There was a good study by Dorff and he looked at grip strength in elbow flexion compared with grip strength in elbow extension and if you get a five to ten percent decrease in elbow extension compared with flexion it's supposed to be indicative of a lateral elbow tendinopathy so it kind of rules it in almost.
SPEAKER_00:Elbow pain can be persistent and tricky in the clinic. So today we have Val Jones. She's a physiotherapist of 20 years. She's been recognized by the British Elbow and Shoulder Society, as well as the European Society for Elbow and Shoulder Rehab. She's also published on several articles. Well, today Val took us through some really unique assessments, particularly distinguishing whether it is an acute or a more chronic and persistent elbow, and that that second type is actually more common than we think. Then she walked us through how she might treat those two separate conditions differently. Val has also done a masterclass, which we're going to put in the show notes, and you can try that for free. This was a really great, insightful episode, taking our rehab of the elbow to the next level. Please enjoy this one. My name is Michael Risk, and this is Physio Explained. Welcome, Val. Thank you for joining us.
SPEAKER_01:Thank you very much for asking me to speak.
SPEAKER_00:We're talking elbows because you've just done a masterclass for us and we're going to put a free trial of that masterclass in the show notes. So if you like what you're hearing today, you can go a little bit deeper in the masterclass. But Val, we were talking off air that a lot of elbows now could carry with them some central sensitization. Could you go deeper into that and then what we might do about that?
SPEAKER_01:Yeah, so a lot of the research is when it's looked at tendinopathy with central sensitization, I think 14 out of 21 papers have actually looked at lateral elbow tendinopathy, which is what tennis elbow is more commonly referred to as now. And so things really in your assessment that I'd be looking for are extreme pain on palpation. So I'm really lucky I've got a pressure algometer that I can use to quantify how much pressure it takes to put over the lateral epicondyle and what's right compared with left. Other things you can look at is that are they exquisitely painful when you sort of do cold testing? So Leanne Bissett and Prutilli and Greenhalgh looked at things like looking at ice cubes over the area. So one test you can do, put an ice cube over the area, hold it there for 10 seconds. And if it gives you a visual analog scale, pain-wise of more than five out of 10, after 10 seconds, you can be sort of fairly confident in the fact that your patient might have thermal hyperalgesia. So that's another quick test. and then you can do a pin prick test to look for something called temporal summation. That's where you get repeated afferent information into the elbow and it summates to produce a really nasty sort of pain. So what you do is you get a sort of a pin and you hit the lateral epic on now once, get the patient to give you score visual analogue score out of 10 and then you repeat that process but you do 10 repeated pinpricks in the same area one beat per second and if the pain after 10 repeated in sort of pinpricks is bigger than one pinprick alone it shows they've got evidence of temporal summation you think well so what why does that matter well the thing is if you think you're going to do manual therapy or taping it shows that that repeated sort of stimulus on the skin or around the joint might actually irritate them so it means take a hands-off approach you can do your exercise but leave your manual therapy leave your tape alone and maybe get them to do some more kind of whole body exercises cardiovascular stuff for more than 10 minute blocks etc so that's what i'd be looking for it would make me slant away from getting my hands in there and using the taping and things
SPEAKER_00:oh my goodness there's so much that you didn't tell me about before the podcast So those things that you just mentioned, the prick sensitivity, the cold sensitivity, they wouldn't be there in what we might think is just an acute tennis elbow? So they wouldn't have that?
SPEAKER_01:Yeah, so I'd assess that in all patients who presented with a tennis elbow. And if they had that, or if they had a high pain score, or if they've got, we use the patient-rated tennis elbow evaluation, which is a self-administered outcome measure as well. If they had a high score, Evidence of any of those one of the three out the central sensitization measures, it would make me think, right, I'm not going to go into pain with exercises. I'll remain pain free and I will keep my hands off. We're going to have to talk to them about general, maybe aerobic type exercises. So it just changes the way I am. approach them whereas somebody who has no evidence of central sensitization i'll let them go into sort of small amounts of pain even initially as long as it settles within half an hour of them having done their exercises so it just changes the slant slightly
SPEAKER_00:just like regretting all the patients who have missed this on and have never done the pin fruit test and the ice test
SPEAKER_01:it's just it's just really easy to do clinically and it might help you just quantify who's more at risk of developing a long-term problem and if you push them too hard they'll flare up and it's really hard to get patients back on board isn't it if you flare them up really badly they lose some confidence in you so it's just trying to channel out those ones that may have a flare up and being a bit more cautious that And
SPEAKER_00:is time a factor there? Are you generally finding, oh, well, you've definitely had this for three or six months and the higher proportion of those are coming up positive on those tests?
SPEAKER_01:I mean, I work in a care setting. So by the time I get to see most people, they're chronic anyway. So there are a large proportion of my patients who have that. But I think, you know, even in the acute stage, assess it, assess it because you don't want to miss it.
SPEAKER_00:Yeah, that's really good. And you had some other measures here, like the handheld dynamometer and you're saying our patients love that. Could you go into that?
SPEAKER_01:It's great, because most patients are competitive, aren't they? So first of all, you give them a handheld dynamometer, you can use it to assess whether they've even got a tennis elbow in the first place, because there was a good study by Dorff, and he looked at grip strength in elbow flexion compared with grip strength and elbow extension. And if you get a five to 10% decrease in elbow extension, you can use it to assess whether they've even got a tennis elbow in the first place. compared with flexion, it's supposed to be indicative of a lateral elbow tendinopathy. So it kind of rules it in almost. So, and that's supposed to be, you know, highly specific, sensitive, et cetera, because when you extend the elbow, it compresses the tendon as well. as well as loads it. So you can use it in your assessment, but then also that pain-free grip strength is really reliable, sensitive to change over time. So it's really great outcome measure. And you can also look at normative data and say to your patient, look, you work in construction. You should, as a male, be able to grip 60, 70 kilograms easily. And you can't, you can only grip 40. So you're not as strong as you think you are. Maybe you're not job fit. So that's why we need to do the loading program with you to make your tendons able to tolerate load more comfortably and you can watch progression over time and they love it it's just a bit of competition and they really engage with it and yeah I want to beat last time scores brilliant yeah get that thing out get that grippy thing out so it's great it's good
SPEAKER_00:it's refreshing because It's very easy to get, oh, this is a tennis elbow, private practice. I'm going to settle it down and just get straight into like my elbow eccentrics or isometrics. And I'm probably not seeing on ground a lot of people considering the central sensitization part. So this is really refreshing that you're giving some different assessment measures that might guide our treatment a little bit more specifically than just loading it up. Yeah. We'll just touch on the acute before we, I want to go deeper on central. What's your treatment approach at the moment with an acute tennis elbow who don't have some of those central sensitization markers?
SPEAKER_01:Well, even though it's acute, most of the ones I see, they're degenerative, aren't they? They kind of have that degeneration and reactivity in the same tendon sample. So I'll be looking at systemic features as well. I think your tendons are a great barometer for what's happening inside you internally. So if you're diabetic, if you're obese, if you're high cholesterol, doing a little bit of this in somebody who's metabolically not very well, forget it. So we start talking, right, your BMI is 35. What's your level of activity? Are you doing your 150 minutes a week of moderate intensity exercise? So it's getting it right first time and making every intervention count. Talk to them about general health and why you're being overweight, being diabetic, et cetera, affects the tendons. Why does it do that? As well as working on the tendon as well. So we would start with all of those and we would do the loading. I'm still going to load it. You can treat the elbow as much as you like, but you've got to treat those systemic factors as well.
SPEAKER_00:And just at the start of that, you said a little bit of this and you were motioning the wrist extension exercises. And it's true though, because how many elbows have we had that they're progressing in those exercises and they're just not better. And it's probably not about, I like how you framed that, that the tendon is a barometer for everything in the system. And you could probably just say that and nothing else. And the patient would start thinking about that in the week, wouldn't they? They would really take that on and reflect about the rest of their health, just with that one line that you said.
SPEAKER_01:And they may have had all the little niggles, you know, often they'll come and see you and say, Oh yeah, I've had a bit of, you know, Achilles tendinopathy or plantar fasciitis or my shoulder hurts on that side. And there's been some great work done in Liverpool where they look to upper limb strength in general with a patient who presents with elbow tendinopathy and you get a reduction in general strength throughout the whole of the upper limb. So you can't just treat the elbow. You've got to go and strengthen the whole upper limb, but then look at them systemically as well.
SPEAKER_00:Yeah. And again, Central sensitization. So when that's playing a role, which is a lot of your patients, what do you do differently? I'm starting to think curiously about with the Achilles tendon and how we were doing it to a metronome to try and override some of that feedback response. Is there something similar you do?
SPEAKER_01:I mean, I will use the metronome basically because my patients can't do slow exercises from the look of it. It just helps to pace them. But again, it would be making sure that exercises, if they did have central sensitization, were pain-free initially. So it's very much individualized to the patient. Every patient gets a different load. You know, somebody else's tolerance point to fatigue isn't the same for the next person that comes along. So it isn't just your three sets of 10 or whatever with a one kilogram, two kilogram, weight and also as well as looking at the wrist extension strength I look at supination strength because you've got to remember it's a it's an extensive supinator mass on that lateral side so don't forget to test forearm rotation so sometimes if it's too painful to do wrist extensions I'll just work on supination resisted supination and that can help
SPEAKER_00:how do you test that sorry
SPEAKER_01:so I mean I supination so it's a bit more difficult it's just manual testing but just compare right with left
SPEAKER_00:You blew me away with all the other tricks. I thought you might have something.
SPEAKER_01:Oh, no, I wish I did. I'm not a magician. I'm sorry. I'm sorry. But yeah, and again, I would sort of look at them and sort of get them doing the general aerobic type exercises, bilateral stuff, trying to sort of think about what Joe Gibson calls brain rich rehab, looking at functional motor patterns that they're used to involving lower limbs involving bilateral arm movements, rather than just doing single sort of wrist extension, strengthening maneuvers. So looking at the whole of them, if they've got more of that central sensitization problem.
SPEAKER_00:And this makes rehab fun too because it's exciting.
SPEAKER_01:We do all sorts of things. We'll be getting a balloon. Balloons are great. Balloons are marvellous. You can do sort of single hand jumping around in the gym, pushing balloons from one hand to the other, all sorts of things. So I always have in my handbag a big bag of balloons. So people look as if they've left a toddler's party by the time they've left my clinic. It'll be great fun.
SPEAKER_00:That's fun and making rehab fun and, yeah, brain rich That's a nice term. With the central sensitizations, I'm wondering if I wanted you to go deeper on you want to push them into pain. What's the reasoning behind that?
SPEAKER_01:Because I think that they are much easier to flare up anyway. And as I said, if you lose them after day one, after your assessment, and it's always easier to add in. You know, if you give them some exercise, it doesn't play them up fine. And I'll always give them a video of them doing their exercises on their own mobile phone. So they've got something to check and take home with them. But on the video, I'll also tell them how to regress, how to progress and what symptoms are acceptable and what isn't. So I'll talk about low level symptoms, no more than three to four out of 10 that settle within half an hour. And if it hasn't settled within half an hour, they've pushed too hard or done too many reps, back off. And I'll maybe say, don't start this every day. Certainly never every day. Maybe start off every other day, have a rest day in between and gradually increase things.
SPEAKER_00:And so the mechanism behind, if you're thinking at central sensitization is, We don't want to flare them up too early because we can lose them and shatter their confidence.
SPEAKER_01:Yeah, and it can exacerbate, obviously, their pain problem. So, yeah, we need to find a different way in.
SPEAKER_00:And when will you start to kind of introduce pain, as it were, or show them that the pain can be there but they're getting stronger? Yeah.
SPEAKER_01:I mean, obviously the grip strength's improving slightly and, you know, the sail pain's the same, but my grip strength, you know, you can grip harder for five kilograms more. That shows me that the capacity to tolerate load is actually improving so then you may push them into it a little bit more and often you know they may be frightened to push into pain as well so it's about look you can do this let's try you're doing the stuff into elbow flexion look you're more comfortable let's just and generally just making them that little bit fitter and bit stronger.
SPEAKER_00:So I'm imagining that you've rehabbed some elbows without touching the elbow is that is that a fair thing to say?
SPEAKER_01:Yeah I mean it Some patients, I don't, we'll do general exercises and I'll give them sort of upper limb exercises. Some patients may improve with the MWMs, but, you know, often I'll not touch the elbow. We're just sort of making them fitter, making them stronger, making them systemically better.
SPEAKER_00:Yeah. What treatments have you found help around the shoulder and neck? Is that just, I'm going to do some general strengthening on the shoulder whilst I'm waiting for that elbow to settle? You mentioned MWMs at the neck?
SPEAKER_01:I will do MWMs either sometimes at the neck, at the elbow, if they haven't got that central sensitization. But I think it is, look at the whole upper limb. As the Liverpool study showed, you get decreases in strength. So make sure that you look at the shoulder. Make sure you look at the hand. Make sure you look at the other upper limb as well, because that you can get bilateral changes, even with unilateral symptoms. So assess both upper limbs, assess them well, treat what you find. So don't forget the joints above and below.
SPEAKER_00:Val, that was a really beautiful spread of, you got a bag of tricks there. A whole nother definition I haven't heard of. I need to call a fair few of my patients from five years ago. And you've gone deeper on this in the masterclass too. So we'll put that in the show notes that people can try a bit. That was a beautiful podcast. Thank you so much.
SPEAKER_01:Well, thanks very much for having me.
SPEAKER_00:Thank you for coming on. I'll talk to you soon.