A COMPREHENSIVE APPROACH OF MANUAL THERAPY AND EXERCISE IN

LATERAL EPICONDYALGIA: A CASE SERIES

Amy Garrigues PT, DPT, OCS, FAAOMPT
Manual Therapy Fellowship Regis University Manual Physical Therapy Fellowship Program, Denver, CO

INTRODUCTION METHODS 120

112
RESULTS
To date, few studies have investigated Outcome measures included maximal grip 100
Patients 1 and 3 (symptom duration 24
the combination of local and regional strength as measured with a hand dynamometer in 80
80
and 12 months) experienced a clinically
manual therapy with exercise in the pounds per square inch, Numeric Pain Rating Scale 65
significant decrease in symptoms in 17 and
treatment of Lateral Epicondylalgia (LE). A (NPRS), and Disabilities of the Arm, Shoulder, and 60 57

16 visits, respectively. Patients 2 and 4

recent review identified the use of elbow Hand (DASH). These measures were completed on 40 35
42
(symptom duration 5 months) returned to
manipulation [local] and therapeutic the first, fifth and final visits. Patients were treated 25 23
normal levels of activity without symptoms
20
exercise in the short term as the most until symptom resolution or acceptable progress with within 13 and 10 visits respectively. Figures
1
effective treatment . Subsequent literature regional and local manual therapy as indicated by re- 0
Case1 Case2 Case3 Case4 1-3 represent initial and final outcome
has investigated the effect of manipulation examination. In addition to manual therapy, patients Initial GripStrength Final GripStregth measures for each patient.
in the cervical spine [regional] and found were instructed in eccentric wrist strengthening and Figure 1. Initial to final change in grip strength,
those receiving manual therapy to the scapular stabilization. Regional manual therapy measured in PSI.
cervical spine were discharged in included cervical and thoracic manipulation (grades SUMMARY-CONCLUSION
10
2 I-V); pictures 1 & 2. Local manual therapy included A comprehensive, upper quarter,
significantly fewer visits . The purpose of 9
mobilization with motion into elbow flexion, and 8 impairment-based approach resulted in
this study is to describe the outcomes of 8

gripping; pictures 3 & 4. Other local interventions 7 increased grip strength and decreased pain
patients with LE treated with local and 6 6
included lateral mobilization to the elbow, radial head
6
as well as clinically meaningful improvements
regional manual therapy and exercise, 5
5

manipulation, manual stretching and nerve in function. While cause and effect
using a pragmatic approach. 4

mobilization/gliding. 3
3
relationships cannot be inferred from this case
2
2
series, the outcomes are similar to others
1
0 0 0 reported in the literature.
SUBJECTS Case 1 Case 2 Case 3 Case 4 Looking toward the future, a randomized
Initial Pain Final Pain
controlled trial of local and regional manual
Two male and two female patients, ages therapy and exercise is warranted to provide
Figure 2. Initial to final score change in NPRS
42-58, with symptoms ranging 5-24 months further evidence in support of effective
with maximum grip. MCID 3 points
were referred to physical therapy for lateral conservative treatment of lateral
epicondylalgia (LE). Examination of the 80 epicondylalgia.
upper quarter confirmed the diagnosis and 70 68

identified impairments in the cervical and Pictures 1 & 2. Supine Thoracic manipulation,
thoracic spine, peripheral nerves, shoulder
60
REFERENCES
Cervical Mobilization
55

girdle, and upper extremity. No competing 50

1. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review
diagnoses of cervical, thoracic, or UE origin and meta-analysis of clinical trials on physical interventions for
40
lateral epicondylalgia. Br J Sports Med 2005;39:411–422.
were noted during the exam. Treatment 30 28
32

included impairment-based manual therapy 2. Cleland JA, Whitman JA, Fritz JM. Effectiveness of manual
21 physicaltherapy to the cervical spine in the management of lateral
and exercise interventions, education 20
14 epicondylalgia: A retrospective analysis. J Orthop Sports Phys Ther
regarding symptom management and use 10 2004;34:713–722.
of a compression band during aggravating 0
2 2
3. Vicenzino B, Paungmali A, Buratowski S, Wright A. Specific
activities. Case1 Case2 Case3 Case4
manipulative therapy treatment for chronic lateral epicondylalgia
Figure 3. DASH at evaluation and discharge.
Initial DASH Final DASH
produces uniquely characteristic hypoalgesia. Man Ther
Pictures 3 & 4. Mobilization with Movement (MWM) 2001;6:205–212.
MDC 15-20 points.
elbow flexion, and MWM with gripping.