah, primarily if a younger, then joint is more likely, like if you are seeing young athletes, gymnasts, throwers, think about joint being a source of pain. If it's still that older population, then yeah, it can be a little bit of various instability. So loss of that lateral collateral ligament, lateral arm, collateral ligament. The other things that they might complain of is pain more when they're lifting or underload in that sort of mutual position where that lateral area of the elbow is uppermost. So there is a bit more of a various stress on the elbow. That's more provocative. The clicking or the popping that they get can also be a pliker. So there's some, in some cases, it's a little bit of an anatomical variant. You can get a little bit of a synovial fold into that lateral joint space. And that sometimes it's normal in people, but sometimes when it becomes irritated, it can give you a little bit of a click and a pop. Okay. But that is probably, yeah, it's probably those adult versus child versus the adult with the child history. And then the generation or the instability, I think you said, is more like in the older population. Just that happens over time or is there like a specific reason? They have to have a lot of movements are overloading on the elbow during their life or it's just getting old and a normal process. Yeah. Look, I think it can be variable. If someone has a history of a dislocation. So if someone's had elbow trauma, elbow fracture, elbow trauma, anything like that, then it can be something that is there. And then when they load it, so it may not cause problems straight after an acute trauma because they're managed well and they're not loading it. It's not until people then start loading it more that you start to see some of these pains develop. So it can be a history of trauma, but it can be a history of just degenerative overload type of activities. And again, it's kind of like the tendinopathy. There's been some studies, some imaging studies that are found in people with lateral elbow pain who present with tendinopathic changes, for example, on ultrasound imaging, that also have degenerative changes in the lateral collateral ligament. And it's just this close relationship, maybe between the tendin and the ligament underlying it, that the degenerative, whatever that pathophysiological process is, starts to impact the quality of the ligaments around there as well. So you can, and it's not often reported because people aren't looking for it. Our testing can differentiate. So using your manual skills, applying a, so you can hold the radio head, stabilize the ulnar and apply an enteroposterior glide to that joint and feel the amount of movement. Look for laxity compared to the other side and see if you can, if you feel that, that increased play in that joint. And then part of my, if my clinical reasoning around that, if I think that this radio humoral joint, radio ulnar joint complex is involved, then in terms of my treatment direction test, I will try and stabilize that and repeat whatever that provocative movement or activity is. So it might be the gripping or it might be, you know, some other might be your flexion extension range, whatever it is, but trying to stabilize that radius, that head of the radius and repeat that provocative movement. And if you take away their pain, then clinically you might feel that that's something that that correlates. The other one I will say, the other group who probably at risk of this lateral instability are golfers because they, at lateral elbow tendon, I put these five times more prevalent or tennis elbow, it's five times more prevalent in golfers than golfers elbow, medial elbow tendon and a funny statistic, but it's their lead arm. So it's their lead arm where they're at risk of that valgus, sorry, virus force at the elbow repeatedly, especially if they take divots and they hit the ground if they're not great golfers, they're at risk of sort of overloading that lateral elbow complex then too. Yeah. Okay. Now moving to the assessment, I was thinking about the ligament because I was like, "How am I going to think about that when I'm assessing the patient?" So going to the assessment, thinking about those differential diagnosis, right? So why helps you to differentiate when you're assessing patients? Okay. So the gold standard for diagnosing tendonopathy is pain on palpation over the common extensive tendon, right? Over the epicondole down onto that extensive tendon. And it's easy to find if you just get your patient to lift their middle finger up and down. So if you've got your patient lying on the bed, arms down beside them and you just ask your patient to lift their middle finger up and down, then that tends to activate extensive carpeoradiolous breathes, which is part of the common extensive tendon and the portion that's most commonly involved with elbow tendonopathy here. So you can pulpit that muscle activation all the way up the forearm to the point of the epicondole. And then you know you're on the tendon, you're on the common extensive tendon because you can feel it underneath. So that's where they should be getting their pain. Obviously, reduced pain free grip strength. Now this is worth mentioning when we test pain free grip strength, test it in elbow extension forearm pronation. So standing or sitting on both side or lying down on both side in extension pronation. Now I realize this is not the standardised position for testing grip strength, right? Which is neutral shoulder elbow 90 degrees neutral forearm. But this position, the standard position with elbow 90 degrees neutral forearm is not pain provocative in these patients. So you'll get a ceiling effect, you'll find your patients can grip, even if you say, look, stop if you get pain. They're often, they've got a strong grip almost equivalent to the unaffected side. So the, so what we're more interested in is pain free function. So what have they got in terms of grip strength just to the onset of pain? And their most provocative position that they'll always complain about is when they're reaching out to pick things up, particularly with their palm down. right? So in that extended pronated position. So test your grip strength in that position. And not maximum because maximum is really painful, just a P1. So how much you know, grip up slowly, smoothly, stop when you first fill pain. Look at that compared to their unaffected side. And you'll see then the real functional difference in their pain, in their pain free function. And then that makes sense to the patients. So your patients will come in and they are telling you this is really painful that they feel like they're going to drop a cup. They can't pick the milk cup out of the fridge. They can't pour a jug. And yet if you test grip strength in this not, you know, 90 degree position, it looks okay. And it like doesn't make sense to the patient, but you test it in an extension pronation. And then they will, then it makes sense because oftentimes their pain free grip strength severely impaired compared to their unaffected side when you do it in that position. So palpation, pain free grip, confirming the tendon, isometric wrist extension, isometric middle finger extension, and/or one or the other, often middle finger extension is more provocative than wrist extension because obviously wrist extension has other wrist extences involved as well. So that's your diagnosis, Fentanyndanopathy. For lateral collateral ligament, I would do a lateral collateral ligament stress test. So you take them into extension just out of extension. So 10, 20 degrees just out of extension and apply a various stress to the elbow that will reproduce pain if the lateral collateral ligament is involved. I, as I mentioned earlier, look at that play in that radio-humeral radio ulnar joint that complex with the radius, head of the radius, your palpation. So the painful areas are more around the radio-humeral joint line. So from your epicon dial, come more posteriorly and you'll feel the joint line. And so the palpation is more posterior on that lateral side than it is right up the top when they're in that position. So palpating the joint line will be more provocative if they've got joint involvement, if they've got OA changes or some sort of intra-articular pathology, range of motion is impaired. So look for a particularly a loss of extension range of motion. In the tendon opathy's full, the elbow joint has full passive pain-free range of motion. But with especially flexion extension, but with joint pathology, you flexion extension impairments are there. Okay. And then with the nerve, it will be just the symptoms, like the area and the distribution, the pain pattern. So pain pattern, palpate, the radial nerve trunk. So you can palpate the radial nerve spirals around the humerus laterally. So you can palpate it as it spirals around the humerus between, so biceps and triceps. You can palpate it through the middle of that, that intamuscular septum. You can palpate it further down as it passes through the supernater muscle. So it actually the motor nerve, the posterior interrosis nerve, which is the motor branch of the radial nerve, distal to the elbow passes, has to pierce through supernater. So generally, you can palpate the radial nerve just on that antelateral border close to the joint line of the elbow, but then four fingerwits down from that lateral epicondole if they're in pronation. Palpate there for more provocative so palpating along that nerve trunk is important. If there's motor impairment in that pin, in some cases, when it's severe, you'll lose power, but the power is in the thumb extension and abduction. So test your thumb strength for power loss. And then, as I mentioned before, it's commonly not a neurological impairment in terms of loss of nerve conduction. It doesn't often get to that because it's more often times I think it's this dynamic compression. It's not there all the time. It comes and goes with that muscle contraction. So mechanosensitivity in the nerve, in when we elongate the nerve is another important differential test, and that reproduces their symptoms. So what I'm talking about there is that neural, like the upper limb neural dynamic tests with a radial nerve bias, and that will reproduce symptoms, will change with when you sensitise the manoeuvres. So for example, using shoulder elevation depression will bring it on elevation, we'll relieve it. And then oftentimes different to the other side as well. Okay, great. So now I just wanted to ask about imaging. Do you think there is any rule for imaging during, to helping the assessment process? I think that the imaging issue is really different around the world, and it's driven oftentimes by medical colleagues, if that's where patients go to first. So sometimes, or oftentimes they'll go to their GP, their general health practitioner, and say, I've got this elbow pain. What the doctor does drive, often drives this habit or this experience of imaging. In Australia, here, our GPs tend to send everybody with elbow pain for an ultra-sounding image. Now, there's really good quality evidence to suggest that that is not helpful. Like all tendinopathy, there are changes present on imaging in people who are asymptomatic. You have no pain, no injury, no history of pain or dysfunction in that, in that area either. And in the elbow, it's around about 50%. Look, Hills did a study, a really nice blinded diagnostic study of healthy controls and people with pain, and a blinded radiologist assessed the images, and around 50% of healthy people aged in that 40 to 60-year-age group have degenerative changes on imaging, or have these changes, if we don't even call them degenerative, they're just possibly age-related changes on imaging, no pain, no impairment. So, ultra-sounding has a confirmation of a diagnosis of tendinopathy is not helpful. I think it's also dangerous, because people come present with pain in their elbow, and then the GP goes and images them, and they told they've got tendin-self bone, and their pain is not anything to do with that area. So, where it probably is useful is to rule out. So, if you want to exclude tendinopathy as the primary source of pain, then that's where maybe you could send them for an image. Bear in mind, if they're that 40 to 50-year-age group, you've got a coin-toss chance, they're going to have changes, right? And they may or may not be related. So, use your clinical diagnosis, like I said, tendinopathy, the gold standard is your clinical diagnosis. Now, where an imaging I think does play a role. If you feel, if you suspect, radial nerve entrapment, especially if you suspect pin entrapment, if their pain is in that mid-disturbed forearm region, if it's related, it can be related to gripping, but also supination, right? Where this pin passes through the supinator muscle. If they're really strongly sensitive mechanically when we do our neurodynamic testing, then a good musculoskeletal ultrasound, if you guide them and say, this is where you want to target your image, you can see a pin entrapment, because what happens when it passes through the supinator, it passes through this little canal called the arcade of fresh, and that's almost like a ligament type of tissue. That can sometimes become very tight, and then it is a true peripheral nerve entrapment, and you'll see this hourglass appearance in that nerve at that point of entrapment where it swells above and below. So if you suspect the pin entrapment, I think an ultrasound image is important. If you suspect articula pathology. So one of the other common articula pathologies is a spur, So postural lateral or postural medial impingement within the joint often again related to a little bit of instability, medial or lateral instability where the electron on then doesn't sit in the faucet. It moves around or it gets compressed and irritated on one side. Then it can develop a spur, same with the tendon insertion, so triceps tendon insertion. So if you suspect any kind of intra-tikule pathology, then a normal radiograph and x-ray might be indicated. And then you'll find that these cases are common in practice, are not very common. Oh, you'll see them. Of course, tendonopathy is the most common. But when we run the risk, I think we run the risk of just always assuming everything is tendonopathy. And then not. That's something really important to remember. If it doesn't, if it looks like a bit of a weird picture, think about the alternative. If you treat it as a tendonopathy and it's not getting better, stop. Take a step back, reassess your differential diagnosis. Think about the joint system, think about the neural system and see if there's something there that you feel like you've missed. I think it's just too easy to go, or every patient who presents with lateral aloeba region pain is a tendonopathy. And they are, you will see them, yeah. Just they're not as common as tendonopathy. And then I heard that you also use some mobilizations with movement in your assessment. So would you tell us when do you use it and do you use it? To see if they're going to respond to specific treatment. So how do you use them? Yes, I do use mobilizations with movement. And look, there's science behind it. We've got big clinical trials that have demonstrated the effectiveness of incorporating mobilizations with movement into a rehabilitation plan in aloe tendonopathy. But also there is an art to it. And so I think it's important, people, like they're a great technique. I would encourage physios if you haven't done a mobilization, a Mulligan's course go and do one. They're great techniques to do and then play with it. So the way I use mobilizations with movement, the most, probably the most common one that's useful for lateral aloe tendonopathy is a lateral on a glide. Let's not get into the biomechanics of it. Okay, that's another whole story of mechanism of effect of mobilization and manual therapy techniques. What we're looking for when we perform these techniques is a significant change in their pain. Okay, and their pain-free function. All right, so you might change resting pain. But what we're looking to change is their function pain. Okay, so with tendonopathy, it's commonly gripping activities that they'll complain of or primarily gripping activities. So I'm looking for a significant substantial increase in their pain-free grip strength when I apply a lateral on the glide. And that then helps direct my treatment to incorporate, of course, mobilizations with movement into my management plan. And we'll talk about treatment, hopefully, in a sec. So this is just assessment and how it helps direct treatment. If I try it and I don't really get a change, so you can be very objective with these because I treat my patients in supine light on the treatment couch. The grip, the dynamometer is in their hand. Their arm is resting by their side on the bed. They can't see their dynamometer score, right? Their output. So we do a pain-free grip at baseline. We get that all often then show them compared to their unaffected side. So they realize the level of impairment that they've got in their pain-free function. And it helps validate their experience. They're telling us how bad this is. And you go, well, actually, yeah, you've lost, you've lost grip strength. Without catastrophizing it, it helps validate. So then I'll do a glide and just say to them, same instructions, grip up until you first fill on set of pain. You will know straight away how that's going because they take longer. If it's effective, they'll grip up and then they'll kind of wait and then they'll grip up a bit more. So the first one's often a little bit hesitant because they're expecting pain. So it takes longer. If you get a change, I will do a couple more there and at once, they're more confident with it to see what their true pain-free grip strength changes with that mobilisation with movement. If it doesn't change and you'll know straight away because they'll grip and stop pretty quickly, I will slightly adjust my glide, change the direction, a little bit more anterior. And lateral or a bit more posterior with the lateral. If I don't get any change, I will change the technique. So as I said, lateral on a glide is sort of the go to one initially. But if that doesn't work, then I'll try a PA, post-row anterior glide on the radial head as an alternative. The other technique, and this is not necessarily taught by Mulligan. The other thing I will try with these patients, especially if I suspect there's this peripheral nerve irritation or involvement, is like a manual deloge. So there's a study that's looked at diamond taping for elbow tendonopathy and found that it reduces pain, it reduces pressure pain, threshold measurements at the elbow. So I mimic that with my hands. So I will do this over the elbow or modestly over the forearm, wherever I feel like, suspect clinically reason, that there may be a peripheral nerve involvement and look at whether or not that changes their pain. That's often especially with resting pain, will change, resting pain. And again, it just gives you an indication that if we can change their pain, then we can get them exercising more. This is the reasoning for doing these techniques. They are a technique that's applied to the patient passively, I guess, because it's a manual therapy technique, but it's on top of their painful functional activity that you've identified. And it's about changing their pain during activity, which means they can do more. One of the challenges I guess we have with patients with the lateral elbow tendonopathy is that sometimes the pain is severe. We give them exercises, we send them away and the exercises hurt and then they don't do them. So adherence to exercises is not great with this. And you get this spectrum. If they're mild pain fine, if they're more severe pain, then that adherence is often quite poor. So if we can help them reduce their pain, it means that they're going to do their exercises more effectively. Yeah. They see the light in the end of the tunnel. Yeah. And you were talking about resting pain. So if they have resting pain, could that still be the thin genopathy? Or it would be just with movement. That could be something else. Yeah, that's a really good question. The resting pain, so it brings up now this question of pain mechanisms. If pain is primarily sourced from tendonopathy and we consider it no-siceptive, then it hurts to contract the muscle to use it, to load it, and then there's no pain at rest. That's your typical presentation, right? Resting pain could be so many other factors. It could be inflammatory, right? Because we know inflammatory pain can happen at rest at night. So you've got to match it up with their history with the patient's presentation. It could be inflammatory. It could be neuropathic, it could be nocyplastic pain mechanisms. So it could be coming from alternative pain mechanisms, pain drivers. So again, it's got to match your history, your patient's history, and their clinical presentation to figure that out. And you will see these patients. So if you've got. You know, you know what you, for example, your typical ridiculous presentation, they may have constant pain. Okay, that flares up, that varies, but it's there all the time. And at rest, you can get that same thing with peripheral neuropathy. You can get certainly significant pain. And you'll reduce that pain by unloading the nerve. So if I suspect it's neuro-neuropathic pain, then again in supine, I will completely support their arms. So elevate their shoulder, put a pillow under their arm, bend their elbow, find a position in terms of elbow, flexion extension range that helps to reduce their pain. Doing this, sometimes along the nerve trunk, will also help reduce that resting pain. If it's nocyplastic, and again, you will see these people, they have widespread pain. Their pain spreads, they'll have, so it's disproportionate, so it's severe. And it could be at rest, it could be with activity, it could just come on by itself. Then those ones are, there's a lot of sort of features and characteristics that we look for, in terms of that nocyplastic pain. And it's often chronic, so it's more than three months by definition. And there's a lot of work going on with pain groups at the moment to try and help define and discriminate between these different pain mechanisms. So if you suspect nocyplastic pain, ask your patient about how they are feeling, you know, their general well-being, how their sleep is. So oftentimes they're not sleeping well, they're feeling fatigued through the day. They'll often complain of cognitive impairments, so their brain fog and things like that. Interestingly, and I think again, this is a mistake, physios tend to make sometimes, don't assume that just because they have nocyplastic pain, they have psychosocial impairments. Right, oftentimes we go, oh, they must be catastrophizing, they must be fear of voidant. That is not necessarily the case. Right, and those psychosocial characteristics actually aren't even in the core definition said that the expert consensus panels have come up with for nocyplastic pain, not at this point anyway. So it's more about their pain presentation, their pain behaviour, and it is the psychosocial factors. Certainly they can be there, but it's not always there and don't assume it's there. Okay, great. So let's jump to treatment because it's been all this talk and we've even got to the treatment. It's been great, it's just a lot of things to cover. So how do you start managing the lateral well-being? Because we talked about mobilization with movement, so we know that you use that if they respond well in the assessment, so what else? How do you manage? Look, exercises the mainstay approach for tendonopathy. If we focus on tendonopathy, we know that exercise is important to load the tendon to start getting changes in, you know, if we're looking for that structural change in tendon quality. Right, so we know exercise is important. I'm going to say not all tendonopathy are the same. Another mistake we've often made traditionally is that we've extrapolated lower limb evidence for exercise therapy into the upper limb and it doesn't necessarily work. Reason being Achilles tendon is an energy storing tendon. It's a big thick tendon, it's designed to store and release energy. There's some really lovely work that's been done by a lady called Hazel Screen out of the UK and she's looked at horses and tendonopathy because apparently race horses get tendonopathy as well. And she's done a lot of biological studies, microanalysis of actual tendon structure. And there's a difference between energy storing tendons and positional tendons. So energy storing, of course, have a, you know, they are designed for that type of function. They have a higher percentage of a last and content within that interversicula matrix than when compared to positional tendons. I'm going to argue that, and this work hasn't been done in humans, so I'll copy it by saying that. But I'm going to argue that the elbow extensors, which is sort of the same tendon that she looked at in horses, is a positional tendon. It's not designed to store and release energy. That's not how these muscles and tendons work. They work to stabilize the risk to allow optimized grip or hand function. That's their job. The job of these wrist extensors in particular, counteract the flexion moment of the long finger flexors as they cross the wrist, right? So long finger flexors, if they can track, they would do that. And we can't grip like that with wrist flexor. These muscles work isometricly to stabilize and hold the wrist in space. Under low load, so doing low load activities, things like craft work, writing, playing darts, things like that. Yeah, there's wrist movement, okay? And there's wrist flexion, extension, radial arm and deviation. But as soon as we start loading up with heavier resistance, when we start pushing, pulling, lifting, carrying things, punching, things like that, we need stability at the wrist. These muscles have no moment arm, virtually no moment arm, the elbow, so flexion extension, has less of an impact. It's what happens at the wrist where they insert across the wrist. So if their role is to contract isometrically to stabilize the wrist, why do we go straight to doing reflection, extension exercises under low? It doesn't make sense, right? It's not the functional role of these muscles. So go back to their functional role, go back to what they need to do, start isometrically. Now a lot of tend to not put these going to isometric contractions as a beginning point. With the difference here, I think, is that with these muscles and it depends on the person and what they've got to get back to, I'm going to say that because it will vary. But with a lot of people, the isometric contraction is really where you need to focus your energy. You can strengthen it, you can load it more, you can hold the contraction longer so the progression can be really effective, but still maintaining that isometric load. To add more dynamics to it, you then bring in your upper limb. So it's part of this whole kinetic chain. So you can bring in your elbow movements, your supination, your pronation, your shoulder elevation and rotation movements. And create an exercise that aligns to their patient's activities, the things they want to get back to. If it's golf, if it's tennis or if it's work, you can create this exercise. But the role of these muscles stays the same. It's still that isometric hold. So I can do a whole exercise program, a rehab program and keep that isometric contraction happening at the, at the level of the wrist extensors. Often a co-contraction though, right, with gripping. You can start to back it off to make it really, really light. I will isolate wrist extensors by themselves, so not with gripping. I will teach my patient to do the mobilizations with movement technique. So if they're proven effective in the clinic, I will teach my patient how to do it on themselves. So it's easy to teach them to do a PA on the right or head. It's a little bit harder with the lateral ulnar glide, but you can do that as well, either with one arm or against a wall and things like that. So I teach them how to manage their own pain with their exercise. Where I would go to more concentric eccentric work, rarely would I ever do an eccentric only program. I don't think it's ever indicated to be honest in these muscles, in lateral elbow tendon or pithy. But a concentric eccentric program is when you've got the real high load workers. So people who need to get back to working in awkward positions. So sometimes mechanics, for example, have to get in and around objects and motors and engines. And they're in an awkward position. They need a strong grip. They need to be able to move in and you know with their wrist in those positions, those awkward positions under high load. Bear in mind, these people also at very high risk of developing. developing tendinopathy because of the actions that they're doing with their arms. So in order to get them back to those jobs, I'll work at trying to modify where we can, like the way they're doing things, but also bring those sorts of activities back into the rehabilitation program and their exercise program. So we're indicated, I will do it, but the majority of people don't need that. The majority of people need this functional control of the wrist when they're using their whole range of different ways. Okay, so when you start with the isomatrix, you do it with the grip or you just do the extension of the wrist. And how do you do it? Do we do it like a pereabend or is just with some weights? How do you find that's better? Based on the patient depends on the severity of their presentation at baseline. I, as I said, I will teach them to do their own MWMs. If they're more severe, easily provoked, so irritable with their paint presentation, then I will start with just like even low load, just no load, getting them being able to just, or through range, perform that wrist extension holds. And if they can do that, then start loading them. And I typically use resistance band because it's really nice. You tie a loop around it, you tie it over their hands. They can put it in their pocket, they can stand on one end of it and they can load their extensors and hold. And positions important, don't let them go into extension, finger extension, extensor digitorium is part of the common extensor tender, but it also has a tendency to try and compensate for the wrist extensors. So fingers curled lightly, they're a band or resistance band over their wrist and then isometric holds like that. With their MWM, I time it. So I'll get them to lift up, hold isometrically and I'll time it to P1, so back to the onset of pain. If they can do a 30 second hold without pain, I'll stop there. What's the other really, there's another really key component to doing MWMs, both in the clinic and teaching them at home. And that is that MWMs, when they work, they're incredibly effective at taking weight pain and some people, they'll have maximum pain free grip strength while you've got a glide applied to the elbow. The problem is, after, so you let it go, the patients relax, you release your glide and then they go to move and it's almost like this rebound pain, they'll go, "Oh, that's really stiff and sore now." Right, they'll get this real reaction afterwards. So pain free during pain after. So the key is that you've got to do your MWMs and then with elbow flexion and extension, okay, to clear that resting pain or that rebound pain. So I'll do that with them as well. Do their isometric exercise to P1, if it's earlier than 30 seconds or two, 30 seconds, and then drop the resistance band, hold the elbow. So you've got your glide happening and do flexion extension until the pain goes away, okay, until it's clear. So make them sort of, you know, back to their baseline levels and then repeat it and do your next load and the same thing through your repetitions. Clear that pain in between repetitions and then keep going. With there's been studies that have shown, if you exercise the inter pain, all you do is provoke pain. You don't change grip strength. You don't change anything, at least in the short term, all you do is increase that pain. If you either MWMs, you can do more exercise pain free. So they grip strength is higher, their resistance load is higher, if you can get them doing their MWMs at home. The higher the load, the more effective the exercise is going to be, right? Like if we start really low load and we don't progress, we're not going to induce changes in the tendon, you know, in that inequality that we're looking for. We need significant, we need to be able to impart significant strain, significant load to a tendon in order to get these cellular changes happening. We can't do that when it's really painful. And these people are in a lot of pain. And I don't know if it's because it's that upper limb and it impacts their life in so many ways. But you know, you've seen these patients, I'm sure, when they're in a lot of pain, they can't brush their hair, they can't brush their teeth, they can't shake hands. Like the lightest of activities can be really painful and it's just so debilitating. So anything we can do to reduce their pain is really effective. So resistance load and I will keep loading, I will prolong, I will increase reps, change the resistance. So you go up in color. And as I said, I'll progress maybe from elbow flex to elbow extended while they're doing their exercises and then add and progress the whole upper limb chain. So add your more complex movements into that. If the self-MWM's and their own are not effective, I will also tape. So the diamond deloting tape I mentioned earlier is very effective at also maintaining sort of a sustained level of of pain relief. And it's really, again, let's not talk mechanisms. Who knows? Because all we're doing is like with my hands, you know, all we're doing is really just punching up the skin, right? What are we really doing? It's not a mechanical effect. But interesting with patients, you put the tape on and I've come to now, I know the, I'm going to talk out a turn a little bit. I know the recommendation for wearing tape is that you wear it for a maximum of 48 hours you take it off. And of course you need to be cautious with skin sensitivity. The way I will tape, I will alcohol wipe their skin to clear it of any, any pathogens if I possibly can. I will use hypersyfix or fixamil, so hypoologenic undalai type first. Then I tape over the top with rigid tape and I tell them to leave it on for as long as they can. Giving them the appropriate warnings if it gets itchy, irritable, increases pain, take it off. And then I just leave it on and leave it on for five or six days. And patients will come back and say, oh yeah, I left it on. It was all great. You know, I think it really helped. It gets manky, it gets loose. The edges start to fray all of this sort of stuff. But then they'll say, oh yeah, so I took it off and then the pain came back. And I haven't got an explanation for how it works, but it seems to work. And maybe it's placebo, but if it reduces their pain and gives them the confidence to do their exercises, then it's a way in. Okay, we can get them exercising without that thing in the back of their head that their pain is going to get worse. Okay, so many questions. Is it a matrix? Pain free. You said that's usually painful, right? So do you have a pain like level that should tolerate? You try to do it pain free. So how do you manage that pain level? Because then if it starts to hurt much, they are going to drop out, right? So how do we manage that portion? Yeah, so if to begin with, like especially in the early days, as soon as the pain starts to come on or increase, I stop the exercise. Do this clear it, try again. So rest it, settle the pain using your MWMs between times and then do another one, another repetition. If they can't settle it, if the pain's going up, I also do low reps in the beginning, maximum of five reps, sometimes only three. I test it in the clinic to see, to establish that baseline level. And I work with the patient getting feedback all the time, what's happening, tell me what's going on with your pain, how does it feel when we stop? What can you clear it? How long does that take to settle that pain before the next rep? So it really depends on the patient, but sometimes it's three reps, sometimes it's five reps. To start with, once a day. So what I'm trying to do here is give them some early wins. And I guess in the back of my head here, I'm thinking about those bad ones, right? That's the ones on focusing on. That there's lighter ones where they've got none of this problem and they're great to go. And you give them the exercise and they're fine. These are the kind of not so good ones, the real ones with really quite severe pain and things. So I start quite gently and give them that early win, give them that sense of control. over how they do their exercises, how many they do based on what that pain response is. And I recognize this as a little bit counterintuitive to the way we're talking now about chronic pain. Because all the talk about chronic pain is, you know, it's not about the pain, you just got to exercise and you know, you go to your, you know, you're four out of 10, you're five out of 10 pain and that's okay. Again, in some people, that's okay to do that too with these people. But given the range of potential diagnosis, you've got around luch or elbow pain, neuropathic pain included, it's better to err on the side of caution initially. If you provoke neuropathic pain, all you do is make them worse and you're not going to have any benefit. Right? And bear in mind they can have this combination, they can have a 10-denopathy in addition to a neuropathic pain or something. So you've got to work that out clinically, you know, and try and figure out, don't just go, oh yeah, I'm just going to throw the same old 10-denopathy program at them because they don't, it doesn't work. And this is where I think there's a sense of frustration with clinicians because we give it to some people and it works and then other people it doesn't work. It fails, they don't come back, it's too painful. So I think we've got to be a little bit more nuanced and a little bit more patient-centered with how we approach it. Certainly a little bit of pain is okay because they can clear it. Right? And I'll also say now this is, this is your responsibility now as to how much pain you get. You control how long you contract for, you clear it between times. Sometimes I'll even give them the neurodynamic, so some neural sliders and gliders to try and do between repetitions. Okay, so if you suspect that there is a neural component, I will give them those as a pain relieving exercise between reps. And so it's their responsibility to manage this pain level. Don't just blindly do 10 times, 10 second holds because that's what we prescribe for every tendinopathy. Yeah. And when you say start with low reps, so you're talking about like a few times a day, like two or three times a day or how is the like the dodged dosage on those really bad cases and they just hold far as long as they can tolerate before, you know, being starts and then they stop. So like how do you, how do you control that dosage? So the really, you know, I'm talking about out of 10, 9 out of 10 time pain people tested in the clinic, see how many you think they can manage. And if you start to see, so their pain should stay level and it might increase with a little bit with the exercise, you should get it back to level, back to baseline, whatever that baseline level is before you do your next rep. Do that tested in the clinic, see what happens. If you get to three or four reps and their pain staying high, they've now got resting pain that they didn't have before, stop. Mm hmm. Okay. So we did four reps, but that last one wasn't great. Now you've got resting pain. I only want you to do three at home and I only want you to do it once a day to start. So really low light, I only want you to do it once a day. Just try it and see how you go. If they're confident with it, they'll come back and if it works and they'll say, oh, actually yet, but I was then able to do it, I actually do it a couple of times a day, but I don't necessarily prescribe that. I will just say to them, all right, we've tested this. You can do three without flaring up, getting a really major flare response. I want you to do three. I only want you to do it once a day. Let's see how you go and then get them back in a week or so and revisit, recess. First thing I do when they come in after saying, hi, how are you? How is the traffic? I will then say show me your exercise. So make it a priority. If we prioritize, if you do the exercise at the end as they're walking out the door, then it's not a priority. They perceive that and they won't prioritize it. I make it a priority. Right as soon as they come back, show me your exercise. How'd you go? Let's see how you're doing it because then you'll know whether or not they're doing it, especially teaching them an MWM because it can be a little bit awkward. If they've practiced it, they'll know it. If they haven't, they might not be able to do it. Yes. I'm going to learn that pretty quickly. How about the upper extremity exercises that you combine then with the isometric? So you show like a grip with a little bit of extension. How do you just ask them to grip? Do you give them any resistance? Why are they doing the movement? How do you do that? For the global, like upper kinetic chain exercise team. These posture's important. Right from the start, I teach them how to grip with a relatively neutral, slight wrist extended position. So if they put your forearm flat on a table and make a fist, I say that's where you should be, okay, that position. So because a lot of them will tend to grip with some degree of reflection as well. You don't want them up here. Like you don't want them really cranked up high. So just that neutral position is where that's what we aim for with those isometric holds. I'll still use resistance band, but in standing. So they stand on one end. It might still be wrapped around here or they might be gripping it and holding it now. And then it's about being creative with what you do. If you've got somebody, let's say you've got a 55 year old lady and she gets, she heard one of her biggest complaints is hanging out washing. So I will get her doing an exercise where she's reaching out like that, coming in, pushing up, reaching out, pushing up to try and, but she's holding the thera band and she's maintaining that wrist position. So she's using, so you're going to get some global uplimbs strength work. Again, there's good evidence to show that the whole kinetic chain does become impacted, especially with chronic tendon opathy. So doing some, especially scapular strength stability works shoulder stability work is important to incorporate that as well. If it's a golfer, then I'll get them doing holding a thera band and practicing their swing or coming across their body in that direction. You can also then start using the equipment and get them to bring in their equipment. I've had kayaker bring in his paddle and added thera band to the paddle and then got, got resistance going when trying to be, you know, to paddle. So be creative a little bit about where what you do. So the goal is just like kind of like a neutral wrist position grouping to just activate those muscles engage those muscles. Yeah. But you can do supination pro nation, right? So you can do a neutral wrist holder tennis racket and practice that supination pro nation movement but maintaining that posture. So supination pro nation comes through the forearm. The wrist is still even when you're playing tennis, the wrist has to still be stable. Mm hmm. Okay. Very interesting. And just one more question. No, we are, we passed our hour here. How about cord is on injections? So there's a lot of conjecture around cortisone injections. They have a fabulous short term effect in tendon op, the in elbow tendon op, the they've been used for the first sort of six to eight weeks. Great, great pain relief. The problem is the pain comes back and then it stays bad for a long time. And then when we pull data from two of our big clinical trials, they're worse off at six and 12 months than if you do nothing at all. So it is this trade off. And there's other studies that have shown cortisone into like an intra tendon injection has more degenerative effects. So it can really impact in a negative way the quality of a tendon tissue. So it's got to be a trade off and a conversation with patients. I think our patients need to be well informed. Sure you can have like some of them are in excruciating pain, right? Mm hmm. They're just desperate for some pain relief and the doctor is offering them a cortisone and the chances are it will give them fabulous relief in that initial stage, but they need to be aware they could be long term consequences to it. [BLANK_AUDIO] Another way we can give them pain relief is there something else, you know, and maybe it is medical support. Maybe it's an all-gizic medication. Maybe it's anti-inflammatory medication. Maybe it's something else that gives them some sort of pain relief rather than a court of zone injection. Certainly into the tendon should be avoided at all costs just because of the quality of the tendon change and this long term negative effect. But there's still a lot of it happening. Yeah. And if you had to say one thing for clinicians that are, you know, the most common mistake or something that they can improve to just have better outcomes, anything else that would like to say, we forgot to mention, you think it's an problem? Oh. No, I think we've covered everything. I guess think about pain mechanisms when you've got your patient. If you're not getting the response, patients not responding the way you think about it, reconsider your differential diagnoses. Don't rely on imaging. It's only, you know, it's probably only indicated when you're looking for those other differential diagnoses. Don't assume all patients have psychosocial impairments. They're not all catastrophisers. They're not all fear of avoiding. In fact, oftentimes you'll see these people who are the opposite way and they are stoic and their copes to their detriment as well because they don't modify or stop their aggravating activity. And don't be afraid to use hands on. I think there's a, you know, this whole swing we've seen over the last few years around. Don't put your hands on patients, I think, is to our patient's detriment and to our detriment as, you know, it's part of our skillset and we can really help patients and be impactful if we use it appropriately. Okay. Great. And you said if they don't improve, consider differential diagnosis. So timeline, when would you think like, well, that's not working. Like I'm not seeing any, like any improvement. I know it's a hard question because it varies. But generally speaking, when would you expect to see if like results are some improve? Yeah, I would typically see patients maybe once a week for six to eight weeks. If after three weeks or four weeks, when not seeing a change, I'd be really, really stepping back going, okay, what have I missed? I'm going to go back and reassess and just and try, yeah, try something different. Yeah. Okay. Great. Leigh and thank you so much for your time. I know we passed a little bit. If people want to reach out or contact you, is there a way that they can find you? I work at Griffith University. If you Google me at Griffith University, you'll, you'll see my email. You can email me that. Yeah. Awesome. Thank you so much. This was great. A lot of great information. I think that's going to be very helpful. To our PTs here, our audience, so I appreciate your time and your, all your knowledge. You're very welcome. Thanks for the invitation, Maryana. That's all for today's episode of PT Pro Talk. We hope you enjoyed this discussion. 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