Speaker 1:
Jared Powell:
Today's guest is Leanne Bisset. Leanne is the undisputed queen of tennis elbow. Pretty much every major tennis elbow publication over the last 15 years has Leanne's name somewhere on the authorship team. And thus, it may come as no surprise that the topic of this podcast is tennis elbow, or is it lateral elbow tendinopathy or lateral epicon neuralgia, or some other obscure name. You'll have to wait and see.
Jared Powell:
Tennis Elbow is an underrated musculoskeletal condition. In my humble opinion, having suffered from tennis elbow personally, I understand how disabling it can be, especially if your occupation or recreation of choice involves significant or repetitive use of the elbow extensors. As a primary healthcare professional, you will almost certainly see a case of tennis elbow every week in your clinical practice. The question is, are you able to diagnose it accurately, provide UpToDate advice and information regarding the condition, and are you able to intervene to shorten its natural time course? Leanne talks us through these very important clinical questions and more. This is really a golden episode that is both research and clinically focused Without any further delay, I bring to you my conversation with Leanne Bisset. Leanne Bisset, welcome to the show.
Leanne Bisset:
Thanks, Jared. Thanks for having me.
Jared Powell:
Leanne. You're probably the greatest lateral elbow tendinopathy researcher in the world. I don't want to hear any humble comments after that, just except the compliment. Every single, every second paper, no, every paper I read on lateral elbow tendinopathy, you're just about an author on, and so we're gonna be talking about that today. No surprises. But before we get into the academic stuff today, Leanne, can you please introduce yourself professionally and personally? Sure.
Leanne Bisset:
Thanks Jared. Thanks for the intro. So my name is Leanne Bisset. I'm an associate professor here at Griffith University on the Gold Coast. I teach into our physiotherapy program and have worked clinically up until recently. I've taken a little great just to focus on full-time academia for a bit. Of course, my main research passion is in upper limb tendinopathy and the elbow in particular. And I guess from a personal perspective, I have a son who's just turned 15. And and so my husband and I have the usual challenges of, of wrangling a 15-year-old. And what I like to do in my own time, I do a type of dancing called physical culture. So anyone out there who knows Izzy knows, knows what I'm talking about to, but to a lot of other people, that's a completely unknown entity, but it is just a, a type of a, a, a dance stream. And I also love snow scheme. Just don't get an opportunity to do that much of it or living on the Gold Coast.
Jared Powell:
Yeah, it's, yeah, the Gold Coast doesn't scream snow skiing as a, as a hobby, where do you like to go? Do you go to Europe, north America, Japan, New Zealand?
Leanne Bisset:
Look, I've been all over. Yeah, unfortunately, I think the Gold Coast the Gold Coast, I think Australia's ski season probably has a limited lifespan now due to, you know, thanks to climate change. But my current favorite place is Europe. St. Anton in Austria is the place I've been going to.
Jared Powell:
I could go, yeah, I could, I could do the European help every single year for the rest of my life. Yeah, enjoy the, the, what is it? The, the upper ski, the drinks after. Yeah. And it's, there's nothing better that alpine air does something to your head. Yeah, in a good way. They do
Leanne Bisset:
It well, don't they?
Jared Powell:
Absolutely. awesome. And so just briefly describe fizzy, the, this dance that you are talking about. How can I picture it?
Leanne Bisset:
Physical culture, I, I tend to describe, it's, it's routine based dance. So we do individual routines, but we also do team routines. And I describe it as synchronized swimming on land because some of the positions and, and it's to music, a lot of the routines we do look, not unlike synchronized swimming, but on land on the floor.
Jared Powell:
Yeah. Awesome. And does it, I assume it's, does it, is it vigorous? Does it get your heart rate up? Is it, is it intense or is it more of slow and steady? Oh,
Leanne Bisset:
Look, it, it does, the thing I love about it is that it's women only. Although in this day and age, you'd think that'd be discriminatory, wouldn't you? But it is still women only and from all age groups, from like three years of age right through we've got ladies in their seventies dancing still. So it's, it's one of those things where the routines change depending on your age. And some of the girls, the, the young women who are sort of in that age group of probably 15 to to 25, the work they do is just phenomenal. But it gets a little bit easier when you get my age group, thank goodness, .
Jared Powell:
Yeah. I, I love the fact that, you know, in modern day and age, it's very much, I feel like gym and strength training and resistance training is like the dominant mode of exercise. And you know, that's probably, there's some reasons behind that. It is very good for you, but there's so many different ways to move your body for general health benefits and social benefits. Yeah, I sometimes think in physio we're really quick to push people into doing resistance training and you know, I'm not really speaking about the elbow here, maybe for back pain or Mm-Hmm. for shoulder pain or any other sort of types of pains, knee, knee pain, they don't, they might not have to go into the gym and do three sets of 10 of squats. You know, there might be lots of other different ways to move your body and yeah, that just got me thinking. That's really cool.
Leanne Bisset:
Absolutely. Yeah. And, and this type of dance is, is really good for balance and, and body control and body awareness, so joint position sense and, you know, postural control and things like that. So it's probably, you know, along the same sort of lines as Pilates, but it doesn't use any equipment. So it's just really floor based routines. Awesome. And so yeah, you can do it anywhere really.
Jared Powell:
Yeah. Awesome. Okay, so that's great. People get a bit of an idea on what Liam Bissett is like outside of the tennis elbow. Let's talk about tennis elbow. Actually, that's a good place to start. What the hell do I call this thing? Like, diagnostic labels are contentious these days. Tennis elbow, lateral elbow tendinopathy, lateral epicondylitis. Where do we go?
Leanne Bisset:
Yeah, I think the challenge with it is that it, it keeps changing over time, right? Over decades. So we have, as you, as you mentioned, we've gone from calling it an epicondylitis through to epicon neuralgia, which, you know, that just means pain at the epicondyl when we really didn't understand the pathology and, and to a certain extent we still don't. It's really quite complex. So maybe epicon neuralgia is still relevant, but the current consensus is that we should be calling it elbow tendinopathy. So medial and lateral elbow tendinopathy. And that's consistent with all of the tendinopathies that we see in the body, lower limb and upper limb. So at the moment, that's where we sit, you know, for patients coming into the clinic, they'll still call it tennis elbow because you'll still see on social media and, and on, you know, if you Google it, if you look at Dr Google it, tennis elbow is still certainly the, you know, a prevalent layman's term I guess the condition
Jared Powell:
Yeah. At the coalface of like a patient clinician interaction. Does it matter what we call it is, do we need to correct somebody if they say, I've got a tennis elbow, I think I've got a tennis elbow, do we need to give 'em a whole spiel on why they're wrong or do we just let them go with it?
Leanne Bisset:
That's exactly right. You know, I think that, that we need to think of carefully about what's important to educate our patients on, because, you know, being the, coming across as the know-it-all I know what this is, and I'm gonna tell you, and by the way, you're say you're calling it the wrong thing doesn't benefit anyone. I don't think it doesn't benefit that relationship and that rapport we're trying to establish with our patients. And, and it doesn't add to the, to the, to their level of understanding either about the conditions. So I'm more than happy if my patients come in and go, Hey, I think I've got tennis elbow, then go with that.
Jared Powell:
Yeah. 'cause tennis elbow is not, not an NOIC term, you know, it's not really gonna like force you to go down a surgical or injection based pathway where maybe some other labels for other conditions would. So, so yeah, I can't see any issue with it. It, it makes me cringe, Leanne, when you're saying like, early in my new graduate career and maybe some new grads go through this, where a patient might say something and I'm very quick to want to correct them in terms of no, we're not calling it that. No, it's not itis anymore. It's not inflammatory. I remember when those, the early Jill Cook papers came out on tendinopathy and she was challenging the inflammation present and people saying tendonitis. And I was like, I used to just in my head just go, no, you can't call it tendonitis and blah, blah, blah, blah, blah. But over 15 years I've really mellowed with that, you know, and become less paternalistic, I guess, and less authoritative and less like, no, you must call it this because that person's probably had a long journey into why they're calling it what they are and what value do we give them if we just shoot them down in one aspect, in one moment in terms of developing a therapeutic relationship and all of these things.
Leanne Bisset:
Yeah, I think you're exactly right. The concept of tennis elbow doesn't conjure up some terrible condition. You know, it doesn't conjure, it doesn't relate to pathology. So in some ways, maybe calling it tennis elbow is a way of you know, downplaying the severity of the condition to a certain extent. Yeah,
Jared Powell:
I jumpers knee tennis, elbow, golfer's, elbow, you know, all of these things they, like you said, they're not pathological, they don't give rise to non-evidence based treatment or anything like that. So yeah, I'm a hundred percent fine. Good that you say that as well. So what is lateral elbow tendinopathy? How do we disclose it? Just elbow at your lateral pain at your lateral epicondial, or are there other things we need to consider?
Leanne Bisset:
Yeah, it, look, this, that's a good question, Jared. I, I guess it, there's similarities in all the tendinopathies that we label as a tendinopathy as opposed to a classic acute inflammatory itus tendonitis. So these tendinopathies, it is an overuse overload type of situation that most likely, you know, results in the development of this pain more common than, more often than not. And the pathology that exists within the tendon is very consistent. So there is this, you know, breakdown in, in collagen tissue, this in infiltration of a OID fatty type substance, the presence of lots and lots of cytes, but disorganized collagen matrix and, and the loss of that collagen structure. So that's pretty consistent in terms of the pathology that underpins this condition. And we see that in people 100% of the time if we, if you do an ultrasound or whatever. I guess from a clinical perspective though, you think about, and it's in the common extensor tendon, now, the common extensor tendon is about half a centimeter to a centimeter long.
Leanne Bisset:
It is not a big tendon. So if we are talking about nociception, so pain that is directly related to that tendon structure itself, be it the connective tissues or the neo vessels that are infiltrating it, wherever that pain source is from. And look, to be honest, we still don't exactly know where that, that pain comes from, but if it is part of the tendon, then the patients will describe a pinpoint tenderness, like they'll point to their lateral epicondyle or just below it with their finger and say, that's where my pain is. So if you've got somebody who's got radiating pain down into the forearm or up into the humerus, down into the back of the hand, anything like that, then I think we need to think of carefully about our differential diagnoses. And that might include pain mechanisms, right? So it might still be a tendon pathology, but different pain mechanisms at play. But typically the clinical presentation is that pinpoint tenderness over their peon, they'll complain of pain that on contraction of those wrist extensors. So activities such as gripping, picking up objects, particularly with the elbow extended and, and the forearm pronated pouring a kettle, picking up, you know, a container of milk, those sorts of things. And in and really severe cases, you know, there is this spectrum of presentations, but in really severe cases, you know, even things like holding their phone, you know, so any even light gripping activities can be painful.
Jared Powell:
I think tennis elbow, I'm just gonna call it tennis elbow the end because it's too much of a mouthful to say lateral elbow tendinopathy and this podcast will go for four hours. Otherwise, yeah, it's an underrated condition, I think in terms of the disability that it can inflict someone with, you know, especially if it affects your dominant arm, maybe it affects your sport or hobby of choice or it affects your occupation, it can grind you down experiencing that pain day after day after day, perhaps year after year after year. And we'll talk a little bit about the clinical course of the condition in a moment, but yeah, maybe you've done some qualitative work or been involved in some qualitative research on it. What happens when we interview patients or explore their experience with a tennis elbow? This is not a question that I I'd sent over. Have you done any research on that or been involved in any research on that?
Leanne Bisset:
I haven't with this group. I think after, like from having treated them, you know, clinically for the last 30 odd years mm-hmm. But more in concentrated form for the last 20 years. I think you're right, there are people who have, who experience really severe, you know, pain and disability with this condition. And I think, and maybe it's my personal bias, I think that it negatively impacts people to a greater degree than even lower limb tendinopathies because if the elbow is so painful, you know, that, that you can't pick anything up, then you can't feed yourself. You can't get a glass of milk to your mouth, you can't do your hair, you can't take care of yourself. And it's those, even though just those simple activities of daily living that sometimes become really challenging for patients and it commonly is the dominant that's affected equally in men and women, it seems, you know, I think that when it really becomes impactful and they find they can't use their dominant hand, that then what follows is this whole cascade of the more psychological, the negative psychological and the negative social impacts that can follow because of the severity of this symptoms.
Leanne Bisset:
So I think it's a really interesting area to try and explore with patients when they come in. They've often had it for a long time because initially it, it's an insidious onset oftentimes, right? That it just comes on gradually over time. So initially they think, oh, this is nothing, and rest off a little bit and it'll go away and then it doesn't, and it continues to aggravate them and they continue oftentimes to push through trying to continue doing whatever it is, you know, the aggravating activities, be it work or sport or just daily activities, and it continues to increase in pain. And then you've got this cycle of, you know, the psychosocial impacts of that continuing pain, which then, as we know, can negatively influence the pain experience as well. So they, their pain gets worse because their psychosocial state gets worse and that they feed off one another. So it can be really challenging if the first time you see these patients, they're already like that.
Jared Powell:
Yeah, I agree. I don't want to diminish lower limb tendinopathies, but there's a massive difference between, you know, having pain when you jump or run or do high load activities versus when you're brushing your teeth or picking up the kettle in the morning. You know, like for me, and I, I have experienced tennis elbow, I developed it stupidly as a early 20-year-old doing like pronated barbell bicep curls. Oh yeah. Because I wanted big forearms for whatever reason. Yep. And yeah, it ru it ruined me and at the time I was studying exercise science and I was laboring like in a scaffolding yard at the time, and so I had to go to work with it and it was brutal. And I was like questioning my all my life choices and where I'm going and I've got this sore elbow and I'm only 20 years old. Yeah. Anyway, so that's just a, a personal anecdote, but when it affects those basic activities of daily living that you can't escape it, it does wear you down. And so I have tremendous sympathy and empathy for, for people that are going through it. And I think you would sort of reiterate this, we as clinicians must have that empathy. Sure.
Leanne Bisset:
And if you see the work cover data on this condition as well, the impact financially is huge and the prevalence is reasonable as well, you know, within work related industries. So yeah, you talk about the impact of on people if they can't work and if they feel like they can't return to that job, especially you know, and then have to change careers and change jobs, it can have, you know, really devastating personal consequences, but financial consequences as well for individuals. So think and look, like I said, maybe I'm just biased, but I, I see, you know, the negative impacts of this condition really can be quite significant. So when we see them in the early stages trying to, I think there's that, we have a really important role to advocate for these patients to get best practice care in a timely fashion to try and stop that cycle of it, you know, continuing into a really chronic state that does impact their whole life in so many ways.
Jared Powell:
Yeah, no, a hundred percent. We're gonna get into that best practice care in a minute. I wanna ask you a question about imaging. Leanne, you said a moment ago that pretty much everybody who presents with a suspected tennis elbow will have radiological findings that indicate some sort of lateral elbow tendinopathy or common extensor tendinopathy in the shoulder. We see a lot of times people without pain with pathology on imaging. Do we see the same thing in tennis elbow as well?
Leanne Bisset:
Yes, we do. And, and Luke Hills has done some of this work and in a really well controlled study, he found around about 50% of age and gender match. So people, you know, typically get these tendinopathies are in that age group of sort of, you know, 40 to 55 years of age, 65. So it's that working population age group, right. And, and around 50% of people in that age group have tendinopathic changes at the elbow on imaging with no symptoms, no history of elbow pain. So it's, and this is not uncommon to, as you mentioned, to a lot of tendinopathies, shoulder elbow, you know, Achilles, you know that they all experience this same sort of thing. So diagnostic imaging is not indicated for these tendinopathies. I think that's a really important take home message. Don't send them for imaging. If you wanna confirm, you know, tennis elbow, we do that clinically. That's our, our specialty and that's the, the best clinical, that's the best diagnostic tool is their clinical presentation. Where imaging may be indicated is if you wanna differentially diagnosed. So if you suspect that there is, for example, lateral collateral ligament involvement or radial nerve involvement or some other differential diagnose around the elbow joint pathology, for example, arthropathy, whatever, then maybe imaging is indicated, but not for tendinopathy on its own.
Jared Powell:
So it's a clinical diagnosis in line with other tendinopathies. We don't need to rush them out for ultrasound MRI. Fantastic. Just on diagnosis, again, quickly, you mentioned like focal point tenderness at the lateral epicondial. Are there other clinical tests that we should do? You know, the classic, what is it? Middle finger, extensive carpi radi brevis test. What else?
Leanne Bisset:
Yeah, so isometric resistance of middle finger extension, isometric wrist extension. Yep. As well. So in elbow pronation and full extension, just resisting wrist extension, it should be positive or middle finger extension, pain on palpation. And then pain-free group strength is another really important measure. And this is slightly different to the way we, you know, the hand therapists especially are typically trained to measure grip strength. So the classic position of measuring group strength is elbow 90 degrees flexion neutral shoulder for neutral forearm and then gripping in that position. But what is the position that's most sensitive to change? And that's gonna give you a far more clinically important measure. Clinically relevant measure is to put the arm in elbow extension, forearm pronation and to measure pain-free grip. So we ask the patient to grip in that position up until the first onset of pain. Mm-Hmm. And so that's really a measure of pain-free function rather than strength per se, but it's far more clinically relevant to the patient's condition.
Leanne Bisset:
Right. To tennis elbow because they get pain on gripping. That's how we measure pain-free grip strength. And then you compare it to their other side, hopefully unaffected side. But you know, that side, same position, you can measure maximum grip strength. So there's been some work to show that pain-free grip is a, is a far more sensitive measures, far more sensitive to change over time. And there's some more ongoing work on that to try and demonstrate the validity of that. Because if you measure maximum group strength with the elbow bent and the forearm in neutral, oftentimes it's not that impaired. It's not that painful. So
Jared Powell:
Provocative position is
Leanne Bisset:
Reduced because all their finger flexes are still intact, right. And working fine. And they're the force generating muscles in that gripping task. So oftentimes in this elbow bent position and neutral forearm biomechanically, most likely there's, you know, the positioning of those extensive muscles is not causing as much pain through their elbow. So they can grip, you know, relatively well in that position. So you get a bit of a ceiling effect if you measure it there. Mm-Hmm. Yeah,
Jared Powell:
No, that's good. So pain-free grip strength in a elbow extended and pronated position as opposed to just going all out on a maximal grip strength. Good. I love it. Now a really important question for me, Leanne. I like to have, you know, these discussions with patients shared decision making, right? So I like to lay it out there. This is the evidence in terms of your average outcome or expected outcome. If we were to intervene, this is what we might expect. If you do nothing, this is what we might expect. If you proceed with an injection that you so desperately want, and we'll talk about specifically a little bit later, but I want to talk about the clinical course or the natural history on average of tennis elbow. What can we say to patients? Like, do we say you're gonna get better in a year no matter what? Do we say perhaps two years? Is it better if we do this dry needling or exercise program? Give me the full picture please, Leanne. Yeah,
Leanne Bisset:
And look, it's a, it's a really complex, this is a really complex question and, and, and there's no easy answer. So cut me off if I start rambling , I'll try and do this in, in a sensible order. So the first thing I would do seeing a patient like this in clinic is take the patient rated tennis elbow evaluation, which is a self-reported condition specific outcome measure, right? So, and I'll just call it the PRT, the pre t, right, as an abbreviation. This outcome measure, we can use it to stratify patients. So you can stratify them if they score around 30 and it's added up and it, and it gives you a score out of a hundred. So if they score 33 or less, so around 30 or less on that outcome measure, generally speaking, they fall into a mild subgroup for the condition. And they're more likely those ones are more, more likely.
Leanne Bisset:
This is not unlike the startback tool, I guess to a certain extent, but it's really just pain and function. There's no psychosocial questions in this questionnaire, but that mild subgroup are more likely to do well, minimal intervention. This has not, I'm gonna caveat this by saying this, this has not been validated yet, been confirmed by a longitudinal research study yet it's been looked at retrospectively. So, so mild pain and mild dysfunction or functional impairment, they're more likely to do well and maybe, you know, natural history kicks in there. And what we've shown in our RCTs is that people with tendinopathy in general, if you give them sound advice and show them ways to modify their activities so they don't continue to, I guess, aggravate and overload their tendons, then they, you know, in the majority do get better after about 12 months.
Leanne Bisset:
The majority, however, there is still around 20% who don't. And that number increases in certain situations where they're, they've got higher risk factors for a poor prognosis and that includes corticosteroid injections. You know, I, I know we can talk about injections on their own down the track, but, but having had an injection is a, a risk factor for a poor prognosis at 12 months follow up. If they score back to this pre T questionnaire, if they score 54 out of a hundred or higher, they're in a much higher, much more severe subgroup. So they're the other end of the spectrum and they are more likely, those are the ones where you, I think you, we really need to be careful with our differential diagnoses that you might consider how their nervous system is involved in their pain presentation. Because there is this mismatch between the severity of symptoms and often what is seen on imaging.
Leanne Bisset:
So even though everybody has, ima, you know, changes on imaging with tennis elbow symptoms, the severity of the changes on imaging don't correlate with the severity of symptoms. Is there another differential diagnosis there that you, you might be missing? Consider those, that pain management is probably one of your key criteria there and how you're gonna manage their pain as well as then obviously the old functional improvements they still need. And then you've got the middle group that score between 33 and 54 out of a hundred, and they tend to respond really well to our programmed approach. And there is really good evidence that we can get people better faster than natural history. So the research we've done has shown that, you know, certainly in the short term, we get better people better faster with a physiotherapy approach, which is a combination of manual therapy and exercise compared to wait and see alone.
Leanne Bisset:
So yes, natural history is there and it is a good conversation to have with patients to say that is an option, but bear in mind it's gonna take you six months to a year at least to see that recovery. And in some people it doesn't work in about 20% of cases, you'll continue to have pain down the track. So, so those are the ones I think are a real challenge, right, is to, is to be able to identify people early who are at risk of a poor prognosis. And then the biggest question is, what do we do about it? How do we manage those?
Jared Powell:
Was it that middle group that you said respond well to the physio or exercise and manual therapy, or was it both the middle and the, and the lower group that outperformed the natural history
Leanne Bisset:
When clinical trials, we didn't discriminate from the mild, moderate and severe subgroups. Yeah, so we, they were all included. Yeah. And so globally as a whole, and the physiotherapy group responded well in the earlier days, so, so we get them better faster, and then they maintained their improvement over time. So, so we can get them better faster if they have physio, and that's whether they have mild, moderate, or severe symptoms at presentation. So yeah, physio is still relevant. It's just, I guess working, again, taking that patient centered approach. So part of it is, you know, making sure we've got the right diagnosis. But the other part of it is, you know, saying to the patients, having those conversations of, look, this is really mild, why don't you try this first? Give them, you know, assess them, give them a, a self-management plan, and then maybe it's a review 2, 3, 4 weeks down the track to see how they're getting on when they're, they're in that mild state.
Jared Powell:
Yeah. And so what, what does a good physio program or course of physio, and I won't just limit it to physio, let's just, any allied health musculoskeletal professional, what, what should we do? Is it run, run through it all, if you don't mind in terms, and this is, I'm, I'm happy for you to give me your own pet interventions here as well. It doesn't have to be all evidence-based. What do you like to do with people with tennis elbow?
Leanne Bisset:
Yeah. Okay. So I guess my clinical approach has also changed a little bit over, over the last 10 years or so, as well as, I guess as more research does come to light, but also just through understanding the role of the forearm extensors in upper limb function. So a lot of the research out there, I don't know whether where I start talking about the research now or later, but you know, the mainstay, the go to approach with tendinopathy is exercise, right? I think regardless of profession exercise should be, you know, one of the foundation interventions that we do for tendinopathy, because we know that exercise loads tendons, we know that a functionally appropriate intervention that if we can improve muscle strength, we, we are going to improve that efficiency in the muscular tendon as complex. If we do appropriate loading, we can increase the tensile strength of tendon, at least our healthy tendon research shows that and influence collagen deposition and influence organization of reorganization of collagen.
Leanne Bisset:
And all of that is sorts of biological responses to load right positive things. So we know that exercise should be the foundation of management with tendinopathy. There's certainly a number of systematic reviews out that have investigated the benefits of exercise. But I think one of the things we've failed to do is to think specifically about function of the forearm, the wrist and forearm finger extensors, and the role that they have in up limb function. So these muscles, especially like extensive carpi radi brevis and extensive carpi radial extensive carpi naris, which are both part of that common extensor tendon at the lateral epicondial along with extensive digitorum, but ECRB and ECU, the role is they, they, they insert at the base of the wrist, so at base of the metacarpals and their role is to stabilize the wrist to allow gripping and loading activities, especially under high load.
Leanne Bisset:
So under light load they move the wrist, right? So if we are doing something like if we're throwing a dart or if we're writing with a pen and paper, if we're, what else is like, like doing craft work, like knitting or crocheting or things like that. And even badminton, which is a fairly low load, you know, like using a light racket and a light sh light activities like that involve wrist movement. And those muscles, E-C-R-B-E-C-U are involved in that wrist extension movement. However, as soon as we start holding things with that require a reasonable grip, if we start picking up loads like even a water bottle, then their role changes, their function changes. They are designed to stabilize the wrist to stop the flexor moment that takes place at the wrist during long finger flexion, right? So the flexor digitorum, superficialis flexor digitorum profundus cross the wrist.
Leanne Bisset:
So when they, and all the thumb, you know, the long finger thumb tendons as well. So when we are gripping with our fingers, curling our fingers over there is this flexion moment at the wrist that has to be counteracted by the wrist extensors. And that's because optimal grip strength is in a neutral to slight wrist extended position. So they work isometrically, I guess that's my long way of saying they work isometrically. So functionally when we start exercising these muscles, you know, the research that's been done in the lower limb, particularly in the Achilles tendinopathy, has been translated and generalized to the upper limb and particularly to the elbow. And people classically start going into the straight, into the concentric eccentric or worse still eccentric only exercise protocols for the elbow. And it's just not functionally appropriate. It's not how these muscles work and that they are often painful doing that is type of ex activities, those types of exercises.
Leanne Bisset:
So the exercise prescription, especially in the beginning, in the early days when you're first seeing these people and you're getting them working, should be isometric 'cause that's functionally appropriate unless you're trying to retrain writing or throwing a dart and in which case you don't load it right? You, you might do through range flexion extension exercises, but not under load, not carrying weight. That's just not how they work. Soon as we start loading it, it should be isometric. Well we know that the research tells us how these muscles function. So that's all evidence-based. What we can't do at the moment from the evidence is, is show categorically that one type of exercise is better over another. There's been systematic reviews done and they tend to pull all the exercises all together and say, well there's, or when they compare them, they're not unimodal, you know, exercises delivered in a multimodal treatment plan.
Leanne Bisset:
So it involves it, you know, sometimes it's massage, sometimes it's stretching, sometimes it's manual therapy. Something like, there's lots of different adjunctive treatments that have usually been given in these research studies, in these clinical trials. There's been a recent Cochrane review updated as well that looks at manual therapy and exercise for lateral elbow tendinopathy. And if you look at the studies they pulled, they pulled everything from studies with mobilizations with movement. 'cause My clinical trials in there to massage with a chiropractic tool to contract relaxed stretches, to eccentric exercises, deep friction massages, you name it. They pulled all these different interventions together under this broad term of manual therapy and exercise. So, you know, there's, again, it's not helpful because it, it doesn't help us to identify what approach is better than another in terms of exercise. So I think the functional approach is in best way to go at the moment.
Leanne Bisset:
And that is start isometrically right and load isometrically because that's functionally appropriate. And then the other thing where we do have evidence of effectiveness is in pain control and pain management using our manual therapy techniques and in particular mobilization with movement, manual therapy techniques have demonstrated really sound effectiveness greater than placebo effects. So that's been done. People will often say, oh, it's a placebo effect, but there's been some really well controlled studies by a tali. And he, he looked at a sham comparison to an MWM and a control and found that the MWM was superior in terms of changing pain. So changing perceived pain with pain-free grip and changing pressure, pain thresholds as well. So a more, you know, mechanical hyperalgesic response I guess to pulpation. So we know manual therapy works, isometric exercises are functionally appropriate and there's evidence of effectiveness of taping techniques as well.
Leanne Bisset:
Now there's a lot of other evidence as well, if you wanna look at the, the, the whole gamut of, of options acupuncture, there's some evidence of acupuncture effectiveness, there's some evidence of laser therapy effectiveness. So some of the passive modalities have demonstrated effectiveness at, at short term responses. So, so improving pain in the short term as you know, I guess a, a long-term plan is how we can, you know, like, like reducing pain. Let's, let's not throw that out, right? That, that is important in a lot of these patients. If you can reduce their pain in the short term, then you're more likely to be able to get them exercising. And if we can get them exercising and adhering to an exercise program because we can make it less painful, they're gonna, they're gonna do it and if they do it, they're gonna get better in the long term.
Leanne Bisset:
Such poor evidence. People, you know, implement these studies into interventions that involve exercise and they don't measure adherence. They don't measure how much people are doing. And clinically patients drop off and often they might say, oh yeah, no, it's better, but it's because exercise hurts that they stop doing it. And how many times have you heard that clinically, you know, a patient will come in and say, oh, they gave me these exercises but I didn't do 'em 'cause they hurt. So if we can reduce that pain, get them exercising, then they don't become reliant on us. They, they can do their exercises and get better in the long time. So adding manual therapy, adding tape, adding some of those adjunctive treatments in the short term is beneficial as long as we have a process by which we can start with drawing that hands-on treatment so that then continue with their, you know, that active intervention in the long term. Does that answer it, Jared?
Jared Powell:
Yes. Comprehensively, Leanne. Really well said. I, I've got a couple of follow up questions if you don't mind. With the isometric exercise, is that just a simple sort of wrist extension, isometric, are you talking about with a dumbbell in your hand or TheraBand or, or something?
Leanne Bisset:
Yeah, so what I usually start with is resistance band because we can, you can adjust the, you know, you can find a, a load that's appropriate and you can make it stronger and you can change the position with the patient. And also it's a way of just specifically targeting the extensors without that open contraction of the flexors initially. So just getting the extensors working optimally and, and correcting wrist posture. 'cause Sometimes their wrist posture's a bit dodgy when, you know, watch these patients grip when you do their pain-free grip assessment and they'll often, you'll see them start to grip into a more, more risk flex posture, which is, you know, not effective, not efficient way of gripping. So I'll often start with TheraBand, tie a loop and put that over the back of the hand so they don't have to grip it. It's just is, you know, isolated wrist extension.
Leanne Bisset:
And then I'll start that in whatever position is optimizing their contraction but not aggravating their pain. So it might be in pronation, but with a, a bent elbow. But I'm working towards trying to get them into elbow extension, full elbow extension in pronation because that's obviously the more provoking position and, and more challenging position for these forearm extensor muscles. Then once they can do that, then you can start, you know, increasing the load, it will go to weights and the progression from there is then to make the, once they've got that good control, make the move more complex and more functional. So you might bring in elbow flexion extension or shoulder movements, shoulder rotation, shoulder abduction, shoulder flexion and things like that. You can certainly progress isometric exercises away from just this static hold mm-hmm. They're still doing the isometric exercise, but on top of a far more complex upper limb exercise because we also know that there is global strength deficits in tendinopathy, in elbow tendinopathy, particularly with the chronic cases. So scapular control there, upper limb strength, biceps triceps weakness that they've got global impairments when they've got this condition for a period of time. So that's usually how I would start.
Jared Powell:
Are you doing, I mean obviously it would depend from person to person, but is your aim typically for this low load longer holds ten second holds, 22nd, what, what's your, your modus upper operandi? Either,
Leanne Bisset:
So I will usually try for long holds if, but it's, you know, assessing the clinic and see where pain starts Yeah. Where pain starts to increase. And if pain goes beyond a three or a four out of 10, that's where I would stop. The other thing I do with these exercises is teach them to do a self MWM. So self mobilization with movement, especially if I've assessed it in the clinic and the n wms effective at reducing or improving their pain-free function. So oftentimes it's pain-free grip is my outcome measure. So I will do a lateral glide on the elbow or pa glide on the radial head sustained during that grip and look for an improvement in their pain-free group. So if they get an improvement, then I will teach them to do an MWM on themselves. Now the easiest one is, is a PA on the radial head.
Leanne Bisset:
So getting them to hold their radial head, you know, in that posterolateral position there, you can get the, their other hand to hold that play. Just gentle pressure should be painful and while they're doing their exercises, so again, try it without the MWM try it with the MWM and if they get, they can do more, hold it for longer with less pain, then do it. Right. We're not making anyone dependent on anything except giving them another tool in their toolkit to manage their pain and show them that they can exercise without increasing their pain drastically. So I'll often do that. So yeah, I'll, I'll usually go for fewer reps initially, measure them in the clinic and see how many they can do. But you know, maybe it's five or six repetitions and aiming for a 30 to 45 second hold and then just once a day to begin with because I want success, I want early success with exercise and I don't wanna repeat that pain provoking experience for them where they just go, no, this is all too much. And then gradually increase that, you know, they can do it twice a day. They can increase the number of repetitions. They can increase their load.
Jared Powell:
Yep. Perfect. No, it all makes, I love it. It makes perfect sense to me. I wanna, I'm just wary of your time here, Leanne, I wanna ask you one more question if you don't mind. We've skirted around corticosteroid injections here and I want to get into it now. So some of your work has been quite seminal on corticosteroid injections for tennis elbow, and I don't wanna ruin the punchline, but can you sort of tell us where we're at with corticosteroid injections? Should we entertain them at all for our perhaps maybe highly disabled patients or are they just a no-no for every subgroup?
Leanne Bisset:
Look, this is a good question and, and I think you can't say
Jared Powell:
Never say never no
Leanne Bisset:
For everyone, right? We've still gotta keep the patient at the center of this and it's gotta be a shared decision making process. But there is strong evidence and not just our studies, but other studies and even synthesized, you know, systematic reviews and editorial showing that and suggesting that corticosteroid injections have negative long-term effects on tendons. So we know that if that, there's been cases where it's injected into the achilles tendon and they've had ruptures into the elbow, it hasn't necessarily resulted in ruptures, but corticosteroid injections have been associated with greater levels of degenerative changes and involving the lateral collateral ligament in people who have had multiple corticosteroid injections. Our clinical trials and Brooke Coombs ran one as well and published that in 2013 in JAMA and Mine, which is old now, it was published in 2006 in BMJ, but we both shown that corticosteroids have incredible pain relieving effects in the short term, but by about 12 weeks they start to recur, the pain comes back and it comes back substantially less so in around 70% or more of people.
Leanne Bisset:
And then they have a slower recovery rate after that. So there is a really, so my conversation often with patients when they're considering corticosteroid injections is it'll give you short-term relief for short, but be aware that it's likely to come back after about eight to 12 weeks and then you're gonna be worse in the long run and you'll be worse at six months and 12 months than if you did nothing at all. Right? So they're worse off at 12 months compared to people who just wait and see and modify their activities. So it really comes down to how, you know, can we give them alternative pain relieving strategies in the short term that mean they don't feel the need to go for those corticosteroid injections. I think one of the challenges we've got at the moment in Australia is that you know, GPS will typically refer people for an ultrasound image or an X-ray of their elbow if they, if they see people with suspected tennis elbow and then the interventional radiologists at the moment are then recommending ultrasound guided corticosteroid injections, ultrasound guided or blinded corticosteroid injections have no difference in outcomes. It doesn't matter if they're ultrasound guided or not, if the corticosteroid is being injected into the tendon, they will have a high recurrence rate and poor long term outcomes. So yeah, they're one of those things where I think we need to make sure our patients are well informed about the consequences of having an injection and giving them alternative options for pain management.
Jared Powell:
Yeah, totally. I mean, this is why shared decision making is so important because you, you can very comprehensively and concisely lay out the evidence against corticosteroid injections. You know, it's not really a judgment call where like should you or shouldn't you, it's not really a gray area. The evidence is, as you suggested, quite strongly against it. So I think that can be quite compelling to a patient and when they see that from really solid level one evidence, like your study in BMJ, like Brooks in, in jama, that these are prestigious medical journals that this stuff's getting published in. Thanks for that, Leanne. You've given us a few compelling narratives to, to share to our patients. I just wanted to ask you one more question about the corticosteroid injection. Like why do you reckon, and this this might be just a hypothesis or something that you may have or you may have solid data, why do you reckon the pain comes back worse? And then why do you think it's protracted? Do you feel like it's because of the deleterious effect of the corticosteroid on the tendon tissue or the LCL or do you just think that maybe it's a bit of psychological stuff going on there, the pain got better, but now it's coming back. Do I need another injection? You know, what do I need to do? So on and so forth. So it's like this anxiety hypervigilance, blah, blah blah, blah, blah.
Leanne Bisset:
Really good question because even before that, we still don't understand what the analgesic effects of it are. They usually mix it with a, like a long-acting local anesthetic. But you know, given that these tendinopathies have, you know, especially the chronic ones have this distinct lack of inflammatory mediators present in them, you know, what, what is it that's really giving them that analgesic effect? We're not really a hundred percent sure on that either. And then I, I suspect that at least in some cases what you've said there is true that the perception of how bad the pain is is maybe higher when people have had this period where they thought they were cured, this whole concept of being cured, I've got no pain, I'm cured, and then it comes back. Mm-Hmm. And that can be quite devastating to people I think psychologically. And so their perception is that it's worse than it ever was.
Leanne Bisset:
You know, it's worse than it was before I had the injection. Mm-Hmm. Where in reality, perhaps it's not when with those studies, when we have monitored them over time, certainly it's not just pain at that local elbow area, but it's things like their pressure, pain thresholds change. So there is some return of hyperalgesia, you know, within their nervous system, whatever's, you know, driving that, whether it's, you know, it, it can't all be psychologically, there's gotta be some nociceptive driver that restore, you know, that creates that new occurrence or that recurrence of pain in that situation. But you know what that is, we are not sure. We don't know why it comes back the way it does. What else was there that you asked? Was, did that answer your
Jared Powell:
Question? No, that was perfect. Yeah, that was good. It's, I mean, I think it might, might be different as well in terms of like, it's an unfair question to say why does it come back and when we don't even know why it works in the first place, you know, and the complex pathophysiology of a tennis elbow complaint of individuals pain experience of the relationship between nociception and pain of the relationship between the tendon structure and pain. Actually just quickly, Leanne , I just gonna stop saying this. Within the tendon we've talked about macroscopic tendon structure, so how, you know, collagen, disorganization, neovascular infiltration, et cetera, et cetera. What about at a microscopic level in terms, has there been much work done? Are you aware of like, you know, biochemical mediators of pain in the lateral elbow tendon, like in the shoulder? We've got some evidence that substance p are found in higher concentrations in rotator cuff tendons and those with pain and without pain. Do we have similar data for the tend for the lateral elbow tendon?
Leanne Bisset:
Yeah, they have done some some, some work using microdialysis Mm-Hmm. They, they tend to get away with these kind of studies, invasive studies in Scandinavian countries.
Jared Powell:
Yeah. Scandinavia, they're crazy aren't
Leanne Bisset:
. Yeah. Where yeah, they have found, found CGRP, so that calcitonin gene related peptide and, and substance P presence in the pathological tendon state. So yeah, they are like that pro nociceptive, pro-inflammatory or pro nociceptive mediators which is, you know, part of building that concept of, well this is a bigger problem than just local tissue pathology, that there is changes taking place within, within the nervous system as well. Mm-Hmm. So I think that is part of it. The other thing that I think is slightly different, so while the, the pathophysiology is different, the tendon structures are slightly different in different tendinopathy. So, so a lot of the works, a lot of the buildup around eccentric exercise has been based on energy storing tendons such as the achilles tendon, right? There's a group in the UK hazel screen and her group have, have looked at horse tendons because horses have, apparently they get tendinopathy, especially race horses, and they have very similar tendinopathy and, and very similar presentations to human presentations.
Leanne Bisset:
They get tendinopathy in the achilles tendon equivalent. So in these energy storing tendons, but in horses, the opposing tendons, the antagonist group are positional tendons. And you can argue that the elbow is a positional tendon. It's not an energy storing tendon. And, and structurally they're different. So there is a greater percentage of elastin con content in energy storing tendons, which makes sense because that's what they're designed to do and that's within the interfa matrix. So they, they're structurally different to positional tendons. So while eccentric exercise and plyometric loading and things like that is relevant for achilles tendinopathy to improve tendon health tendon structure, it's not the same especially in the elbow extensor tendons that they're designed to position a hand in space, a wrist in space, and not to act eccentrically concentrically in an energy storing fashion. There are some structural differences, I think as well that we need to take into account.
Jared Powell:
Yeah, I completely agree. I think the, the generalization from low limb tendon to upper limb tendons has been a huge red herring over the last 10 to 15 years. And I can understand it, it's biologically plausible that a tendon is a tendon is a tendon, but when you, when you go into the weeds, they're very different. I think the shoulder and the elbow approximate each other far more than, than the lower limb tendons do to the upper limb tendons. Yeah. Lean, I've gotta let you go. You've been wonderful. This has been a fabulous chat. We've covered literally everything I've had on my list, so thank you so much. I'm sure the audience will, will get a ton from it. Are you like, where can people find, are you on social media or anything, or you fortunately haven't got caught up in all that?
Leanne Bisset:
I don't get caught up too much in the X sphere or the Twitter sphere. But I am on, I am on Twitter, I am on LinkedIn as well, so, and people can search for me at Griffith University as well.
Jared Powell:
And papers are everywhere. Just type in Leanne Bisset elbow and you'll, and you'll be fine. You'll find all your work. Leanne, thanks so much and I'll chat to you again soon.
Leanne Bisset:
Thanks Sharon. Thanks for having me.
Jared Powell:
Thank you for listening to this episode of the Shoulder Physio podcast with Leanne Bisset. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
