Physio Network

[Physio Discussed] The elbow uncovered: tendinopathies, imaging, and management with Dr Leanne Bisset and Dr Val Jones

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In this episode, we discuss everything elbows. We explore: 

  • Medial and lateral tendinopathies in the elbow
  • Distal biceps rupture
  • Usefulness of imaging within the elbow
  • Outcome measures within the elbow
  • Management of common conditions within the elbow

Dr Leanne Bisset is an Associate Professor in Physiotherapy at Griffith University. She is also a Musculoskeletal Physiotherapist as awarded by the Australian College of Physiotherapists. Dr Bisset's combined academic and clinical track record is underpinned by her clinical and research experience in Musculoskeletal Health and Persistent Pain. 

Dr Val Jones is a Physiotherapy Specialist working at the Sheffield Shoulder and Elbow Unit. She also works in private practice and lectures internationally about the assessment and rehabilitation of the elbow joint. Val has published in peer reviewed journals and is a previous AHP representative on the British Elbow and Shoulder Society Council, as well as being the current UK national delegate and board member of EUSSER. She is also an associate editor for the Shoulder & Elbow journal.

Want to learn more about the elbow? Dr Val Jones recently did a brilliant Masterclass with us, called “The Elbow Demystified” where she goes into further depth on common elbow conditions and their treatment - https://physio.network/masterclass-jones1

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @sarah.yule from Physio Network

SPEAKER_01:

What are the most common elbow presentations in practice? And what does treatment look like? What are the red herrings to be on the lookout for? We explore all this and more in today's episode of Physio Discussed with Dr. Leanne Bissett and Val Jones. Dr. Leanne Bissett is an Associate Professor in Physiotherapy at Griffith University and a musculoskeletal physiotherapist. Leanne's combined academic and clinical track record is underpinned by her clinical and research experience in musculoskeletal health and persistent pain. Val Jones is a physiotherapy specialist working at the Sheffield Shoulder and Elbow Unit in the UK. She also works Thank you. She is also an associate editor for the Shoulder and Elbow Journal. Today's episode has plenty of insights into effective treatment and management of elbow pain. This episode is packed with clinical pearls to sharpen your skills. I'm Sarah Yule, and this is Physio Discussed. Welcome to you both, Leanne and Val. I'm very excited to explore the elbow with you both today, and I know you both are as well. Thanks for having us.

SPEAKER_00:

Yeah, thanks for the invite. To what is by definition from Shauna Driscoll, the beautiful joint? Because L in Spanish means the, B in French means beautiful. So it is by definition the most beautiful joint in the human body.

SPEAKER_01:

What an introduction. That's fantastic. We've hit clinical pearls already straight off the bat. Well, what are the most common presentations for the most beautiful joint in the body? I was just going to say I would totally agree with that definition too, Val, because if your elbow isn't functioning, then you can't get your hand to your face and you can't eat and you can't look after yourself. And I think we've seen patients who have had devastating consequences because their elbow condition impairs their functional ability. The patients I see the most and are in the literature most prevalent are the chronic elbow conditions. So that's what I will speak to. mostly today. And the most prevalent of those chronic conditions is tendinopathy. So medial and lateral elbow tendinopathy are the ones I see. And they're certainly prevalent in the general community. The literature tells us it's up to about 3% of the general community at any given time, but that prevalence has increased with workers up to 15 to 20% in certain industries, particularly industries that involve highly repetitive hand tasks and manual workers. And yes, it does happen in tennis players, but they're not the majority of the patients that we will see in clinical practice. But another small pearl is that tennis elbow or lateral elbow tendinopathy is five times more prevalent in golfers than golfers elbow or medial elbow tendinopathy, which is pretty interesting too. Val, what about you?

SPEAKER_00:

I've got a slightly different take because I work in a regional trauma center and I work in the fracture clinic. So I see lots of fractures and dislocations and people may not realize that the elbow is the second most commonly dislocated joint in the human body. And it's often missed. People think that they just had a fall onto an outstretched hand and then wonder why they've got a bit of bruising, why they can't extend their elbow. And it's often a missed dislocation because people can spontaneously relocate as they just jump back up into standing again. So it's really important that you screen patients very, very carefully. And one of the other things we're seeing, because I didn't realize until I read a piece of literature recently how much the prevalence has increased, is distal biceps ruptures. In the last two decades, the prevalence has increased 400%. They think because men are going to the gym, weight training, ladies too, but I've only ever seen one lady with a distal biceps rupture in my whole clinical career. And I think we used to see on average maybe one a month, maybe 14, 15 a year for surgery. Well, We're now seeing one or two a week coming through the fracture clinic. So it's really important that physios don't miss that full fitness distal biceps rupture.

SPEAKER_01:

There's a lot of gems in that that I think we'll unpack. Going back to you, Leanne, in terms of the medial and lateral tendinopathies, do you mind just running through how they would present typically clinically? They typically present, if it's just isolated tendinopathy with pain and localized to either that medial or lateral elbow region, but particularly over the epicondyles and then the common flexor or extensor tendons that attach to it. And I think we need to remember those tendons are not particularly long. They're not large tendons. So the actual area and region of pain is usually quite localized. It's aggravated and the patients will often complain of pain in if they touch it or hit it or bump it, so on palpation, and then functionally. So gripping activities, resisted wrist extension or middle finger extension for that lateral elbow tendinopathy, and that's typically our clinical diagnosis. Pain over that region, that's aggravated by palpation. Gripping, so gripping tasks, and then resisted wrist or middle finger extension. So those are the most common presentations for tendinopathy at the elbow. And do you find yourself zooming in on any particular tendons or do you more keep it broad to the common extensor tendon origin versus a specific tendon? Yeah, so in terms of the lateral elbow tendinopathy, the most common region of the tendon or the muscle that contributes most, it seems, to the tendinopathy is extensor carpi radialis brevis. The tendons, I mean, the forearm's amazing, hey? The number of muscles that cross the elbow or originate around the elbow, it's really phenomenal how many muscles sit within this region. And there's four muscles that contribute to that common extensor tendon, which include ECRB, so extensor carpi radialis brevis, extensor digitorum, extensor carpi ulnaris, and then extensor digiti minimi. which is interesting. So there's two wrist extensors and then finger extensors in there. And the ECRB tendon kind of sits in the middle and deepest to that muscle group that insert into that common extensor tendon. And it seems to be that middle deep part of the tendon that's most commonly involved with the tendinopathy and the degenerative changes that we see on imaging. So it's that deep portion that sits deep in the tendon and closest to, interestingly enough, that radio humeral joint and the head of the radius as well. There is certainly a lot of complexity in the forearm. I recall it learning all of those muscles at uni fondly. Val, speaking of the radial head, Val, in terms of the second most commonly dislocated joint in the body, I definitely didn't know that. What does it look like when people are missing it and what are we mistaking it for?

SPEAKER_00:

We get patients through sometimes that have just said they've had an elbow sprain because they've fallen onto an outstretched hand. There've been quite a few studies now that look at the mechanism. There was a Schreiber study where he looked at 72 people who'd had an elbow dislocation because loads of people post the videos. They're usually skateboarders, young guys who were sort of, you know, you see them come off the skateboard and then they hold their arm in a funny position afterwards. And it was the hyperextension. We'd always thought it was a hyperflexion injury before from Shauna Driscoll's work, but it seems more now that it's maybe a hyperextension injury. And then people sometimes, as I've said, they spontaneously reduces as soon as they get into A&E, their elbow looks relatively normal because you can have a simple elbow dislocation, which is an elbow dislocation without a fracture. So on x-rays, they'd look normal. But one of my big things for me is look at bruising. Look for bruising around the elbow. Anytime you've got bruising, it says to me, you've had a probable ligamentous injury, maybe even a common flexor origin or common extensor origin injury, because they're the secondary stabilizers to varus or valgus stress. If you've got that medial So bruising to me is a real flag that something's gone on that needs investigating further.

SPEAKER_01:

So it's sounding like subjectively the mechanism of injury is obviously very relevant and then bruising was specifically location of bruising.

SPEAKER_00:

I think females, the mechanism of injury is usually a fall from a standing height. So it doesn't need to be anything really that people may consider significant. Males, it's usually related to sports or I'm afraid if they get involved in physical altercations, those are the most common mechanisms for an elbow dislocation.

SPEAKER_01:

Okie dokes. And in terms of that distal biceps rupture, I think you said 400% increase. That's a massive stat. Yeah.

SPEAKER_00:

Yeah.

SPEAKER_01:

What are we mistaking those sorts of ones for? I

SPEAKER_00:

think we don't mistake them. I think we just don't see them. And the problem with the distal biceps rupture is if you don't pick it up quickly... then the results of surgery are worse and the risk of complications increases. We like to see them and the research shows, you know, they need surgically repairing in the fit and able within two to three weeks. So it's quick diagnosis and then quickly sending them to the emergency room so they can be seen by an appropriately skilled elbow surgeon. So it's somebody, again, it's usually that hyperextensional injury and they feel a pop. They'll feel something go and then they'll get pain, probably bruising. But bruising may not present for a few days. So you may see them beforehand if you're working in private practice. It's usually males between the ages of 40 and 60. And it's seven times more likely to happen in a smoker than a non-smoker. And you may see a change in the bicep contour, but you may not. So people often think, oh, if the biceps looks normal, they mustn't have a distal biceps. But I think part of it depends on whether you actually tear the bicipital upon your otis as well. A couple of quick tests you can do are look at supination strength, because when you actually tear your distal bicep, it's supination that's mainly actually affected rather than flexion. So you'll find that the supination strength is about more than 50% down. And the other test you can do is the hook test. So I'll just demonstrate. You put your hand in, get the patient to actively hold their hand as if they're doing Paso Dober. I imagine doing a cape in front of them. So, you know, we'll do a bit strictly here. So you put your hand in front of them and then in their anterior elbow creases, they're holding their arm in flexion and supination. You can get your index finger, which I think you can just see it there. And actually feel that sort of distal biceps in that elbow crease there. So you look to see if it's intact. You also look to see if there's more play compared to the opposite side, because that can show that you've got a rupture as well.

SPEAKER_01:

And when you say a bit more play, are you looking for as in there's more movement of a ruptured distal bicep tendon?

SPEAKER_00:

There's more movement, yeah. So you can actually feel the tendon move up and down more on that side. So it may show that the tendon has torn off the bone, but the bicipital aponeurosis is still intact. So it hasn't retracted completely. So you can still feel it, but you've got a bit more play. So that's when you'd be sending your patients very quickly up to the emergency room and saying, I think they've got a distal biceps rupture. Can you send them on to see the appropriate person? And we'd see them in the following fracture clinic in the UK.

SPEAKER_01:

You mentioned that most of them are surgically repaired?

SPEAKER_00:

Yeah, it depends very much on the patient, what their lifestyle is. But most of these are sort of males who are 40 to 60, have active lifestyles, active jobs. But you've always got to counsel them about the risks of having a repair. The general complication rate from Greg Bain and Joy Deep Fadness' paper is about, and they looked at 3,000 patients in sort of a systematic review, 25% complication risk with 5% being major complications such as re-rupture, Artery injuries, nerve injuries, compartment syndromes. So it is an operation that although it has great benefits, you've also got to counsel the patients. It has significant risks attached to it.

SPEAKER_01:

Absolutely. So it's sounding like subjectively they're describing a pop type moment and obviously a traumatic mechanism of injury. Val, what do you think is responsible for that massive increase in prevalence or in presentations?

SPEAKER_00:

I think more people now use weight training. I think people before used to think going to the gym and aerobic fitness was enough. But, you know, even the World Health Organization guidelines talk about strength training, two to three sessions. And we're always trying to promote that. But I think the other thing is we're probably recognizing them better as well, to be perfectly honest. More people are aware of them. But the other thing is I think there is... that steroids are more readily available, especially by alternative methods. So a high proportion of patients may as well be sort of taking steroids, which may predispose you then to these distal biceps ruptures. And I've had a look at all our patients and I asked them, did you ever have bicep symptoms before? Every single one has said no. So it's not like, you know, they've had a grumbling distal biceps tendinopathy. So Andy Carr from Oxford used to describe tendons as good tendons, bad and ugly. The good are your pain-free ones. The bad ones are the ones that grumble along and give you a bit of pain. And the ugly ones that never give you a day's pain until they suddenly rupture. A bit like your Achilles tendon. You know, when we always tell patients, oh, if it's painful, don't worry, you can exercise through it. It's not going to rupture. A bit like your distal biceps tendinopathy. I'll say, you're fine, keep going. But they never have a day's pain until it suddenly goes.

SPEAKER_01:

And I think this is a really interesting point because they can have that pre-existing tendinopathy and it's completely asymptomatic. And that's consistent with other areas of tendinopathy as well, right? So Luke Heals has found that around 50% of the general population, age and gender matched, around that 50, you know, 45 to 55-year-old age group have tendinopathy in their elbow. but are completely asymptomatic and have never had symptoms or any cause for the concern. So it's something that's consistent. It's just the elbow doesn't typically rupture the way the biceps tendon does. And on that, Leanne, do you typically see, I suppose, in going into differential diagnosis of things like lateral and medial elbow pain, are there other tendinopathies like a distal biceps tendinopathy that you think is being missed in the mix? Not so much the tendinopathies, although biceps tendinopathy is something that we would consider with anterior elbow pain, but there are differential diagnoses around the medial and lateral elbow. And in that lateral elbow in particular, or I think the elbow in general as a region is unique in that there are three significant nerves that pass across the elbow and they don't follow a simple trajectory. They're often... you know, spiraling and going superficially and then passing deep to muscles and through muscles, between muscles and things like that. So I think the elbow is unique in that often there is this potential for maybe a true neural entrapment, like, for example, in the cubital tunnel, the medial side of the elbow, or through the arcata frosch, which is piercing when the posterior interosseous nerve pierces through supinator muscle. But I think there's also this potential... for dynamic entrapment of these nerves, like in particular, you know, the radial nerve as it passes under the common extensor muscle group. And it has a fairly bony, rigid, unforgiving floor in terms of, you know, the radial head. All it often may take is increased cross-sectional area where there is some tendinopathy, repetitive overload, lots of muscle contraction. happening with you know sustained over a long period of time with very little risk because we know that's a risk factor for lateral elbow pain and it's not unreasonable to consider that the radial nerve in that instance might become irritated and you know there's a branch of the median nerve that passes between the two heads of pronator teres same kind of thing you know it's not a true bony entrapment point, but it's something where it might dynamically become irritated over time, especially again, with the people who are doing a lot of CrossFit or heavy gym work, lots of like body weight lifting and things like that, where some of those flexors and that pronator flexor muscle group can become really overactive and tight and tonically active, I guess. So I think neurally related pain is one of the differential diagnoses. The other thing I think we see, especially around the lateral elbow, and I'm curious to get Val's thoughts on this, is instability. Now, subtle instability. I'm not talking about the really gross instability where they've had a major traumatic event, but subtle instability in that radial head. And it might be related to an old injury, traumatic injury, like a fall or something. You know, as Val's described, or overload, repetitive chronic overload that's resulted in this subtle change in the passive restraints around that radial head. And some of the imaging recently has shown that degenerative tendinopathy that we see in the common extensors tendon can extend into the lateral collateral ligament complex as well. I think that instability is another key important consideration when we're looking at differential diagnosis around that lateral elbow region.

SPEAKER_00:

Totally agree, especially if your patient isn't responding in the way you think they are or their examination doesn't point to it being a lateral elbow tendinopathy. So, you know, they haven't got pinpoint pain or most of the lateral elbow tendinopathies, I call it the pasta draining sort of test. If they don't like putting their arm out and draining the pasta out because they're in an extension and pronation, they have different mechanisms, say weight bearing through the arm might be a little bit more painful around 30 to 40 degrees. Or did they describe slight clicks or whatever in the area, then I know there's a cohort of patients who do have these sort of instabilities. And I think of all the patients who go on to surgery, which is about by 10% of all the people who present with tennis elbow, there's up to 40% may have subtle instability that hasn't been picked up around that lateral ligament complex. So get your diagnosis right, I think is the first thing. So you need to be really careful when you first see somebody. If they present atypically, Shakespeare had a saying, temptation the fiend at my elbow. And the temptation with lateral elbow pain is to put it, lump it all together with lateral elbow tendinopathy. You've got to be really careful that they have haven't got an instability. And remember that things like Previous steroid injections may also predispose you to that. Or previous tennis elbow release surgery can also predispose you to these instabilities on that lateral side. So I would always check. There are a variety of different things you can do. You can look at the varus stress test. You can look at the posterior lateral rotatory instability tests, which are all like the tabletop push-up and relocation test to test for that. And then if they did have examples of that, you could try and dynamically stabilizing by using the common extensor origin and anchineus and also the lateral head triceps but I would probably also that would probably going along to see Amjad Ali who's one of my surgeons in Sheffield who's one of Leanne's biggest fans when she came to Sheffield for the course he actually gave up his Saturday to come and see her because she was one of his superheroes which is wonderful he came

SPEAKER_01:

he was there in the audience wasn't he He was. And look, I think you're spot on, Val, with that. And that differential diagnosis is really key. And the presentation is different, isn't it? You know, people are presenting with pain that's not over that common extensor tendon. And our palpation skills are really key here. If the pain is more in that radio humeral joint line posteriorly, or it's over that lateral collateral ligament, which you can palpate onto the common extensor tendon there, Then thinking about those differential diagnoses is important. And the same with the neurally driven pain. They're the ones where the pain radiates. Pain's down in the forearm. They'll sometimes complain of pain radiating to the wrist, the back of the hand, up the arm. And it's not necessarily neurological symptoms. It doesn't necessarily have to have pins and needles and numbness. It can be sometimes just pain, depending on what component of that nerve is being irritated and how it's being irritated. If there's no loss of conduction, they won't necessarily get pins and needles. pins and needles and numbness as part of that presentation. And the posterior interosseous nerve is primarily motor. So it typically won't present with pins and needles and numbness. It'll present with motor weakness in the thumb, abductors and extensors is all that's pretty much innovated by that below that point of the supinator. So I think, yeah, we've got to use our clinical skills in our differential diagnosis. I think there's a lot we can do. And the sensitivity and the specificity of that tabletop relocation test or chair push-up test that they'll comment it on. So if you weight bear through the arm and at that 30 to 40 degrees elbow flexion, they experience pain or apprehension, you repeat the test but stabilizing, manually stabilizing the radial head and if that changes their symptoms in a positive direction, then that can be indicative of that radial head instability. What does manual radial, what does stabilisation actually look like? Is it just holding it where you would tape it? A posterior anterior directed sustained force applied to that head of the radius is really all it is. Okay.

SPEAKER_00:

Yeah. So you just repeat the test. So you do the test without any manual stabilization of the radial head. And if they've got pain or apprehension as they sort of reach that 30 to 40 degrees of elbow flexion, as they're doing a tabletop push-up and they do it in supination, because that's where you actually cause the ligaments on the lateral side to become lax. So you get more play. So that's when you're going to feel it. And they weight bear through both arms equally. And if they get pain or apprehension, that's a positive test. You then put the manual pressure on the radial head. So you're kind of pushing it back to where it almost ought to be. And if you get a reduction in pain or the less apprehensive or more range, then that for me is a positive test.

SPEAKER_01:

As someone that loves quotes by the sound, I don't know if it was Shakespeare that says it, but I feel like when you have a hammer, all you see is nails. And it sounds like we're needing to really make sure we're screening for things beyond lateral elbow pain and medial elbow pain, which I think it's sometimes very tempting to And it sounds like subjectively we're needing to be screening for the burning or the neuropathic type pain or the clicks and clunks and things that fall outside of the pattern. So I think that discussion is a really good reminder for us clinicians as well.

SPEAKER_00:

So I think look at the age of the patient. Tendinopathies, I'm afraid, they're like me, they're degenerate, aren't they? They're sort of, you know, over the hill, on the slippery slope down. If you've got a young person, the one thing I really hope that people don't miss is people say, oh, they've got a reactive tendinopathy in a young athlete. Ever you've got a young athlete with lateral elbow pain who's kind of, you know, mid-teens to sort of mid-20s, I always say people like gymnasts, throwers, weightlifters, swimmers, you've got lateral elbow pain, they should always be screened for an osteocondyl defect first because that is the main presentation. It's over usually on the capitellum. is where they find the lesions it's usually can be unilateral sometimes bilateral they can't usually recall a single event that caused it so it's cumulative and they end up with this deep ache on that lateral side they can present with clunking and giving way but not usually but it's recognizing an osteochondral defect and sending them to somebody to actually get ct scan um shauna discourse looked at it 50 of them are missed on x-ray mri is not as sensitive as ct for picking them up so anybody who is under the age of 25 who's who's sporty for me and presents with lateral elbow pain is an osteochondral defect until proved otherwise and they may get pain on gripping catching clunking so people may think oh they've got a reactive tendinopathy just not really likely and if you don't catch an osteochondral defect early then it can create a larger defect and by the time it actually becomes a loose body there's only a 50% chance I'll return to elite sports ever again.

SPEAKER_01:

Wow.

SPEAKER_00:

Yeah. Don't miss it, guys.

SPEAKER_01:

On the medial side as well too, right, Val? Like if they're developing medial joint pain, then consider instability, consider valgus laxity. And again, in that age group, it's really important that they are assessed carefully radiologically as well because the growth plates around the elbow fuse quite late, like often 18 to 19 years of age in boys or men. So there's always a risk of an apophyseal injury around that medial humeral epicondyle in particular with the athletes who are unloading in that valgus direction. So again, the throwers, javelin throwers, baseball throwers, gymnasts who are weight bearing through their arms. So medial and lateral elbow pain, I would say in that age group, be very careful with. It's unlikely to be tendinopathy. The other thing I was going to say about imaging, just going on from the imaging point, is that there's probably different practices between countries, but here in Australia, GPs will often refer their patients. If someone presents and says, I've got elbow pain, they'll refer them for maybe a plain x-ray, but usually an ultrasound. And again, if it's this population, over 40, it's a downhill all the way, as Val said, they are likely to have changes on imaging, on ultrasound imaging. And that does not mean that that's the source of their symptoms. And it's so common that patients will present and say, oh, I've got tendinopathy. And it's not. Tendinopathy is their primary problem. Yes, they may have changes on imaging, but it's not the source of their symptoms.

SPEAKER_00:

British Elbow and Shoulder Society guidelines have just come out for lateral elbow tendinopathy in the last 12 months, which we were all part of. And it said, you know, imaging is just not important in diagnosing tennis elbow or lateral elbow tendinopathy, but patients all know it as tennis elbow, don't they? And also when you read papers, papers in the past have used imaging changes or diagnosis by imaging as their sort of select or inclusion criteria and part of their outcome measures. But it bears no sort of relation to what's going to happen to that patient clinically over time. So if you read a paper where they've got sort of imaging changes as one of their outcome measures, I'd probably think, well, let's have a look and see if you've got any other good outcome measures rather than imaging changes alone. Yeah.

SPEAKER_01:

What sorts of outcome measures would you have a preference towards, Val?

SPEAKER_00:

Well, Leanne and I worked on that sort of consensus, didn't we? The core outcome set for lateral elbow tendinopathy. So I always love my handheld dynamometer. It's my most useful piece of kit in the clinic and it's great. So that pain-free grip strength for me is huge. And the patient rated tennis elbow evaluation for patients with lateral elbow tendinopathy. But I find it's really good in diagnosis. So I use sort of pain-free grip strength in inflection, elbow flexion, and then I'll put them into it. extension then after that where they compress the tendon more. So I'm looking for a 5% to 10% sort of decrease in grip strength. And that for me really hits the nail on the head. But I find it a really useful piece of kit because I can say, well, this is, they've got standardized data for grip strength for males and females and age. So I say, look, you're probably not as strong as you could be if we look at this and let's work on unloading you. I tend to use the isometrics shown by Leanne and they really like those. And then it's a really good way of getting buy-in because they keep testing it. And even if they don't feel any better, you can say, you may not feel any better, but look, your growth strength's gone up five kilos. So they think, ah, so I am improving and it's much more likely to get a buy-in for me. So my most useful piece of kit in the clinic is that.

SPEAKER_01:

Do you share those sentiments, Leanne? Absolutely. Yeah. So the paper we published last year, We were part of that group. The core outcomes set recommend at the moment that patient rated tennis elbow evaluation, which is a self-reported condition specific questionnaire. But I think it's good for a range of elbow disorders because it's got a pain subscale and a function subscale. And so that's been well validated and highly cited within the literature and used a lot across, you know, elbow research. So that's one of our core outcome measures and pain-free grip strength, as Val said. And I tend to do the elbow extension pronation position with pain-free grip because it's a measure of their pain-free function and particularly in that provocative position. And it is sensitive to change, as Val said, like you'll often will see that those changes in that position. Whereas in the elbow flexion with the neutral forearm position, which is the recommended, you know, the standardized position for measuring grip strength, often it's got a bit of a ceiling effect. They don't feel as much pain there, so they can grip harder in that position, you know, before pain onset if there is pain. So both positions are valid. Certainly the neutral position or the elbow bent, that's That's well standardized. And as Val said, there's lots of normative data out there to compare it to. But in terms of getting a sensitive measure that can show change over time, extension pronation is good. Fantastic. I think it's always nice for us as clinicians to actually hold ourselves to account and have those standardized measures. Before we move on to treatment and still on imaging, aside from trauma, you both mentioned before when something isn't tracking as well as it should or treatment isn't responding as well as what it should, how long do you give it before you change treatment or perhaps send them for further imaging on something like a tendinopathy, as I suspect we diagnose many of? I would say clinically that you should know quite soon, you know, within two, three, four treatments max. whether or not they're progressing as they should. If you've got the diagnosis right, then with the approach that we use, then you often do get good patient buy-in. As Val said, they enjoy the exercises if they're not overly provocative of pain, that they can manage their load well. And I think you'll see that change reasonably quickly in terms of improving pain-free function, as well as that reducing pain. Reducing pain, maybe resting pain often is something that reduces sooner rather than later as well initially. So if they aren't changing within three or four sessions max, I would be rethinking my diagnosis. I would be revisiting, going back over how they've presented, what have I missed? What have I not ruled out or ruled in? What have I not tested thoroughly? I wouldn't necessarily be sending them straight away off to a specialist or back to their GP for imaging or anything like that. I'd be thinking really critically about my own questions, my clinical exam. Have I done everything that I should have done? What have I missed in their history first? Val, did you have anything to add to that?

SPEAKER_00:

So yeah, I usually say to the patients that we should be seeing a difference within four to six weeks, hopefully the four, but it might, you know, and then we'll carry on and by three months, they should be so much better. And the evidence, I mean, you know, there was the Aikinen paper, wasn't there, that looked at patients anyway. I think it's to give a message of hope with patients with lateral elbow tendinopathy and say, look, the chances are in three months time, 50% of patients with lateral elbow tendinopathy will be very much better or completely resolved. So let's Just keep on going with it. Keep on doing the loading program in a non-physiological manner. And there's a 50% chance in three months that you'll be very much better or will be fully gone.

SPEAKER_01:

Fantastic. That's always nice to hear. I was going to say, if we're talking statistics, that's a really good point, Val. And it is something that you can use with your patients because they'll often say, well, what other alternatives are there? And a lot of the research shows that with an active physiotherapy approach, that they do get better within six to eight weeks and they stay better. You know, that we will get the majority of them well recovered. And certainly by six months, there's 80 to 90% of them. are very much better or completely recovered versus if you do nothing. And it's not truly doing nothing. Wait and see approaches within clinical trials are often still involving education and advice and encouraging people to modify their activities and things like that. They too will get better, but it will usually take them six to 12 months before they start to see that level of improvement. So it's good to give people time options and anticipated timeframes.

SPEAKER_00:

And I think we still get patients. It may be different where you are, guys, but we in the UK still get patients. But my friend had a steroid injection and they got so much better. And I was saying to them, I said, yeah, you know, but your chances of recurrence and your risk of physio being successful are markedly reduced. So you'll be better for six weeks. It'll feel brilliant. And then boy, oh boy, will it return. And I liken it to, we all know somebody, we all know one person who smoked 20 cigarettes a day and lived to a hundred, but they forget the other 350 that died before the age of 70. So steroid injections may be great for one person, but for the The vast majority of patients, they're a real absolute no-no, but they still come in and ask about them.

SPEAKER_01:

Absolutely. And the growing body of evidence around corticosteroid injections promoting even further degenerative changes within tendons is there as well. So we know that they are worse off at 6 and 12 months with pooled data from multiple RCTs. They're worse than if they do nothing. That's a really powerful message to tell patients. It's like, sure, you can do this and get some short-term pain relief, but there are alternatives. If someone's in severe pain, there's alternatives to corticosteroid injections for short-term pain relief. But in the long term, you need to know, as Val said, that you will be worse off than if you do nothing.

SPEAKER_00:

And I always remind the medics, the first rule of medicine is do no harm. If you're actually making their outcome worse than if they'd had nothing done at all, where do you stand with that one?

SPEAKER_01:

Great point. Leanne, you mentioned alternatives. What are the typical alternatives for pain relief in that short term? So what I'm talking about here are those patients who present with really severe pain. I'm talking about 8, 9 out of 10. Often they have resting pain as well. I think that they often will demonstrate mechanosensitivity within their neural system as part of that pain presentation. We can't always put our finger on exactly where what is the source of their pain sometimes, right? Like they may present with a history that suggests possibly an acute tear within the tendon. So a really sudden acute overload on, I'm thinking, for example, of a patient who was breaking up a concrete footpath with a sledgehammer. and had a sudden sharp stab of pain in his elbow and basically lost all strength, grip strength at the time. So that type of presentation is quite different to the chronic overload type of presentation that we'll typically see in our elbow tendinopathy or tennis elbow patients. So if they're presenting with that really severe pain, I think be careful with the differential diagnosis. But oftentimes we can't do a full assessment on them because of that pain being so severe. So those ones where they've just got this terrible pain, then there's lots of alternatives. This is where we pull out of our normal kit, all the things that we perhaps used to do 20 years ago, but are still relevant. You know, if it's heat pack, if it's compression, if it's rest, some of those sort of typical acute management type of modalities, or if Other medication. So sometimes simple analgesics, simple anti-inflammatories may be effective. If they need something stronger for a short period of time, then sometimes that's indicated medical-wise. So sending them, referring them back to their GP or a medico to give them some other stronger analgesic support for a short period of time is sometimes helpful as well. Fantastic. Thank you. Now, treatment. You've spoken about education and where we refer on and actually once you've done hopefully the really in-depth objective and subjective assessment to get your diagnosis, what do your active physiotherapy treatments look like for the commonly seen conditions like the lateral tennis elbow or the lateral elbow pain? The most common approach I guess I take with elbow tendinopathy is And we've got some data to show we're in the process of writing up a manuscript, hopefully in preparation for publication, to show that adding our manual therapy techniques, and in particular, we use mobilization with movement techniques to an exercise program, improves time under load for our exercise prescription or exercise capacity with the patient. So we know that exercise is important. for their recovery of symptoms. How it changes tendon pathology over time is a completely different topic, but a lot of this evidence comes from healthy tendons where a high load, so 70% NVC is required in order to get tendon adaptation in normal healthy tendons. Well, we can't achieve that, certainly not straight away in people with tendinopathy because of the level of pain and disability that they've got. So what our manual therapy techniques do is reduce pain during exercise, such as gripping, and allows them to then exercise more effectively. You know, they've got more exercise capacity. And I think a lot of it is very much around, I guess, it's getting that patient on board. It's getting them compliant or adherent with an exercise program and going, oh, I can actually do this and it doesn't leave me with seven out of 10 pain for 24 hours afterwards. So we do use a combination of those manual therapy techniques with exercise and the provocative exercise is typically gripping. But it could be resisted wrist extension. It could be anything like that. The approaches with the exercise, at least in the beginning, is isometric, is what we recommend. And that is because it's functionally appropriate. That's what these wrist extensors do. They stabilize the wrist to allow our hand to function, particularly under load. They mobilize the wrist when we're doing light activities, for example, writing or throwing darts or fine arts and crafts type of things like knitting and things like that, or light exercise like badminton and things. So under light loads, yes, the wrist moves and these muscles engage that wrist flexion extension activity. But as soon as we start loading, as soon as we start picking up heavier objects, the their role changes to one of stabilizing and that resists the flexor moment at the wrist, which is generated by the long finger flexors. So isometric exercises are absolutely functionally appropriate for the wrist, particularly in those early stages. So we do isometric through gripping or resisted wrist finger extension, things like that. So that's a typical approach. I will use supportive modalities such as taping, to again provide a bit more of a sustained analgesic effect if they're effective and teach patients to do their own manual therapy techniques as part of their exercise program at home. So that's sort of been our approach for a number of years now, but that varies according to the patient's needs as well. And it's sounding like you're creating, finding that window of opportunity pain-wise. or the entry point.

SPEAKER_00:

Yeah, and I'd like to sort of echo echo that with a patient. I remember when Leanne came over and she showed us the isometrics with the TheraBand. And I had a patient that we've been doing through range work with a large weight. And his job was to actually just push a cage for long periods of time in the warehouse. So we got him to do the isometrics instead because his progress had plateaued a little bit. And I remember I just gave him the piece of TheraBand and got him to move into pronation. And then we extended his elbow as far as we could with sort of a loop of TheraBand around his hand. And We said, right, let's see how long you can hold this for. And after 30 seconds, he was like, oh, man alive. He didn't use those words exactly because he came from the middle of Sheffield. But he was saying, this is really making my whole arm work. And I think that's what we need to remember as well, the whole arm deconditions with a lateral elbow tendinopathy. So you have to strengthen everything else. And I think that the isometric works beautifully with that piece of TheraBand. The other thing I'm going to say is... I think your tendons are a great barometer of your metabolic health status. doing something about their overall health status. We can try and treat the tendon as much as they like, but if they're a bag of chemicals that are going inflammatory, inflammatory, inflammatory from all those pro-inflammatory cytokines, you're fighting a bit of an uphill battle, I think.

SPEAKER_01:

Absolutely. And you're right. Global upper limb muscle strength is depleted. Smoking, you mentioned earlier, is another common presentation with people. And if you ask them when they come, have they ever had other symptoms tendinopathies like this, often they will have in multiple areas, maybe genetic, maybe lifestyle related factors. So getting them that health behavior change is a really integral part to a more holistic approach with these patients. That's a really important point. I think those are all fantastic points. And I feel like we could talk about this for a very long time. But I thought before we wrap up today, I'm curious as to, Leanne, you mentioned there's some things that you bring out from 20 years ago, and I'm sure there's some things that you've left behind as well. How has it changed over the last 5, 10, 15, 20 years? And what should clinicians out there, what's a key takeaway for them? I think there's been a lot of change. I think our awareness... of individualizing patient care has improved immensely. I think we've become more aware of the multidimensional aspects to these presentations. It is certainly not one size fits all. You may well have a tendinopathy But overlying that is some more global sensitization because again, those inflammatory cytokines Val mentioned also sensitize the sensory system and that might be playing into it. They may have other stresses and other somatic presentations like poor sleep, stress related to a poor relationship with their employer and things like that. So really understanding your patient and developing good rapport with your patient, getting your patient on board with the treatment and centered around the patient, using your motivational interviewing skills to ensure that our goals align with the patient's goals and vice versa. I think that there's really a lot of progress that's been made in those sorts of more soft skills, I guess, almost. That has improved our outcomes, I think, immensely compared to just going, this is what you've got, this is what you need. I'm going to give you these exercises and you're going to go home and do them. Some people might, but some people do not approach that type of strategy particularly well. So I think we've improved a lot in terms of understanding the complexity of pain and the contributing factors and the risk factors and prognostic factors related to elbow pain conditions. Great points. And

SPEAKER_00:

Val? I think there's been a shift in the UK. I don't know what it's like where you are as to whether... Everybody moved away from manual therapy. It was like, ooh, it's like the pendulum went exercise only, exercise only, exercise only. But there's lots of research out there that shows the elbow's a bit proprioceptively vacant when it comes to your joint capsule, your ligamentous structures, in comparison to, say, the shoulder and the wrist and the hand. It was back of the queue at the elbow or the proprioceptor sale. So where it gets most of its proprioception from is the cutaneous receptors. So the evidence has shown is Baratti's paper with Joy McDermott is just by doing things like manual therapy or putting a tubular bandage on or some of the tennis elbow sleeves you can get, that can massively influence or normalize, hopefully, that proprioceptive input. And therefore, it has an immediate effect on pain-free grip strength and also pain on palpation as well. So I think we've got an evidential basis here to say, look, I am going to put my hands on a patient. You're not going to make me feel bad because I do a bit of manual therapy and send everybody out with a piece of tubigrip as an elastic bandage because the elbow loves a good hug, I feel. I feel it's much maligned, misunderstood, and all it needs is a love and a hug and careful attention and it will respond beautifully.

SPEAKER_01:

Oh, don't we all? Said perfectly, Val. Well, thank you both for such an enriching conversation and for sharing such incredibly practical and insightful clinical pearls for us on managing elbow conditions. I'm sure all of us are going to benefit tomorrow in clinic from this conversation. Thank you so much. Thanks very much.