WHEN IT COMES TO TREATING lateral epicondylosis – more commonly known as tennis elbow – doctors of chiropractic today are serving up some powerful aces.
No longer limited to such passive techniques as icing or immobilization, chiropractors are now using a number of myofascial release, pin-andstretch cross-friction techniques, instrumentassisted soft tissue techniques (IASTM), lasers, dry needling, acupuncture, Fascial Manipulation and eccentric rehabilitative exercises. These newer techniques typically produce far better results than the medical community can achieve through anti-inflammatory drugs or steroid injections.
“This is where we can shine as chiropractors,” says Sherri LaShomb, DC, a certified chiropractic sports physician, certified athletic trainer and president of the American Chiropractic Association Sports Council. She practices in Lewiston, N.Y. “We can treat the initial injury, then we have the ability to help with the soft tissue, help with rehab and help with counseling to get better.”
Despite its name, tennis elbow is only rarely related to playing tennis – though it’s estimated as many as 70 percent of tennis players will eventually develop the condition. More often, it’s office workers or construction workers or factory workers or musicians – anyone who engages in the same sort of repetitive activity with their hands, day after day.
Whatever the root cause, this repetition begins to affect the extensor carpi radialis brevis, the muscle in the forearm that extends and abducts the wrist. The pain typically begins around the elbow, and usually progressively worsens, especially when those who suffer from this condition attempt to open a door, squeeze or grip something.
When a patient presents with such complaints, as always, it’s critical to take a good history, and to rule out other potential diagnoses, including synovitis, osteochondritis dissecans, ligament tears, Posterior Interosseus Nerve compression syndrome, arthritis or bone fractures.
“We want to watch for any swelling, any inflammation in a joint, to rule out infection,” says Kelly Lange, DC, also a certified chiropractic sports physician in Ashland, Ore., and first vice president of the ACA Sports Council. “Infection in a joint is very dangerous.”
Once satisfied with the diagnosis, treatment can proceed, and a number of approaches may offer relief, including Active Release Technique®, the Tyler Twist®, Instrument-Assisted Soft Tissue Mobilization®, the Graston Technique ®, Functional and Kinetic Treatment with Rehab (FAKTR)®, Fascial Manipulation and crossfiber manipulation. Ultrasound may also prove useful in some cases, as well as laser, dry needling and acupuncture.
“Making an accurate diagnosis is often difficult,” says Tom Hyde, DC, of Asheville, N.C., a diplomate of the American Chiropractic Board of Sports Physicians. He is co-author of the textbook Conservative Management of Sports Injuries and co-developer of FAKTR, along with Dr. Greg Doerr.
“Very few, if any, treatments are effective 100 percent of the time,” Dr. Hyde says. He feels it is important to have multiple options. “We now know muscles move as units with their tendons and fascia, and this requires us to look at those soft tissues and how they interact, and further, how they might be involved in this particular condition or any soft tissue condition. We need to know what activities reproduce the patients’ pain and exactly where that pain is manifested. Does the pain appear at the site of the complaint or elsewhere within the kinetic chain?”
Dr. Hyde’s favored treatment, not surprisingly, is FAKTR, so that’s the one he usually starts with. He taught Graston Technique® for ten years, which led to the creation of FAKTR. His treatment of tennis elbow may involve using the Tyler Twist while incorporating a myofascial treatment technique at the same time.
The Tyler Twist incorporates a wrist extensor eccentric exercise using a flexible rubber bar (Thera-Band Flexbar®). The technique has proven so effective in treating the condition that researchers stopped a trial midway through so that the control group not receiving the technique could start, and thus begin experiencing its benefit.
The technique was developed in 2009 by physical therapist Tim Tyler, a research associate at the Nicholas Institute of Sports Medicine and Athletic Trauma in New York City. When the New York Times ran a story about the technique, the YouTube video of the technique didn’t exactly go viral, but it did garner more than 180,000 views over the following year.
The protocol is simple and involves grasping a FlexBar® in the hand on the injured side, with maximum wrist extension. The other hand grips the top of the bar and twists, all while keeping the involved wrist in extension. Both arms are brought in front of the body, elbows fully extended. The twist in the bar is maintained by holding the non-involved wrist in full flexion and the involved wrist in full extension. The bar untwists by allowing the involved wrist to move into flexion. This movement is repeated 10 to 15 times, up to three times a day.
Response time will vary from patient to patient. Dr. Hyde says some patients see resolution of the issue in as little as a single visit. In some cases, a longer treatment is needed.
“If you’ve treated someone two or three times and they aren’t showing signs of improvement with your treatment protocol, you may need to ask the patient additional questions regarding the history of onset, activities of provocation, and perform a new examination,” he says. “Always ask additional questions related to prior injuries to the elbow or above or below the elbow.”
Simply treating the presenting injury is futile if the patient continues doing whatever caused the injury in the first place. That’s why education is critical.
“In chiropractic, we believe in getting more toward the cause of problems,” says Dr. Lange. “It’s not that we don’t treat the symptoms, but we want to ask about the aggravating event. We treat it, then we want the patient to stop doing whatever is making it bad.”
If the root is subluxation, then manipulative therapy will be helpful. If it’s ergonomic or behavioral, then patient education is key.
Follow-up care is also crucial.
“We try to teach them active care they can do at home,” says Dr. LaShomb. “We can fix things, but if you can prevent the cause, it definitely helps it from reoccurring. So teaching patients proper ergonomics, stretching exercises for the elbow and how to increase circulation are very important.”
“I find that getting patients to take frequent breaks and teaching them some stretching exercises helps,” she says. “Also finding more ergonomic tools. The classic example is carpenters using hammers. I try to get them to use hammers with softer grips. Or people who write a lot can use larger pens with softer grips. Little changes can sometimes make a big difference.