BraceLab Clinical Clues

September 2021 No. 23

Tips on Elbow Joint Mobilization to Relieve Lateral Elbow Pain

by Karol Young, OTD, OTR/L, CHT & Jerry Ditz, DPT, Dip. Osteopractic, Cert. SMT, Cert. DN

Joint mobilization of the elbow has been shown to decrease pain and improve functional grip in patients with lateral elbow pain. (1) Although there are many treatment approaches for lateral tendinopathy, we are focusing on some preferred elbow joint mobilization techniques which we have found helpful. Only therapists with appropriate training should perform manual mobilization techniques.

FROM KAROL YOUNG, OTD, OTR/L, CHT

I instruct patients in a self-administered Mobilization with Movement (MWM) program that allows them to actively contribute to their recovery. MWM provides a subtle manual joint position correction which biomechanically decreases pain. (2,3)

IF PATIENT HAS ELBOW PAIN WITH GRIPPING:

Item/s needed: Wall corner and two small towels.

Starting Position: While standing parallel to one wall, place the lateral elbow area against one towel on the wall near the outside corner. The upper arm is resting next to the side of the body and is against the wall. The elbow is flexed to 90 degrees and the forearm is fully supinated. Place the other rolled towel in the hand for gripping. See Figure 1. Place the uninvolved hand distal to the elbow flexion crease on the proximal forearm as shown in Figure 2.)

Figure 1: Starting position for gripping
Figure 2: Lateral elbow glide with gripping

Sequence:

  1. Apply a lateral glide force to the forearm with the uninvolved hand.
  2. While maintaining the lateral glide pressure, grip the towel.
  3. Release grip.
  4. Release the lateral glide pressure on the forearm.

Parameters: Perform the MWM only if pain free: 6 to 10 repetitions, 3-5 times daily.

IF PATIENT HAS ELBOW PAIN WITH WRIST EXTENSION:

Item/s needed: Wall corner and one small towel.

Starting Position: While standing parallel to one wall, place the lateral elbow area against one towel on the wall near the outside corner. The upper arm is resting next to the side of the body and is against the wall. Elbow is flexed to 90 degrees and the forearm is fully pronated. See Figure 3. Place the uninvolved hand distal to the elbow flexion crease on the proximal forearm. See Figure 4.

Figure 3: Starting position for wrist extension
Figure 4: Lateral glide with wrist extension

Sequence:

  1. Apply a lateral glide force to the forearm with the uninvolved hand.
  2. While maintaining lateral glide pressure, extend the wrist with fingers relaxed.
  3. Relax wrist.
  4. Release lateral glide force to the forearm.

Parameters: The patient is instructed to perform the MWM only if pain free: 6 to 10 repetitions, 3-5 times daily.

Figure 6: Lateral glide with full elbow extension

Access the patient’s pain level before and after the maneuver and modify if necessary to ensure pain free performance. Possible modifications are: 1) move the position of the hand providing the glide to a more proximal or distal position, 2) decrease the amount of gripping force or 3) decrease the range of wrist extension. The patient progresses by performing the self MWM first with the elbow flexed and then with the elbow extended. See Figure 6.

FROM JERRY DITZ DPT, Dip. Osteopractic, Cert. SMT, Cert. DN

My preferred mobilization technique for this patient population is a Grade 5 mobilization, called the Mills Manipulation which was first described in 1928 by G. Percival Mills. (4,5) Because it is difficult to learn a therapist-directed manual technique by briefly reading about it, I encourage you to review the Mills references below for specifics about positioning, hand placement, and thrust velocity and to seek mentorship to learn this technique.

WHEN TO USE THIS TECHNIQUE

Mills noticed his patients had full elbow motion when he examined joints individually. But with combined, complex movements there was a loss of range of motion. Specifically, he noted the inability to completely extend the elbow when the forearm was fully pronated, and the wrist and fingers flexed. The limited complex movements were not painful, and the motion was full on the uninvolved side. When a patient with lateral tendinopathy has limited range of complex motions, consider using the Mills technique.

HOW TO EXPLAIN THIS TECHNIQUE TO YOUR PATIENT AS YOU LEARN IT

When learning new manual techniques, therapists may struggle with deciding when to apply them to patients. As a younger therapist, I was afraid patients would be upset if I told them I just learned a new technique and wanted to try it on them. This was far from the truth. Patients enjoyed being part of my learning experience. I would explain I had attended a course or read a review article about their condition and had thought about their case and had practiced this technique. I discussed my thoughts with them, asking if we could try the mobilization their next visit. I also alerted the patient to expect an audible pop and explained that is normal.

A SUCCESSFUL PATIENT EXPERIENCE

The Mills Manipulation is a one-time use technique that, if successful, will have a significant response. When performed effectively, the technique elicits a snap, pop, or cavitation as the patient experiences an immediate 60-80% reduction in pain. (4,5) If the patient does not respond to the Mills Manipulation, move to a different treatment. Do not try it repeatedly.

As with all joint mobilization techniques, only certain patients will respond positively. Since joint mobilization is always only one part of our patient treatment, a successful response to the Mills technique helps us know when it is of value.

 

1. Lucado A, Dale RB, Vincent J, Day, J. Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. J of Hand Ther. 2018; 32:262-276. doi.org/10.1016/j.jht.2018.01.01

2. Reyhan AC, Sindel D, Dereli EE. The effects of Mulligan’s mobilization with movement technique in patients with lateral epicondylitis. J Back Musculoskelet Rehabil. 2020;33(1):99-107. doi: 10.3233/BMR-181135.

3. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzin B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: Randomised trial. Br Med J. 2006; 333(7575): 939. doi: 10.1136/bmj.38961.584653.AE

4. Mills GP. The treatment of “tennis elbow” Br Med J 1928; 1(12). doi:10.1136/bmj.1.3496.12

5. Mills GP. Treatment of tennis elbow Br Med J 1937; 2(212). doi:10.1136/bmj.2.3995.212

 

Download Clinical Clues No.23, Tips on Elbow Joint Mobilization to Relieve Lateral Elbow Pain; September 2021

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Disclaimer: BraceLab Clinical Clues are intended to be an informal sharing of practical clinical ideas; not formal evidence-based conclusions of fact.

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