Beyond Eccentrics for Lateral Elbow Pain

Is there more to lateral epicondyalgia than eccentrics, IASTYM, & TPDN?

I have always felt there was more than meets the eye when it comes to lateral epicondylagia. Frequently, it is a tendinosis (degeneration of the tendon). I hypothesized that compression in the cervical spine would be a mechanism for both pain and tendon degeneration. If there is a subclinical decrease in efferent impulses into the extensor carpi radialis brevis, there can be inhibition due to pain and additional disuse is caused by decreased nerve firing.

While I think this is an important mechanism, in the most recent Rehab & Performance Lab Podcast with Dr. Ann Porretto-Loehrke, I learned that the presentation of "tennis elbow” is often far more complex, involving multiple structures.

It's crucial to approach lateral elbow pain with a specific, systematic examination to accurately determine the true pain generator. Relying solely on traditional tests like Cozen's test is often not enough, as it doesn't differentiate between tendon and joint issues.

Pinpointing the Source: Tendon vs. Joint

A more systematic approach involves testing resisted wrist extension with both radial and ulnar deviation.

• • If pain is primarily provoked with resisted wrist extension and radial deviation, and is significantly less painful or absent with ulnar deviation, it strongly suggests a tendinopathy of the Extensor Carpi Radialis Brevis (ECRB), which is a primary muscle involved in lateral elbow pain. 
  • However, if pain is equal with both resisted wrist extension with radial and resisted wrist extension with ulnar deviation, you should consider an articular pathology. Resisting wrist extension with ulnar deviation specifically loads the humeroradial joint, so pain here points towards involvement of the joint structures. Research, including arthroscopic studies, has shown that cartilage injuries in the radial head and capitulum are frequently associated with lateral epicondylosis, even in the absence of ECRB tears.

Evaluating for Articular Dysfunction and Instability

If your exam suggests joint involvement, several specific tests can help identify these issues:

• The SALT Test (Supination with Anterior Lateral Pain Test): Performed with the elbow flexed to 60-70 degrees, pressure is applied over the radial head in an anterior-medial direction as the patient supinates. Pain provocation can indicate the presence of at least one intra-articular finding like chondropathy or ligamentous laxity.
• The PEPPER Test (Posterior Elbow Pain by Palpation with Extension of the Radiocapitellar Joint): Place your thumb between the radial head and capitulum. Pain provocation at the posterior aspect of the humeroradial joint with elbow extension indicates radial head chondropathy.
• The Pull Test (or Wolf Test): If resisted wrist extension with both radial and ulnar deviation is painful, repeat the resisted wrist extension while applying a longitudinal pull along the radius to separate the radial head from the capitulum. If the pain is less and/or strength is more with the pull, it suggests chondropathy. If pain is worse, it points more towards a tendon issue. This test can be done with the elbow flexed or extended.

The Whole Kinetic Chain and Nerve Involvement

Lateral elbow pain is rarely an isolated issue. It's imperative to examine the entire kinetic chain, as dysfunction elsewhere can contribute to the problem.

Using the Selective Functional Movement Assessment (SFMA) provides a quick, systematic way to determine if adequate shoulder range of motion and stability, thoracic spine mobility, neck mobility and stability, and core function are present. Problems found in these areas need to be addressed. Issues like poor core stability, scapular dyskinesis, and cervical or thoracic spine limitations can be the roo cause and/or perpetuate lateral elbow pain.

Consider that pain in the elbow could be coming from upstream structures, including the neck. Cervical nerve root compression, or mechanical issues in the cervical or thoracic spine (like increased muscle tone), can affect nerve function and the impulse to muscles downstream, potentially leading to underuse phenomena

Ultimately, effective treatment often requires addressing multiple factors – the tendon, the joint, and the entire kinetic chain.

Treatment Pathways: Addressing the Findings

Based on your specific findings, your treatment strategy should be tailored:

• For a primary Tendon Issue (ECRB Tendinopathy):
  
• Consider soft tissue mobilization techniques, including manual release or instrument-assisted soft tissue mobilization. While conflicting evidence exists for traditional transverse friction massage, some studies have shown its value.
• Dry needling has shown promise and may be more effective than corticosteroid injections in the long term for both pain and function. Dry needling may help flush out pro-inflammatory substances like CGRP and substance P found in degenerative tendons.
• Strategic loading of the tendon is crucial. Eccentric loading has traditionally been emphasized and systematic reviews suggest it is superior to other strengthening methods for reducing pain and improving function in the short term. However, the research is evolving to suggest that the key is simply adequate loading, not necessarily eccentric specifically. Again the key here is heavy loading. There should be no reps left in reserve -- perform it to failure or near failure (goal is 3 sets of 15 reps 3 times per week). Now this advice comes from the Achilles tendinopathy research (not lateral elbow tendinopathy) but it makes sense to me. We are trying to get the tissue to hypertrophy and tolerate load better. If that is the goal, then we need adequate recovery to accomplish that. Patient compliance is also better with 3 times per week.
• Might this be an excellent place for blood flow restriction if the patient can't tolerate the load well? Given BFR's pain reducing combined with growth stimulation effects, it seems like a perfect combination. For more research and detailed information, check out the Rehab & Performance podcast on blood flow restriction with Johnny Owens.
• Additionally, while normally I say to avoid doing painful movements, when we are working on isolated muscle-tendon strengthening in the case of a tendiopathy, the exercise may be painful.

• For a primary Joint Issue (Articular Pathology, Microinstability):
  
• Following the principle of treating the joint first, prioritize restoring appropriate joint mobility before heavy tendon loading.
• Techniques like humeroradial joint tractioning can help unload the joint and create space between the radial head and capitulum. 
• If gross instability is suspected (e.g., significant PLRI), referral for surgical consultation may be necessary, particularly if conservative management shows zero improvement after a reasonable trial (e.g., four weeks).

For more on diagnosing and treating lateral elbow pain, you can watch or listen to the entire podcast for free on Spotify, iTunes, and YouTube. If you want to earn CEUs for listening (which to me is a no brainer), listen through the Medbridge platform. 

If you want the best price on a MedBridge subscription, be sure to use the coupon code PLISKY. By the end of the year you could get 20 hours of CEUs just by listening to podcasts, imagine that? That is in addition to the over 2000 courses on Medbridge.