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The forgotten radial nerve: A conceptual framework for treatment of lateral elbow pain

      Highlights

      • Novel approach, a regional interdependence model, to reduce symptoms of upper extremity musculoskeletal overuse in populations at risk by addressing a broader systematic approach versus a localized symptom driven approach for the assessment and treatment of lateral elbow pain.
      • “Think in nerve length and layers”- accounts for nerve tension and muscle balance in the entire extremity.
      • Application of the “Think in nerve length and layers” model for assessment and treatment of SRSN irritation in individuals with lateral elbow pain and proposal of a method for treatment and for further studies.
      • The proposed treatment approach combines mobilization with movement, elastic taping, and isometric exercises to address impairment at each level: joint alignment, neural tension, and the superficial sensory nervous system.

      Abstract

      Background

      Lateral elbow pain is a prevalent musculoskeletal overuse disorder that has serious consequences for musculoskeletal health, occupational performance, and overall healthcare burden. Available treatment options (traditional therapy and steroid injections) have been studied rigorously, yet supporting evidence is weak. The majority of treatment options available are targeted at the local pathology of the common extensor tendon as the apparent source of pain, and do not adequately address the cause, the source of overuse, and mechanism of injury.

      Purpose

      The purpose of this paper is to describe a novel approach, a regional interdependence model, to reduce symptoms of upper extremity musculoskeletal overuse in populations at risk by addressing a broader systematic approach versus a localized symptom driven approach for the assessment and treatment of lateral elbow pain.

      Methods

      The proposed framework - Think in nerve length and layers (TINLL)- accounts for nerve tension and muscle balance in the entire extremity. In this paper we describe the application of the TINLL model for assessment and treatment of SRSN irritation in individuals with lateral elbow pain and propose a method for treatment and for further studies. The proposed treatment approach combines mobilization with movement, elastic taping, and isometric exercises to address impairment at each level: joint alignment, neural tension, and the superficial sensory nervous system.

      Results

      Our findings of reduced pain with a relatively small number of therapy sessions in a small retrospective cohort of patients using the TINLL framework for assessment and treatment supports further formal study of this approach in a larger cohort with longer follow-up to determine effectiveness compared to current treatments.

      Conclusion

      Future studies will test and compare the efficacy of the TINLL framework and model of treatment on the short- and long-term outcomes in individuals with chronic lateral elbow pain compared to traditional therapy.

      Keywords

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      JHT Read for Credit

      Quiz: # 759

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question.
      • # 1.
        The authors are justifiably
        • a.
          advocating EMG NCV testing for most patients with lateral elbow pain
        • b.
          promoting the Mayo Clinic System of addressing lateral elbow pain
        • c.
          enthusiastic about the standard techniques of managing lateral elbow pain
        • d.
          skeptical of the standard techniques of managing lateral elbow pain
      • # 2.
        The SRSN is especially vulnerable because it
        • a.
          courses through the cubital tunnel
        • b.
          lies deep to the extensor wad
        • c.
          sits in close proximity to the radial head
        • d.
          has a low threshold for overload
      • # 3.
        Their proposed intervention includes
        • a.
          isometric exercise
        • b.
          elastic taping
        • c.
          mobilization with movement
        • d.
          all of the above
      • # 4.
        The proposed method was implemented
        • a.
          in a case series
        • b.
          on a limited cohort
        • c.
          in RCTs
        • d.
          for 3 years with 50 patient subjects
      • # 5.
        The recommended program is based on thinking in layers and length
        • a.
          not true
        • b.
          true
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.