How to Master Your Elbow Treatment

6 min read. Posted in Elbow
Written by Dr Jahan Shiekhy info

Elbow pain can be quite limiting to performing daily activities, sports, and even work. Fortunately, as physiotherapists we can use an exercise centered approach to treat many types of elbow pain. Based on your assessment, you should have a sense of what pathology you are dealing with and whether or not proximal joints such as the shoulder and cervical spine need to be addressed.

Here we will walk through practical tips to treat elbow pain primarily through exercise. We’ll also discuss pain modification techniques to improve exercise adherence. In addition to loaded exercises, we’ll outline other techniques such as stretching and neural mobilizations.

If you’d like to see how a world-leading expert manages elbow pain,, be sure to check out Leanne Bisset’s Practical Here, which I’ve based this blog on. With Practicals, you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

 

Pain Modification procedures: Manual Therapy and Self Mobilizations

As with many musculoskeletal conditions, exercise is the mainstay treatment for elbow pain by physiotherapists. However, patients often complain of pain with exercise which limits adherence. Pain modification procedures can make exercises more comfortable and thus improve adherence.

Note that with many of these techniques the research suggests that we are not making permanent biomechanical changes (1). However, there can be changes in pain and neural function that can improve adherence to exercise. With these techniques, we will use a test-retest approach by examining benchmarks like pain-free grip strength or endurance in isometric exercises before the onset of pain, to ensure the technique is achieving the desired effect.

From our assessment, we should have a baseline of pain-free grip strength. As Leanne explains in the below video from her Practical, we can apply a manual technique such as this lateral ulnar glide and then retest pain-free grip strength:

If the technique is helpful, we can repeat it several times and use it in other exercises, such as isometric wrist extension.

For the lateral elbow, we can also apply a radial head posterior-anterior glide while checking pain-free grip strength.

For nerve irritation, Leanne demonstrates in the below video from her Practical, how to use a manual deload technique:

Along with grip strength, we can assess tolerance to isometric loading of the wrist extensors. Note that the wrist extensors are primarily positional muscles, meaning that they function to stabilize the wrist as the elbow and shoulder move. Accordingly, wrist extensor exercises should primarily be isometric.

Using pain modification techniques, we should see an increase in time until the onset of pain. Leanne recommends performing contractions of up to 60 seconds, repeated for 5-6 reps. Also, after performing these exercises, patients may have a rebound effect of pain when they start to move the elbow again. Therefore, Leanne recommends performing these manual techniques through a full range of motion after exercise.

If these techniques are helpful, the patient can use self-mobilizations for independent pain management. For example, in the below video from Leanne’s Practical, you can see a self-mobilization of the radial head:

To see the full menu of these techniques watch Leanne’s Practical Here.

 

Exercise Progressions

Lateral elbow loading

After pain is controlled with simpler movements (such as gripping and isometric wrist extension), we can progress to more complex movements by manipulating elbow and shoulder position. For example, with lateral elbow pain, we may start with performing isometrics in elbow flexion, then progress to isometrics in elbow extension and with isometric shoulder flexion (i.e. loaded shoulder flexion). Other variations could be isotonic shoulder flexion, shoulder abduction or external rotation while maintaining isometric wrist extension.

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Medial elbow loading

For medial elbow issues such as medial collateral ligament instability, we can perform dynamic movements that provide a valgus force to the medial elbow. For example, we can do shoulder internal rotation with dynamic elbow pronation and wrist flexion.

 

Neural Mobilizations

With many elbow pathologies, there can be a neural sensitivity component. As Leanne discusses, these don’t always present as we would expect (e.g. a patient with lateral epicondylalgia can have median nerve sensitivity). To address this she recommends starting with nerve glides, such as those described in the literature by David Butler (2). We can start with 3-4 reps in a small range of motion and then gradually increase the range of motion. As pain decreases we can progress from glides to tensioners.

Check out how Leanne progresses neural mobilizations in the Practical Here.

 

Stretching

Often the wrist flexors and elbow pronators become tight with certain elbow pathologies, so stretching can be useful for some patients. While there are many different positions for stretching, Leanne recommends active motion through stretches versus static holds which can be painful for patients.

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Taping

In addition to pain modification through manual therapy and self-mobilization, taping can provide support for provocative movements, especially during sport and for those who work in manual labor. Most of these techniques provide feedback and proprioceptive support to the elbow/wrist through a tightening of the tape when the arm moves into those provocative positions.

Lateral elbow

For the lateral elbow there are several techniques. We have the classic diamond technique as described in physiotherapy clinical guidelines (3, 4). In the below video from Leanne’s Practical, she uses a spiral technique that supports elbow extension and pronation.

Also, we can apply tape along the forearm extensors to support the wrist in extension, which can be especially helpful for manual labor jobs that require repetitive gripping.

Medial elbow instability

For medial elbow instability, our taping should support resistance to valgus forces at the elbow. However, these forces are often experienced in elbow flexion and pronation, so the technique should accordingly address those positions.

 

Wrapping up

Our primary tool in treating elbow pain as physiotherapists is exercise; both strengthening and mobilization maneuvers such as stretching and neural mobilization. In addition, for pain management we have manual therapy techniques and self-mobilizations. We also can use taping to support the wrist and elbow for athletes and those who work in manual labor.

To learn a lot more about the management of elbow pain and see exactly how an expert goes about their assessment, be sure to check out Leanne’s fantastic Practical Here.

👩‍⚕️ Want an easier way to develop your assessment & treatment skills?

🙌 Our Practical video sessions are the perfect solution!

🎥 They allow you to see exactly how top experts assess and treat specific conditions.

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References

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