Many people suffer from elbow pain. Our osteopaths work in our specialist Cambridge osteopathic clinic with pain management treatment and rehabilitation therapy, working with a vast range of physical capabilities, allowing us to have very positive contact with such pain symptom sufferers. This is why we are some of the Best Cambridge Osteopaths.
In fact, elbow pain (including osteoarthritis, medial epicondylitis, tennis elbow or similar pain syndromes and muscle strain) is currently a common musculoskeletal disorder, and the burden is most likely underestimated. Musculoskeletal illnesses are believed to generate some of the highest costs to society. Elbow pain seems to have large effects on disability levels, quality of life and affects employment.
Some of the most commonly ‘diagnosed’ issues leading to an episode (acute), or multiple episodes (chronic), of elbow pain, with or without ‘swelling’ (filling of the elbow joint and capsule or fluid around the joint area) are:- Functional elbow instability, structural elbow instability, posterolateral rotatory instability, elbow subluxation, collateral ligament sprain, lateral and medial epicondylitis, strain, motor control imbalances, tendonitis, ligament sprain, muscle strains, muscle spasms, elbow tendinopathy, over use syndromes, degeneration, arthritis, cartilage injury, ‘tennis elbow’, ‘inflammation’, ‘wear-and-tear Injuries’, Tendon ruptures, ‘wear and tear’, biceps strain, bursitis, mechanical elbow pain, elbow stiffness, elbow swelling, ‘Golfer’s elbow’, ‘tennis elbow’, ‘radial head restriction’, Olecranon bursitis, ‘Throwing injuries’, capsular laxity, ‘chondral damage’, ‘triceps injury’, fat pad damage, annular ligament injury, ‘tendinitis’ (tendonitis), forearm strain, trigger points, trapped nerves, ‘ulnar nerve entrapment’, ‘sprains and strains’, osteoarthritis, ‘arthritis of the elbow‘.….The list goes on!
The quality of some of these diagnosis concepts, and the actual correlation to your pain, are even more fascinating!
How this may affect people
When this doesn’t go well, it often leads to a very dissatisfying outcome. This can manifest itself as: deconditioning, disability development, depression, loss of confidence in yourself and your body, which ultimately often leads to a dependency on pain altering medications, and poorer physical health.
So, what are we to do? Are we to:- be immobile?, be mobile?, be active?, or minimally active?, train into pain (‘no pain no gain’)?, or train avoiding pain?, stretch the elbow?, or no stretching of the elbow?, use medication management?, topical or oral?, use massage?, use mobilisation?, Osteopathy or chiropractic or physiotherapy?, use prescriptive exercise?, regular treatments or minimal treatments?, have imaging or not to have imaging?, surgery?, should we focus on structure or function?, or is it just age?!!!
Our understanding of the elbow and its associated structures, is still changing and evolving. Sometimes additional investigations are sometimes needed. However, often for ‘elbow pain’, images are rarely needed as a primary input into your assessment and treatment.
Imaging was originally seen by most, as a tool to rule out pathology or disease states, and less to diagnose specific musculoskeletal causes. Often this was due to a poor correlation of images and symptoms. New imaging approaches have developed, and our dependency on them has increased! However, recent studies show that by performing a thorough clinical case history and physical examination you can often, very effectively decide if MRI or additional imaging or other investigations are needed.
There are also recent studies that show that MR Imaging (MRI), may actually increase the patient’s likelihood of continuing in pain or disability status, and elongate their symptom picture.
Then there are studies showing that degeneration changes, are just a part of function and use. These however, have no correlation with pain, or perceptions of illness, or illness behaviour i.e. age and degenerative changes have no clear causal link with pain.
Assessment using, MRI, CT scan, ultrasound, for the elbow joints, are only used to complement the clinical history and physical examination when required, as it will need ‘clinical correlation’ and ‘interpretation’, to help ‘categorisation’ and trends. This sometimes helps rule out, some of the ‘diagnoses’ that are referred to perhaps a little too commonly, and sometimes helps support the clinician diagnosis, from presentation and examination.
On MRI findings, cartilage thickness of the elbow shows a significant variation (not uniform), which is independent of sex and which side of the body. No correlation is seen of cartilage thickness and bone dimensions.
When imaging is needed for elbow assessment, ultrasound apparently is a better diagnostic tool for assessing damage and MRI is better for assessing inflammation.
Overhead athletes, commonly sustain elbow injuries, from the complex forces, which place bony (osseous) and soft tissue structures at risk of injury.
When MRI is used to assess, asymptomatic medial collateral ligament (MCL) injury, there is ‘little correlation to ligament dysfunction’. It might ‘represent the transition period to MCL thickening’ called “adaptation”. Therefore like many imaging techniques, this requires “clinical interpretation”, and alone is not accurate at diagnosis.
One season of ‘high school’ baseball pitching, is enough to create ‘adaptive changes’ to multiple structures of the elbow, including the ulnar collateral ligament (UCL), with alterations of quality and visual thickening of the ligament.
Lateral epicondylitis diagnosis can be made based on clinical findings alone. Knowledge of the clinical presentation and potential causes of lateral elbow pain, are required. Imaging is only required when the clinical history and assessment findings are unclear, or symptoms are resistant to treatment.
In lateral epicondylitis cases, MRI can reflect ‘different disease severity’ between patients, assisting clinicians to then know when an alternative treatment modality could be suitable. However, this is only possible in combination with clinical assessment.
Ultrasound is a suitable way of assessing superficial structures. Common upper extremity injuries involve soft tissue and are believed to be associated with ‘overuse’ (aka misuse). In patients with ‘non-specific arm pain’, repetitive strain injury seems to be a common causal link. Instability can be diagnosed through clinical examination.
Tennis elbow (lateral epicondylalgia / lateral elbow pain) can be seen as a multiple complex system of changes. These can include, local tendon pathology, changes in pain systems, and motor system impairments. These can be integrated as required, for assisting specific treatments or combination therapy.
Indicating that more than just an image is required, additionally, there is a need to look at pain system functions, nerve neurodynamics and tensions, and motor control systems, through physical clinical examination.
Chronic elbow pain sufferers seem to sometimes develop an impaired ability to modulate pain, perhaps from over excitability (hyper-excitability) of the spinal cord, and the mechanical exaggerated pain perception (hyperalgesia) that is associated with lateral epicondylalgia. This perhaps indicates a need to look at treating more than just the local mechanical irritation in chronic elbow pain sufferers.
The most important thing to take from this, is that there are multiple causes to elbow pain, beyond that of just osteoarthritis, or tennis elbow. These pains may be due to the function of the elbow. Many of the presenting issues can be effectively evaluated in clinic, without the need of an image.
What can help
For elbow pain suffers from common soft tissue injuries of the elbow, the effectiveness of passive physical modalities, such as an elbow brace, shockwave therapy, low–level laser therapy, are all inconclusive at this time. In addition, transcutaneous electrical nerve stimulation therapy does not improve the outcome.
For treatment of lateral elbow pain, topical non-steroidal anti-inflammatory drugs (topical NSAIDS), may help for up to 4 weeks, after which time the benefits are less apparent.
In cases of either Medial epicondylitis or Lateral epicondylitis (tendinopathy), oral nonsteroidal anti-inflammatory drugs and localised corticosteroid injections, are only moderately effective in the short term, and then do not demonstrate benefits on long term follow up. Perhaps one reason for this is a lack of accuracy of two thirds of injection therapy treatments on the elbow. This is then in association / combination with how they may even be harmful in the long term. In a large amount of cases, this makes corticosteroid injections another second line intervention, lacking evidential support for their use.
Treatment by an osteopath has been shown by research data, to allow for positive outcomes and satisfaction levels. Manual therapy is effective at improving elbow range of motion and pain perceptions of arthritis sufferers in all age groups.
Exercise therapy has been shown in research to reduce elbow pain symptoms, and help restore normal daily activity.
In cases of epicondylitis, approximately 80-95 percent of patients have success with non-surgical treatment. Mobilisation and movement of the elbow, similar to ‘mulligan physiotherapy methods’, aid in the treatment of lateral epicondylitis (‘tennis elbow’). These help reduce pain and increase grip strength and function.
In chronic cases, muscle energy technique (MET) therapy (which is a part of osteopathic treatment) improved lateral epicondylitis sufferers strength, functional status, and reduced the elbow pain, more effectively than corticosteroid injection treatment in chronic lateral epicondylitis. This leads to the authors’ conclusion that ‘muscle energy techniques’ may be a superior modality in the management of chronic lateral epicondylitis’. Additionally, manual myofascial point treatment (trigger point therapy and myofascial treatment) alongside mobilisation treatments, yielded a positive outcome in chronic lateral epicondylitis.
In cases of medial elbow pain, non-operative treatment and exercise based physiotherapy can be effective for medial elbow pain.
One size does not fit all when it comes to the management of elbow disorders. Combining several interventions to form a treatment plan (multimodal care), for arm (upper limb) musculoskeletal disorders (including elbow pain), seems to help even the persistent (chronic) cases of lateral epicondylitis (epicondylosis).
This rehabilitation process for lateral epicondylosis can include mobilization, movement therapy, and exercises, in treatment with improved function and pain status. Additionally, having a positive expectation of the treatment plan about to be undertaken, assists in additional changes in kinesiophobia (movement fear) and perceived disability.
These non-operative treatment methods for non-traumatic tendinopathy (without rupture), should be used for up to 12 months at least, before surgical interventions are discussed / undertaken.
This method of combination therapy, including neuromuscular re-education, may also assist in treatment of ‘upper limb adverse neural tissue tension’, from occupational injury. This helps improve movement impairment (decrease disability), restoring function to promote full job capacity (ability to do all duties of work). Furthermore, in cases of acute and chronic instability of the elbow joint, in athletes and active people, conservative therapy (sports injury rehabilitation treatment) should be the primary course of treatment.
Then, if surgical interventions are used for chronic instability (from ligament instability), postsurgical rehabilitation treatment should be performed for up to one year.
Whole body integration
Then we can start to look at a more global pattern, and treatment plan.
Cervical spondylosis, facet joint degeneration or irritation, neck muscle tension, and joint restrictions of the neck, can lead to irritation of the nerves as they exit the neck. These nerves innervate (supply nerve communication) the arm, including the elbow. Irritation of these nerves can lead to altered sensations in the arm and elbow (cervical radiculopathy). Treatment of the neck, with manual therapy and exercise can help reduce these symptoms.
This can also include the treatment of the thoracic spine (trunk), to improve arm (upper extremity) symptoms associated with cervical radiculopathy (nerve irritation in the neck).
Mechanical issues of the thoracic spine, shoulder, and neck, can lead to altered nerve sensations and ‘neurogenic’ pain, or even muscle atrophy and altered use in the arm and forearm. Conditions such as Thoracic outlet syndrome as an example, can present with medial forearm and elbow pain. Effective treatment of this can be from exercises, mobilisation, manipulation, Osteopathic treatments and massage. This may create an ‘immediate and lasting effect’.
Core control and trunk stability (core stability) may assist with whole body kinetic chain use, and the upper extremities being use more ‘optimally’, for performance and perhaps reduced overuse developments. This helps protect the distal joints, by aiding distal patterning and generation of force for athlete function.
This may show why whole body assessment and treatment, is reported anecdotally to be so effective in clinic.
These positive effects from manual therapy and exercise, may be due to the increasing body of evidence, that pain is a brain interpretation of data, and the local structure itself, cannot be consistently linked with pain or general function.
Additionally, manual therapy by an osteopath including the use of mobilization and manipulation, and prescription exercise therapy, are all safer than long, or even short term medication treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs). Furthermore, this is statistically safer than surgical intervention.
The point here is that there are many opinions and many solutions, to treating elbow pain (humeroulnar joint pain / humeroradial joint pain / superior radioulnar joint pain). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.
With all treatments, it’s important to get the diagnosis, advice, and treatment programme from people who are trained, skilled and prepared to aid your musculoskeletal needs.
The guidelines for ‘elbow pain’, includes the guidance to remain as active as normal, seek support and advice at a specialist clinic, for diagnosis, education, management advice, manual therapy including mobilisation and manipulation, and soft tissue treatment, hydrotherapy application, increase in muscle strength (strength training) and specialist exercise therapy for rehabilitation.
At Elementary Health we provide a seamlessly layered combination approach, of diagnosis, education and therapeutic application. This includes education of anatomy and pain theories, manual therapy, osteopathy, posture advice and training, lifestyle advice, hydrotherapy guidance, dietary overviews, and dynamic exercise therapy with motor control training rehabilitation. All of these work together to provide a uniquely structured approach, towards the aim of restoring your brain’s interpretation, or ‘mapping’ of your healthy functioning body, giving you back the control!
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