Why do orthopedic tests matter?
What is the underlying mechanism that makes these test relevant?
How is this actually applicable for treatment of elbow pain?
What if this doesn’t fix everything!?
The One Big Idea: The Secret is in the sequence
I wanted to write this because I have no heard this idea thought out elsewhere though it seems incredibly simply and exponentially useful. In terms of a complete treatment plan for elbow pain this is by no means exhaustive. I would categorize this essay as a closely zoomed in view of google maps so please do not neglect zooming out to see the larger picture of each patient. However, let’s dig into some known processes and see if we cant rescue some gems from the often far to familiar and very neglected rubble of orthopedics tests for lateral elbow pain.
Sequence, set up & squeeze
The big 3 confirmatory tests for Tennis Elbow, or elbow pain on the outside of the elbow, are Maudsley’s, Cozen’s and Mill’s. Each has a particular sequence of steps wherein the attempt is to isolate a contraction of a certain movement to test it’s relation to the lateral epicondyle. More simply put, they line things up mechanically to test whether or not a movement aggravates the elbow. The 3 movements tested are finger extension, wrist extension and elbow extension and the set up up allows for the best isolation of these groups to the lateral elbow.
Why do these tests matter? Think about the sequential set up as directions from the your house to the party. Your house is the muscle group and the party is the lateral epicondyle in this scenario. The sequence and set up for these tests answer the question; How can one determine if (insert action of muscle group) is involved in aggravating the lateral epicondyle? The response is the directions given, or if you 1) stabilize humerus 2) make a fist 3) pronate forearm etc etc then you should arrive at the party the ICD-10 calls Lateral Epicondylitis.
Now that we have a basic understanding of the tests let’s quickly review so you have a proper perspective as we move forward. We’ll start at the bottom of the chain and move upward, but as you watch these see if you can discover any other similarities between the tests.
What is the underlying mechanism? These tests tell you that the primary mechanism for lateral elbow pain is extension of the fingers, wrist or elbow. From a patients perspective though it often seems reversed. If your elbow pain is like most elbow pain then beyond these tests it is common for people to complain that the pain is aggravated by grabbing things, holding things or otherwise initialed seemingly by the primary action of engaging the fingers in a state of flexion. We can marry the two findings by saying that engaging in too much flexion will diminish their ability to extend; hence, the previously stated ortho tests focus on various points of extension and now our focus on restoring extension to alleviate the amount of stress and pain of flexion.
How is this applicable to treatment? Let’s bring back this idea of sequencing. We know that the orthopedic tests for lateral epicondylitis are sequence to provide the easiest path from the muscle group to the condyle, but what if we altered one step? It would change the focus of the tension.
Let’s start with Maudsley’s. If this test was positive we should conclude that one goal of our treatment plan would be to restore finger extension. How could we restore finger extension working within the framework of the test that just proved positive? Reverse a step or two so that we can stress finger extension without that stress “getting” to the lateral epicondyle. More specifically, rather than pronating the forearm, we instead supinate the forearm. Then instead of a neutral or extended wrist, we flex the wrist. Then extending the fingers we can do a simple PNF stretch with a contract and relax sequence.
This sequence will isolate the previously provocative action from the patients perspective of finger flexion, or grabbing and holding things, as well as our positive finding of Maudsley’s Test without allowing that action of the finger flexion and the position of extension to “get to” the lateral epicondyle. The sequence and re-positioning of forearm will essentially put a road block between the desired action and the point of pain. Now the same idea can be used for the other two tests as well.
What if this doesn’t fix everything? First, it likely won’t, but it’s a great start and this fundamental understanding of the pain process will hopefully lead to a more thorough treatment plan overall. Second, there is another gem here and it’s literally the first step of each of these tests. These tests assume that the humerus is stable and even if it is not the doctor is instructed to “stabilize” the humerus. As such, we can make a strong argument that though these test seem to stress the various extensors below the elbow the primary (first step) is the stabilization of the humerus. So while addressing the extensor groups is absolutely useful it may all be lost without stabilizing the humerus first.
There are of course many other avenues and factors to consider in a balanced treatment of an elbow, but I hope you find this useful for your patients.
PS: I’d like to thank my friends Casey and Erik for this idea. They worked very hard to help docs like me understand the value of orthopedic tests by creating a massive index of tests that has helped me tremendously. Thanks, friends. Also, thanks to the good people at Physio Tutors for the info!