044. Lateral Elbow Pain Part 1 with Dr Leanne Bisset

This is the Physio Edge Podcast episode 44 with David Pope. [Music] Hey and welcome back to the Physio Edge Podcast. Great to have you with us today for another podcast. Today we're going to be having a chat to a Physio therapist who's got her Masters of Sports Physio, Masters of Minipility Physio. She's also got a PhD. She lectures on the Griffith Uni Masters of Musculoskeletal and Sports Physio. And she's done a lot of research around the lateral elbow, lateral epicondal algebra, and also sensory motor control and chronic musculoskeletal disorders. So she's got a lot of experience. She works clinically as a physiotherapist, treating up limb conditions, and splits a time between her the Uni work, research, and also her teaching stuff. So lots of great experience doing research and then applying in clinical practice. And she's been published really widely, especially around the lateral elbow. So without further ado, we're going to dive in today's podcast, which is with Dr. Leanne Bissett, and we're going to be discussing lateral epicondal algebra. And we're going to be, this is part one of a two-part episode. So in the first part today, we're going to talk a bit about the pathology of what's going on in lateral epicondal algebra, what you should call it to start with, what's happening in that pathology, and then how you can start your treatment of it. In part two, we're going to dive into more detail on how you can progress your treatments, how you can differentially diagnose it from other conditions, and then taking it even further. So that's coming in part two. We answer a lot of your questions that we put it out on Twitter, and also through the clinical edge newsletter to find out what questions you had about lateral epicondal algebra. And those answers to your questions are coming in part two. But for now, we're going to dive into part one with Dr. Leanne Bissett, and as I have been doing for the last number of podcasts, I've got a really nice summary of the main points from today's podcast. So you can go down low that now. That's at clinicaledge.co, and I've designed it just so you can get the most out of the podcast as possible, and remember it, and then implement it into your clinical practice and start getting great results. So that's the goal. Go on down low that one, and it goes really nicely with today's podcast. So let's do it. Hi, Leanne, how are you? Oh, well, thank you. That's good. Today on the podcast, we really want to have a chat to you about the lateral elbow, and lateral epicondal algebra, and lateral elbow pain. So I'm looking forward to having a chat to you about that. Finding out what the best way to assess it is, and be a virtual diagnosis, and then how we can go about treating it. The best way is to treat it. So should be good. Okay, it's my favourite topic. Is it? That's great. So tell us a little bit about how you got interested in tennis always, how? Well, I started my PhD back in 2004 under Bill Vitt Jansino, up at the University of Queensland. I had just completed a Masters in Sports Physiotherapy, and then enjoyed uni so much that I went back and did the Masters of Musculoskeletal, or Manipulative Physiotherapy, it was called at the time. And after that, I was sort of tossing up whether to go straight back into full-time clinical practice or what to do. And Bill had, he offered me the opportunity to enroll in my PhD. He had funding NHMRC grant money, that he was using to run a clinical trial, which became the basis of my PhD. So it was really just serendipitous that I fell into the elbow at the time. Excellent, excellent. So overall, what do you think of the main ways that physios could improve on their management of tennis solv? What do you like to call a first-time response? What would be good to figure out the language first off? Oh, look, tennis elbow is the easiest thing to call it. It's the most, it's still what I are using clinical practice because patients recognise it, and so calling it tennis elbow is fine. Within the research field, you'll see it called all sorts of things, but they're trying to move away from theitis. So it's no longer called epicondylitis. It's usually lateral epicondyl alcohol, but that's not that easy to say. So then we shorten it to Ali, but it swings around about, it's easier to just call it tennis elbow. It rolls off the tongue a lot easier. And I guess there's, you know, the reason why tennis elbow has been such a big part of my research area is because it's the most common condition that we see in the adult elbow, anyway. Perhaps it's certainly not in the child's elbow or the kid's elbow, but it is in adult elbows. And so it's the most difficult to treat typically as well. So that's why I guess there's so much. There's a volume of research out there. If you look at the literature, there's a volume of research. I'm tennis elbow. And they're all, you know, it's a, because we're trying to better understand what's going on underneath, what's causing the pain, trying to work out, well, have we got the diagnosis right? And then if we have, well, then how's the best way to manage it? So it's not just a straightforward, you know, it seems like such a small area of pain, but it's still so difficult to treat and to get better. Definitely. Why do you think it's so difficult? Because I think that the, the, this relatively simple clinical presentation that we had that it, that it, you know, these patients present with really, it's a bit misleading. And I think it, I think underlying it and the drivers behind the pain and the disability are far more complex than what we give that simple clinical presentation credit for. Okay. So what do we know about what's going on as far as the pathology or, of lateral elbow pain? So there's good evidence that there's local, that it is a local tendon opathy. So that's been fairly well established. These patients have signs of local tendon degeneration. That's, you know, it's, it's there on ultrasound imaging. There's potentially inclusion of a tear within the tendon, but there's certainly focal hypoecogeneity, like that degenerative change that they see on ultrasound. There's also been some evidence of related changes to the radial collateral ligament, although that's a little bit less conclusive by the imaging because ultrasound's not the best way to image the collateral ligament typically. But also the, you know, the, in terms of the pathology, we know that it's not a joint lesion. It doesn't involve the joint itself, not the radial humoral or the radial or ulnar joints. It's, it's pretty much within that local tendon opathy. So that's, that's been well established, that there is this local degenerative change. And it's considered, you know, or perhaps the way that we should be thinking about it is that it's a normal part of aging because it's seen in people who don't have pain. So there's been some studies that have looked at cross-sectional imaging of a population, a healthy population as well as a population with albopein. And they're, you know, they've found that around 50% of people who don't have pain still have these changes on ultrasound imaging. So there's got to be something more to the pain profile and the pain and disability that these patients present with, rather than just that local tendon opathy. So there's a few things that can contribute to that. Certainly there's often a history of overuse that there is some kind of an overload mechanism and it, and that might precipitate then a gradual onset. It's not necessarily an acute, you know, immediate response to that overload, but it's often a gradual onset after they've done something to overload it. Now the overload is relative to what their usual level of activity and load tolerance is for that tissue. So if there are, if they're already a manual worker, then the overload has to be something quite high. But if they're a domestic worker or a, you know, a white collar worker, then the level of overload doesn't have to be that hard and sometimes it could be something as simple as cleaning up the garden, working for a few hours in the garden on the weekend, might be enough to then trigger it also. There is that level, that connection between overload, it's not always there in 100% of cases. Sometimes we'll get patients, I'm sure you've seen them, who just present and say, "I don't know what started it, I did nothing different, it's just gradually come on." So, you know, there's perhaps some other underlying causes that trigger that onset of pain that we're not quite yet sure of. And it's a little bit like the lowly, like with your Achilles tendon, or Patelotin and Opelite, there's always people out there that have got those tendon changes. If you're in volume or playing, you've got more, you're more likely to have tendon changes with age and with more playing. So, it sounds like it's a little bit like that, that the more you do physically, you are going to have tendon changes anyway. Yeah, that they're there regardless of whether there's pain or disability. And often they're there without pain and loss of function. So, yeah, it's, I guess, part of what we're trying to seek answers to is, what is it that triggers the pain? And can we identify that early on in the piece? populations, especially in working populations, because there's no doubt it's more prevalent in manual workers and it's more prevalent certainly in people who use their arms a lot. So, you know, the factory workers are a classic example. They suffer quite a bit with a tennis elbow. So what do you tell patients when they say, "So what's going on in my elbow that's causing this pain?" Good question. Words are so powerful and I think we've got to be really careful with what we say to patients. I guess what we don't say, some of the things I've heard come back to me from patients. I've had patients turn up and tell me that they have a black hole in their elbow tendon because they've seen it on image, on ultrasound and someone said, "See, there's black hole here, that's your degenerative tendon, that's why you've got pain." So I think that can be really counterproductive, trying to tell a patient, you know, and showing them sometimes what's going on on their image can be really counterproductive because that's putting thoughts and images into their head about what's going on in their tendon. Now, someone with that kind of a perception is more likely to think that unless they get rid of that black hole, their pain and function will never, they will never get better unless they get rid of that black hole. How can physiotherapy get rid of that black hole? Well, the answer is we can't or we don't think we can. You know, some of the studies that have been done looking at the image changes over time are showing that it doesn't correlate well with changes in pain and function. So they get better, their pain reduces their function improves, but the black hole stays. So I think it can be really counterproductive to talk to patients about what's going on with their local tissue pathology, but also calling it degenerative can sometimes upset people as well and probably also has negative connotations in someone's mind. So I usually try and say things like what we're seeing on this tendon is part of the normal aging process. Intendants, we often do see it in tendons and in people who don't have any pain or loss of function. So it's not necessarily not that it's not relevant, but what we see there is not that is not what we're focusing on when we're coming to treatment. I explain to them that I try to talk about where their pain is coming from and what those pain generators are. Now that depends on the patient. Sometimes if it's just a local isolated area of pain which classic tendon of tennis elbow should be just straight over that trailepicondal. If it's not radiating anywhere, if it's that classic, it's just there when I perform those aggravating activities like gripping or picking things up. If it doesn't affect their sleep, if their elbow's not stiff in the morning, so lots of like negative things that I criss off and if it comes back down to a fairly simple, straightforward presentation, then I talk about one, rest, modifying your activities so that you avoid the aggravating symptoms, aggravating those that pain and the importance of exercise that to date, the evidence sort of tells us that exercise is probably the best option in terms of active treatments, that the injection therapies are not showing any superior effectiveness over an active intervention such as exercise and that we can supplement that with other things like our manual therapy techniques and things. But the focus should be on modifying the activity and in some cases if they're mild enough, then they don't need long-term physiotherapy. Now if you can teach them to do exercises, I think there's things that therapists can do better with prescription of exercise around tendon operty or around tennis elbow in particular. And that's another caveat I'd like to put on this as well as that the upper limb tendon operty is I think a different to the lower limb. For many reasons and some that we probably don't know, some that we just speculate. But certainly for tennis elbow, the exercises shouldn't be painful. Okay, so you basically let the patient know that if there is any changes going on in the tendon, that's just a normal part of aging. You're saying that you don't need to heal up to get a change in your pain and your function that sort of thing. So then they say, okay, so what is the cause of my pain? How do you tend to follow that up? Is there anything you tend to tell them specifically? Oh, what's causing my pain? So I usually say, okay, so what we see on your tendon may well have been there for a long time. This is not an acute change that we're seeing. It's not like a sprained ankle. It's a normal part of aging and that breakdown of tissue that we see there has probably taken a while to come on. Now you've only had your pain for X number of weeks or months in some instances and it's started by, you know, you mentioned to me that it started by, spending a weekend, for example, in the garden. So it's likely that when you loaded your elbow, you overloaded those tissues, those tennis structures, then there was a change that triggered off this pain, this cascade of pain that you're now feeling in your elbow. So it's related back to what you've done, like that overload of tissues, but what we're seeing on the images, not our priority to get better. We don't have to keep in imaging this. Yes, it's there and we can confirm, you know, we're pretty comfortable with our diagnosis, but we don't need more follow-up images to prove that it's getting better. The way we can tell that it's getting better or not is based on what you feel. What we change your pain, that we reduce your pain and that we improve your pain-free group strength and your ability to use your arm. So I still talk about, I guess, with patients that the pain is coming from the tendon in that situation and it's related to the fact that they overloaded it. So then it's easy to say, "Okay, so you need to modify your activities." So they get that. If it hurts to pick things up with the palm facing down, then don't do that. Pick things up with your palm up and really important education. It's really important to educate these patients, I think, around those activity modifications, you know, strategies, keeping weights in close to the body, carrying things with the palm up. Don't pick things up that are, you know, involved elbow extension, pronation type of activities. And that all makes a difference. The challenge we've got, I think, with getting patients buying into exercises that we then turn around and say, "Well, this was an overload injury, but now I'm going to make you load it to get it better." Right? And that's where they go, "Hang on a minute. I isn't exercise what caused this in the first place. I shouldn't I just rest this?" Now in some situations, yes. You know, I would say, if someone has just developed this pain, I would say, "Give this six weeks rest. You don't need to come in for physio and all this sort of stuff. That's probably better off having rest, but then if they've had it for six to eight weeks or three months or whatever, and it's not getting better, then my answer is, "Well, you've had this for a long period of time. You've been modifying and they do. They modify as they go because they're not silly. They avoid their aggravating activities. It makes sense, right?" "Yeah, so you stop doing it?" "Yeah." "Yeah, it's common sense. So they've already modified activities. So then I say, "Well, look, you've already been doing this process and you've still got this pain, so we do need to do something else for you at this point." So then it comes back down to good loads versus bad loads. So they're going to explain, you know, sort of a bit of the, I guess, the physiology of tendon structure and how tendon needs load to grow and to strengthen. And like our bones do, like our muscles do, and you know, when you go to the gym, if you lift a weight you haven't been used to lifting for a while, then a couple of days later you're going to have sore muscles because that load, you know, was greater than what your muscles were typically used to tolerating. They need to repair and then strengthen so that then they can tolerate that and load next time you apply it. Tendons are a similar sort of thing. You need to apply an optimal load that's going to help this tendon and the pain settle down and for you to get strong again. But if it's too high, then it will do the reverse and you'll hurt yourself and it will break down. How do we know what's the optimal load? At the moment, I mean there's some preliminary evidence out there starting to come through in other tendon regions, but most of it's been done around the Achilles tendon to suggest that a 6% load or strain on a tendon is optimal for that tendon function and tendon growth. In the elbow there's no such evidence. So what we've got to go on with our patients is really symptom management. symptom tolerance. So we base it on how they feel. That's how I know how much to load these patients. And this is where I think the upper limb is different to the lower limb because in the lower limb you've seen a lot of the protocols that are out there for Achilles and Patelatein and Ophatis are that you can tolerate some pain. And they go from an extreme of as much as you can stand in terms of your pain tolerance and the old you know Hark and Elfrensen's you know original protocol was around that versus now they're coming back to well it's okay to tolerate some pain maybe up to four out of ten down the lower limb. In the upper limb particularly in the elbow patients don't seem to respond as well if they're having to tolerate pain with their exercises. They just don't get better and I'm sure people have seen that clinically you know giving them these exercises and we're being told and the research tells us that exercise and load is good but they're coming back and saying it's painful. I think the upper limb and this is just I guess my perception I think patients attach different values or or interpret pain in the upper limb maybe a little bit differently to the way they do the lower limb. I don't know if it's to do with the fact that our upper limb is used for communication and used for so much more than just a functional task such as walking that we rely on it to eat we rely on it to perform self grooming you know we can't brush our hair we can't do our eyebrows we can't put on our makeup you know like if the upper limb or the elbow is is affected then there's lots of activities of daily living that are affected as well as work. If you can't run then most people can still survive they can still you know take conduct their normal activities of daily living you know that's probably an extreme and I'm not I'm not putting down the importance or trying to belittably importance of the killies and and patilla tendon opities but I think the the patients reaction emotional reaction to tennis elbows is often so much greater and possibly because of that that they seem to say you know a lot of the time they can't pick up a cup of coffee can you imagine? Yeah you can have your coffee in the morning I mean it's you know it can be pretty emotionally upsetting to them so that might be part of it that if they're then asked to perform an exercise or a home program that is painful why would they do that? Like it just is counterintuitive to the patient to the individual that their elbow hurts already that they can't pick up a cup of coffee or they can't do up their bright and here you're telling me that it's okay for me to hurt it more so a lot of the time patients won't comply they just won't comply if the exercise is painful it won't work and I think that's where a lot of the time we fall down with our exercise prescription in tennis elbow I think one of the especially in the early days when you're trying to get them to buy into the program and to buy into treatment and to and convince them that this is going to be the thing for them is that we should keep those exercises pain free let's just take a quick break and have a chat about a couple of resources that we've got for you and they're over at clinicledge.co so you can grab number number one that free handout that we've got for you that goes along with today's podcast they've been really popular we've been getting lots of great 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once again you can have a free trial that one so there you main resources for today so go over check out the links for today's podcast that free download of the handout that goes along with the podcast and then grab your free trial as well all right let's get back to the lateral elbow and Dr Lee Ann Bissett so you tell them no pain at all when they're doing performing their exercises yeah yeah fantastic and so tell all right let's talk a little bit about that so how would you start someone's program they come in they're having trouble with the cup of coffee in the morning they're a manual worker and they've been hammering or they've been doing something manually with their arm scanning you know groceries or whatever it might be they're having trouble with it yeah how would you tend to start there and they've had it for a while so they've passed that sort of six to eight week mark yeah how would you tend to start their program so I guess the goal of my main priority in that first treatment and and if you ask your patients they will you they will always say this as well is to is to reduce this pain that's probably their number one priority is to settle the pain down and get their function back they want pain free function so I do use our manual therapy strategies that we all have but using techniques such as mobilizations with movements are great because not only does it demonstrate that we can take away the pain while they're performing a painful and otherwise normally painful activities such as gripping that that you know straight away if you can change someone's pain during a gripping task and they realize they can grip harder and it doesn't have to hurt will you will get them compliant with whatever else you want them to do because they realize that they don't have to have pain during gripping and that they can maybe get better that they see some road to recovery so it's a great technique want to start treating their pain but also to get patients you know buy in to your treatment and then if that works I can try I can also add in a couple of other things I'll very quickly in the piece get them to do a self-mobilization I teach them their own way of call it whatever you like, de-load the tissue glide joints I just say all I'm doing is getting you to hold here so that you take away the pain our goal is to take away the pain I don't try and explain why or how it works I just say you know holding and there's a couple that we can do you know the PA posteroentary glide on the radial head or a hand hold that mimics that lateral on the glide or if I can't get them to do those very effectively then I'll take it to try and simulate the same sort of thing the same sort of response all with the the goal of reducing their pain or taking away their pain and allowing them to perform an activity that was normally otherwise painful they still often when they go home it's not 100% pain-free when they do it so they can't go maximum I mean they can't get a maximum pain free grip when they're doing their exercises at home so you have to then still assess them in the clinic and I'll do this day one to see what they can do pain free so one of the exercises I like to start with is an isometric contraction because the other thing the the research tells us is that isometric contraction even in healthy people is has an analgesic response so it's thought to induce some sort of descending part of that descending inhibitory control pathway with a sustained isometric contraction and and so it's a good place to start with these patients it's generally not a painful exercise and the other reason for doing it is because it's functional for these muscles so the main muscles that are affected in in tennis elbow is extensive copyrighty I'll us breathless but the common extent ascended as a hole is often affected, it's just that portion is more prominent. Now the ECRB is a wrist extensor for sure, but its goal in function is to stabilize the wrist and hold the wrist still, during hand activities to allow finger and grip function. So whether it's a gross motor task like a grip, you know like shaking hands or whether it's a fine motor task like using a computer keyboard. Either way, ECRB has to generally contract isometrically, so it's a functional task for that particular muscle. So it's nice way to go. And then in terms of the arm position, starting with the elbow bent to 90 degrees and neutral supination pronation is usually the optimal pain free position for a patient to start in. And then using something like ferro band, ferro tubing, weight if they haven't got any of the band and just holding that isometrically. So up to a minute for a hold. So it's a long hold. Now if they can do that with no pain and no pain gradually coming on, then the next thing I do is start them to pronate over and see if they can pronate over with no pain. And if they can do full pronation with elbow flexion and there's no pain while they're holding a resistance and a light resistance to begin with like yellow ferro band, you know, like a 1 kilo, 2 kilo resistance or something like that, probably 1 kilo, depends on the patient but light. If they can hold there and get into that position with out pain, then the next step is to start extending the elbow out and seeing how far they can push themselves out into full extension pronation with out pain. Now usually there's a limit there because that's their painful, that's their provocative position right. So there'll be a limit where they can't go through that. And sometimes to begin with they can't do any elbow extension in which case they stay at 90 degrees elbow there. And then it's about endurance and hold. So if they can as well as pain. So then see how many they can do, one minute holds in that position without pain coming on. And to begin with I keep the repetitions fairly low even if they have no pain and trial it at maybe three repetitions with just one minute holds, with about one minute rest in between. And that's it. So if they start to and testing it in the clinic first is really important so you can tell them how many they can do, they're not going away unsure of how far they should go, how many they should do, how long they should do them for. So always test them fully in the clinic but if they start to develop pain so they start getting pain or fatigue after and sometimes you'll start to see them shake and all that sort of thing. After halfway through the third repetition stop them there. So all right let's do two repetitions. The third one wasn't successful, we're going to stop it too. This is how many can it go. Also early in the piece I generally restrict them to only doing the exercise once a day, no more, not two or three times a day to begin with to make sure that it is going to stay pain free because again it's about making sure they're compliant with it and if you ask the patient on a scale of zero to a hundred how confident are you that you're going to do this exercise at home. I want them to say I'm 100% or I'm 90% sure I can do this exercise at home. I don't want them going 50-50 whether I'm going to do this or not depends you know. So that's why it's better to keep it short, sweet and pain free and it does the task, it does the job. So then on top of that they can either do their, I give them their self-glides as a, as, and I tell them this is your panadol. So that's their mechanism or their strategy for relieving their own pain. If they, if I, do, I'll work hard at trying to see if I can get them doing a self-mobilization with movement and that's different to gripping task. That's more with elbow, flexion, extension type of activities but holding their elbow while they're doing it and as a pain relief. So if they, if they then during the day do do something, pick something up the wrong way or they've worked and they've stood it up because they've been working and using their arm or if they accidentally bump their elbow you get those patients as well. Then they've got some means of reducing their own pain, you know, by doing it themselves that they don't, you know, they're not putting up with this prolonged pain that lasts for 10, 15 minutes because of what they've just done. And that's a way of saying to them that also that, you know, reducing your pain is important, want you to keep it at a minimum. You're modifying your activities, you're doing this exercise which is pain free, we've taped it or whatever we've done and I'm giving you this technique to reduce your own pain. Now that's a lot, a lot, I'm firing it at all levels. It depends on the patient, which ones of those I will pick and choose from, right? Because for a patient to walk out with all of that, it's a bit overwhelming sometimes. So it's often easier to start them with, you know, demonstrating in the clinic that we can make a change and then send them home with an exercise or something like that, that's pain free. And then the next session, it may be then that we start, okay, I'm going to show you how to do these techniques to help relieve the pain at other times if that's still a problem and so on. It just depends which order I do those, it depends on the patient and what their needs are, what their priorities are. Sometimes the exercise doesn't start day one if they're in too much pain. Right, okay, so there's a ton of great info there. So I just want to come back to a couple of those points here because there was so much gold in there. So you talked a little bit about NWM's first off, so you can either do a PA on the radial head and then in elbow flexion, see if that changes their pain or a lateral glide on the elbow, on below the elbow. Once again, see it changes their pain free, group strength or their pain free function. And I suppose we could talk all day about mechanisms, that sort of stuff, but for now we'll leave that and we'll go back to what we've got time. But in that case, you get them that by and is starting with those NWMs and you might do what three sets of that or a head. First treatment, again, keep it short and sweet, do less is more beneficial. I find if you try and do too many of them, you'll usually end up stirring them up again. So maybe a maximum of five or six repetitions day one. And if they at any point, like if you do it initially and you're getting a really good response at any time, if that response starts to diminish, so you stop getting the big improvement with the glide, then that's what you need to stop. The other thing you're going to be careful of is that there's that you don't, so they get a rebound of pain response after you've done these NWMs, especially with gripping. That's their most provocative activity. So if you do, you know, let's say we do five repetitions and their group strength has doubled or tripled, they're pain free, group strength. And that's the other really important note is that we're testing and measuring and using pain free grip strength, not maximum grip strength. There is no point in testing maximum grip strength in these patients, okay, because one, it's not, there's no deficit. They'll have, you know, there's a number of studies now that will show that there's no deficit in maximum grip strength. You'll just stir them up. They do it with pain. They do it very well, but it's with pain. And so they won't like you for that, either. So there's no sensitivity to change. There's no ability for that measure to improve because it's it's already maximum grip strength, unless you're measuring pain severity, which we're trying not to do. So that we use pain free grip strength, which means we ask them to group just to the onset of pain. No further. But if you, if you're, you know, going back, we do these and they say you've done your five repetitions in the clinic and you've got this great improvement in their pain free grip strength. You see, thank fantastic. Okay, up your hop. First time they go to move their elbow, it will be a scorcher. Okay, it'll be stiff. It'll be sore. It'll be, it'll feel like, you know, they've sat on it for an hour or two and it's a really stiff and sore. The way you can avoid that response is to perform the same mobilization with movement, but with elbow through range. So you still glide, but you get them to bend and straighten their elbow as many repetitions as it takes to settle it down. So it might be sometimes four or five repetitions is enough. Sometimes you've got to go, you know, through two, a couple of sets of ten to settle it down depending on how, on how their response is. But that makes a huge difference because if you maintain that MWM and get the moving, you avoid that big rebound pain response from doing the original and WM's with gripping. - Yeah, excellent. I can see you apply the glide. They do their gripping and you get a change in it and they paint free grip strength. Do you while you still got the glide on, then get them to do you, so you don't release the mobilization and then you do your reflection extension or you give them a minute just to see how it goes or what do you do? - Yeah, I'm okay with releasing that glide because usually if you're doing a gripping, you've got to get them to drop whatever it is in their hands. So sometimes it's easier to just release the glide and I say to them, don't move. Just gonna take this out of your hand, whatever it is they've been gripping on. Okay, now before you move, and then I go back to my glide, I'm gonna do this and then just move with me, bend your hand up towards your shoulder or bend your elbow up and down, straighten it. Yep, and they may still get some pain response but it will be far less that way. Then it will be if you don't do the glide. - Definitely, yeah. - And they send you that, it's very that into extension, it just gets really painful. - Yeah. - Yeah, excellent. Okay, so that gives us a good idea about that. And the other thing I wanted to know, we're gonna have to wind this up in a second. So thanks, Leanne, I think we'll wind the interview up now and I really wanna get you back on the podcast. We're gonna talk more about how we can progress these exercises, the next stages of lateral epicontology treatment and exactly how we can perform these. But we're gonna go for now, but it's been a pleasure having you on the podcast. Thanks for coming on the podcast. - Thank you, David. It's been great. Thank you. - Thanks. (upbeat music) - Fantastic. Well, thanks, Leanne. There was lots of great information shared there from Dr. Leanne Bissett on the, what's going on in lateral epicontology or around the pathology of it, the pain, pattern, and current history, all about communication, your advice for patients and how you can assess and start to treat these lateral epicontology patients. So lots of great info in there. Remember, head on over and grab your hand out at clinicledge.co. We've got that free trial. You can also sign up for clinicledge.co and we're on Facebook, so you can connect with us there. And that's at Physio Edge podcast and I'm on Twitter, so @DavidKpop. So remember, we've got links to all those things we talked about in the show notes, links to Dr. Leanne Bissett and her work and all that's all over at clinicledge.co. So that's all for now. I'm gonna look for you to catch you on the next episode where we're gonna be talking more about lateral epicontology, we're gonna be discussing the treatment, how you can progress that and then differentiate the diagnosing it from other conditions. So lots of great info, all your questions answered. So I shall catch you then. Have a great week.