lateral elbow pain – supinator tunnel syndrome › @bin... · lateral elbow pain – supinator...

Lateral Elbow Pain – supinator tunnel syndrome

Mechanical Interface

Level 1

Progression 1 - static opener

Position - elbow flexion (approx. 35-50° from full extension), passive supination, wrist and fingers in neutral, shoulder elevated if necessary

Offer this as a rest position for pain relief.

Progression 2 - dynamic opener

Passive supination

Can be given as a home exercise

Level 2

Progression 2 - closing technique

Position - ,elbow extension passively

Mobilise/stretch - passive pronation, wrist and fingers in neutral

Progression 3- closing technique

Position - for RNT, obtain elbow extension passively

Mobilise/stretch - passive pronation, wrist and fingers in neutral

Include wrist and finger flexion and resist them actively and perform hold/relax techniques.

Interface release technique

Place elbow in 20-30˚ flexion, find medial border with thumbs and release across the muscle with thumbs. Be careful, it can dig in and be uncomfortable.

This is designed to release supinator as you perform an additional lifting action.

Section 12 Treatment - elbow pain 19

© 2014-15 NDS Neurodynamic Solutions

Neural

Level 1

Progression 1 - off-loader

Use the usual generic off-loaded position for the upper quarter but it can be biased to the posterior interosseous nerve with:

• a degree of supination and wrist and finger extension if so desired

Progression 2 - sliders

Starting position- elbow straight- wrist and fingers in neutral- scapula elevated- shoulder external rotation

Proximal slider - scapular depression/internal rotation

Back to original position - scapular elevation/shoulder external rotation

Wrist and fingers remain in neutral



Progression 3 - sliders

Starting position - elbow almost straight, wrist and fingers in neutral, scapula elevated. Positioning in internal rotation can be used as a progression.

Distal slider - scapular elevation/wrist and finger flexion

Proximal slider - scapular depression/wrist and finger extension

Level/type 3a - Neurodynamically Sensitised

Add CLF.

Level/type 3b - Neurodynamic Sequencing

Position – as for RNT

Movements

• EE/Pron

• wrist and finger flexion

• shoulder internal rotation

• shoulder abduction

• scapular depression

• CLF

The sequence can naturally be varied according to the patient’s needs or what is more practical to peform.



Level/type 3 (C) - Multistructural

Progression 1 - neural massager (slider under thumb)

Performed as a slider at level 2 except you place pressure over the nerve and/or neighbouring structures, eg. supinator, whilst sliding the nerve underneath.

Progression 2 - interface and neural

Contract supinator then, when it relaxes, perform tensioner for the posterior interosseous nerve as per level 2.



Section 13

Clinical ApplicationPractical/lab session

Low back and radicular pain - specific dysfunctions

Piriformis syndrome and the sciatic nerve

Foot/heel pain and the tibial nerve

Low Back and Radicular PainTreatment progressions

Mechanical interface - reduced closing dysfunctionThe techniques below are particularly suited to patients with significant distal symptoms that involve pain, pins and needles or loss of sensation.

IndicationsPredominantly distal symptoms - particularly pins and needles, numbness and weakness, neurological signs

Persistent/ continuous distal symptoms

Not as common to use these techniques with acute /severe low back pain without referral of symptoms into the lower limb

Distal symptoms provoked by closing movements - extension, ipsilateral lateral flexion

Reduced ROM of closing movements

Key aspect - MUST do a neurological examination before and after each treatment.

Treatment is directed at reducing the pathophysiology in the nerve root rather than the mechanical dysfunction. this is because to treat the mechanical dysfunction (ie. closing) would be to risk provoking the nerve root.

Section 13 - low back and radicular pain, piriformis syndrome, foot/heel pain 2


Level 1 - Limited

1. Static Opener

Position - painful side uppermost with a bolster under the lower side.

Progression 1a. Towel between ilium and trochanter

Progression 1b - One leg over the side

Place in open position - painful side up, legs flexed to 90°, one foot placed over the side of the couch.

If this increases symptoms return foot to couch and place a bolster under waist instead.

Do not mobilise.

Degree of opening - depends on response to positioning

Duration - 30-60 seconds at first. If better, repeat several times. If the same, still repeat once more and reassess at the next session.

Monitor symptoms at rest and, if they improve, offer this position as a pain relief strategy.

Either leg can be lowered, depending which is

more effective in achieving lateral flexion and

what is more comfortable for the patient.

Progression 1c - Static Opener

Position - as above, two feet placed over the side of the couch. Dosage same as in progression 1.

Dosage - up to several minutes at a time, hourly. Good gains can be achieved by doing this manoeuvre several times per day.

Progression 1d - manual opening to maximize.



2. Dynamic Opener/mobilisation (Level 1 continued)

Passive opener - contralateral lateral flexion

Can be done as small or large amplitude, in the inner or outer range.

Can be performed as a home also

Level 2 - Standard

Indications/clinical features

At this point, there is little to be found on neurological examination.

The distal symptoms are not easily provoked and are now intermittent or absent.

Neurodynamic testing shows minor signs (overt abnormal response (OAR) and covert abnormal response (CAR) late in range).

The interface dysfunctions are still present (reduced closing).

Now the treatment changes from treating pathophysiology in the nerve root to treating the mechanical dysfunction in the interface.

Dynamic Closer

Closer mobilisation – inner, middle and outer range

Position - start mobilisation in open position and gently move toward closed position

Mobilisation - in the direction of closing but only to the neutral position.

Perform slowly and carefully and with respect to the patient’s symptoms and physical responses,

especially resistance and protective responses.



Dosage - 5-6 gentle movements then reassess. if there is an improvement, repeat several more movements. If the same after mobilisations, repeat sets of mobilisations, stop and reassess at next session.

This can be progressed by positioning the patient into ipsilateral rotation, less hip/lumbopelvic flexion and even into some extension but care must be exercised.

Neural DysfunctionsClinical Features

Symptoms reproduced by movements that produce sliding in one particular direction.

Neural Tension dysfunction‣ SLR painful +/- PNF painful in severe cases‣ Slump - NF painful - KE painful



Moving Through the Progressions

It may not always be necessary to pass through each progression because they provide small increments. It is therefore possible in many patients to jump a progression or two. However, this should always be done carefully with respect to the patient’s signs and symptoms and sufficient time should be allowed between treatments so that accurate observation of patient responses can be achieved.

Progression 1 Position OUT - Position OUT(ipsilateral) (contralateral)

Position – generic off-loaded position for the sciatic nerve, - contralateral hip flexed approximately 90˚ if possible

- contralateral knee extension- hold for approx. 15 secs, longer if comfortable and safe (no problems in the contralateral limb - pins and needles or other symptoms)

Ipsilateral limb Contralateral limb

Progression 2 - position OUT-move OUT (of tension)(ipsilateral) (contralateral)

As above (1) except the knee is extended and flexedPerform approx. 5-10 times. This set can be repeated up to 3-5 more times

Progression 3 - position IN-move OUT (of tension)(ipsilateral) (contralateral)

Ipsilateral lower limb in neutral Ipsilateral dorsiflexion



Add ipsilateral SLR Move OUT - contralateral knee

More SLR Move OUT - contralateral knee

Progression 4 - position OUT-move IN (to tension)(contralateral) (ipsilateral)

Sitting

Position OUT- contralateral knee extension- protects nerve root- dorsiflexion optional

Move IN- contralateral knee extension- dorsiflexion optional

OPTIONS:

‣ ipsilateral dorsiflexion

‣ neck flexion



Progression 5 - position IN-move IN (to tension)

(contralateral) (ipsilateral)

From thisThis was the progression 4 starting position.

Now the protection from the contralateral knee is removed (remove the contralateral knee extension).

To this:

Position IN Move IN - ipsilateral knee extension

Add cervical flexion Move IN - ipsilateral knee extension

WHAT IS THIS?

Option - add dorsiflexion

This is now level 2, the standard slump test.

You now have a wide variety of techniques below level two that are not likely to provoke symptoms.



Level/type 3a - Position IN - move IN (to tension)

Contralateral lateral flexion Ipsilateral knee extension

HERE IS THE PROCEDURE FOR SAFER MORE ADVANCED TECHNIQUE

1. Test neurological function. If abnormal, this technique at level 3a is not recommended.

2. Position the patient comfortably.

3. Ask if the patient has any symptoms at rest. If “Yes”, do NOT proceed. The problem may not be at level 3.

4. Explain that symptoms may occur and, if they do, they must only be mild at most. Generally reproduction of the patient’s clinical symptoms is to be avoided. Stretching sensations are common.

5. Perform a test movement to the first onset of symptoms.

5.1. make sure the patient moves slowly and carefully and that they learn to stop at the right place.

5.2. return to the starting position and check that any symptoms disappear instantly. If not, wait until they do. If they take more than a few seconds, it may be better to do something more gentle.

6. If this goes according to plan:

6.1. perform 3-5 movements the same way, making sure that the symptoms stop between movements.

6.2. return to the start position for at least a second or two each time a movement is performed.

7. Do NOT stay in the end range position for more than about one second.

8. Test the neurological status to be sure that it has not deteriorated. If a deterioration occurs, the technique is contraindicated.



Position - as for slump test

Movement - cervical, thoracic, lumbar flexion, contralateral lateral flexion, knee extension,, dorsiflexion.

Make sure the amplitude is large so you retreat from the symptomatic position each time.

Level/type 3c. Advanced - reduced closing with neural tension dysfunction

Patient position - painful side up

Mobilisation - closing (ipsilateral lateral flexion) + neck flexion and knee extension (ie. two-ended tensioner)

This one often needs practice so the patients gets the movements right.



Starting position Closer with knee extension/neck flexion

Mechanical Interface - reduced opening dysfunctionLevel 1 to Level 2

Position - leaning over the patient with both hands around the pelvis.

Mobilisation - as an opener from the slightly closed position to the slightly opened position.

Should not provoke pain.

This is effectively the opening mobilisation shown earlier except that a sustained opener is not performed for reasons of provocation.

The same as the dynamic opener for the closing dysfunction, but for different reasons.



Level 3c. Multistructural - reduced opening with neural tension dysfunction - dynamic opener

Dynamic opener + one-ended or two ended tensioner

Optional - neck flexion or not, depending on the desired progression.

It is normally positioned. Active neck flexion makes the patients stabilize their pelvis which reduces the opening, not desirable.

This is used when there is:

‣ less risk of provocation

‣ a tension dysfunction with reduced opening - quite common



Distal/Caudad (downward) Sliding Dysfunction

Clinical Features

‣ SLR painful-neck flexion OK or eases

‣ Slump - release neck flexion painful



Progression 1 position OUT (up/cephalad) - position OUT (up/cephalad)

Same as in progression 2 except the neck is positioned in the flexion for a rest position to ease pain.

Progression 2 - position OUT (up/cephalad) - move OUT (up/cephalad)

Aim - to move the neural tissues away from the provoking direction and to do so with little neural tension.

Position - reduced tension (off-loaded) position

• painful side up, neutral spinal position in the sagittal and frontal planes• approximately 45° of bilateral hip flexion, 45° of bilateral knee flexion

Movement - gentle passive neck flexion

Symptoms are not evoked

Observe symptoms as you would in all other progressions.

Progression 3 - position IN (down/caudad) -move OUT (up/cephalad)

Position - same as above, add a small amount of ipsilateral knee extension prior to the mobilisation. This position should not evoke or reproduce any symptoms.

Movement - passive neck flexion again (position

This does not take the system to its end point of sliding, nor does it produce symptoms.

If this is provocative, the patient can be positioned in bilateral knee extension and the mobilisation repeated (PNF).



Progression 4 - position OUT (up/cephalad) - move IN (down/caudad)

Position - painful side up, neck in flexion (to bring the neural tissues into a cephalad position in the canal - position away).

Movement - straight leg raise (move IN to dysfunction - down/cephalad).

Some symptoms may be evoked but they should be mild and should cease immediately after the technique. However, if this mobilisation is provocative, it may be modified, as in the following:

You can then go further into SLR as a progression or add dorsiflexion if you wish.

Progression 5

This progression permits more caudal (downward) positioning (position IN - move IN = position down/caudad - move down /caudad).

5.1 As progression 4 position cervical spine in neutral then extension (down/caudad). Move the SLR for (downward/caudad) movement of the nerve roots.

5.2 Position - sitting across the plinth as if for the slump test, neck and thoracic spine straight

Movements - cervical and thoracic extension with knee extension.

To progress - add dorsiflexion.

Ipsilateral lateral flexion can be added for more effect.



Progression 5.3

Position - ipsilateral long sitting, neck and thoracic flexion

Movement - neck and thoracic extension whilst the patient leans forward to apply distal movement to the neural elements.

Understanding Sliders

Mechanical Effects

‣ maximal sliding with minimal tensile forces inside the nerves

‣ may maintain or improve sliding mechanism, eg. prevention of adhesion or loss of movement in the case of surgery, trauma with bruising or bleeding from adjacent structures.

Physiological Effects

‣ may improve blood flow of nerve

‣ sliders produce greater hypoalgesic effects than tensioners

Behavioural Effects

‣ promote movement

‣ muscle relaxation

‣ reduce pain



Applications

A. Tension dysfunction and pain

‣ useful for patients with a lot of pain who need movement rather than tension

B. Sliding dysfunction

‣ The sliding progressions must be applied so the technique relates directly to the causal mechanisms and progressions

‣ the general sliders above may not follow the progressions for the slider dysfunction therefore may be contraindicated.



Piriformis Syndrome


You can use plantarflexion/inversion or dorsiflexion with these techniques because of the relationship the peroneal nerve has with the sciatic nerve in the pelvis and with piriformis. Sometimes the peroneal component can feature in the patient’s symptomatology.

Level 1

Progression 1 - Static opener

Hip position - slight flexion, abduction, external rotation

Knee position - slight flexion

Ankle position - neutral

Can do this in side lying or supine lying

Progression 2- Dynamic opener

Passive external rotation - slow speed and large amplitude

This is for pain relief and can be performed as a home exercise

Level 2

Progression 1 - interface (muscle) release technique

Passive stretch of piriformis to be performed by therapist then as a home exercise by the patient. Even though this will produce closing during the technique, it will subsequently produce an opening effect as the muscle releases. This can be combined with contract/relax techniques.

Neural

Level 1

Off-loader for Sciatic Nerve and Piriformis

‣hip flexion below 70,˚abduction/external rotation

‣knee flexion

‣foot comfortable

‣can do this in supine also

Section 13 piriformis syndrome 18


One ended slider (distal)

Movements - knee extension and/or plantarflexion/inversion

Two ended slider:

Movements

Distal slider - neck extension/knee extension

Proximal slider - neck flexion/knee flexion

Level 2

Tensioners

As above - neck flexion/knee extension with or without foot movements.

Level/type 3c - Multistructural (interface + neural)

Piriformis SLR Test

Remember that the interface function changes with range of motion of hip flexion, ie. above and below 70°.

Below 70°, the piriformis is an external rotator.

1. Starting position 2. Knee extension

3. Internal rotation 4. Plantarflexion/inversion



Above 70°, piriformis is an internal rotator.

5. Substitute internal rotation with external rotation

Repeat with dorsiflexion instead of plantarflexion/inversion.

Piriformis Slump Test

In the slump position, perform the following movements in the following order:

‣ knee extension

‣ passive external rotation (stretches piriformis onto the sciatic nerve)

‣ check response - reproduction of symptoms etc

‣ differentiate if need to with foot (PFI or DF) and neck movements

‣ sometimes the neural and interface components can be distinguished

‣ release external rotation

- increase pain -> neural, decrease pain -> muscle

Piriformis slump test.



Heel PainAlias - plantar fasciitis, posterior tarsal tunnel syndromeMechanical Interface

Level 1


Ankle position - plantar flexion/inversion, adduction and pronation of the forefoot on the hindfoot.

Nerve component - use generic off-loading positions as for releasing tension along the whole tract.

Progression 2- dynamic opener

‣ Passive plantarflexion/inversion of ankle

‣ Adduction/pronation of forefoot on hindfoot

‣ Technique is important here.

‣ Do it in a plane that both opens the interface and reduces tension in the tibial nerve

Palpatory Techniques for the interface and nerve

DemonstrationLevel 2

Progression 1 - closers

Dorsiflexion/eversion/abduction/supination - gentle because it is a closer - monitor symptoms afterwards, as usual.

Neural - tibial nerve at the ankle

Level 1

Progression 1 - off-loader as a position

Sciatic nerve generic off-loader - rest foot in neutral or open position

Progression 2 - two-ended slider

Toe flexion + SLR, hold the ankle still, you can do this in sitting with the patient leaning forward of backwards or passively as an SLR.

Section 13 - foot/heel pain 21


Starting position

Hold the calcaneum so you can fixate the ankle joint.

Ankle joint should not move during the mobilsation

Do not press on the tibial nerve

PROXIMAL SLIDER – knee extension/toe flexion

DISTAL SLIDER

Hip and knee flexion/toe dorsiflexion

Level 2 - tensioner

Progression 1 - tensioner/slider relative to the tendons

Ankle/toe dorsiflexion with SLR/knee extension

Level/type 3c. Multistructural (interface + neural)

Closer moving the heel into abduction/eversion during a slider or tensioner.

Neural mobilisation and calf stretch- in long sitting slump, test length of gastrocs in/out of neck flexion, see the difference and compare with other side.

‣ do contract/relax in neural position

Section 13 - foot/heel pain 22


References

Abe Y, Doi K, Kawai S 2005 An experimental model of peripheral nerve adhesion in rabbits. British Journal of Plastic Surgery 58: 533-540

Beith I, Robins E, Richards P 1995 An assessment of the adaptive mechanisms within and surrounding the peripheral nervous system, during changes in nerve bed length resulting from underlying joint movement. In: Shacklock M (ed), Moving in on Pain, Butterworth-Heinemann: 194-203

Bove, G, Ransil B, Lin H-C, Leem J-G 2003 Inflammation induces ectopic mechanical sensitivity in axons of nociceptors innervating deep tissues. Journal of Neurophysiology 90: 1949–1955

Breig A 1978 Adverse mechanical tension in the central nervous system. Almqvist and Wiksell, StockholmButler D, Gifford L 1989 The concept of adverse mechanical tension in the nervous system. Physiotherapy 75 (11):

622-636Butler D 1991 Mobilisation of the Nervous System. Churchill Livingstone, EdinburghByrod G, Olmarker K, Konno S, Larsson K, Takahashi K, Rydevik B 1995 A rapid transport route between the

epidural space and the intraneural capillaries of the nerve roots. Spine 20 (2): 138-143Byrod G, Rydevik B, Nordborg C, Olmarker K. 1998 Early effects of nucleus pulposus application on spinal nerve

root morphology and function. European Spine Journal 7(6): 445-449Charnley J 1951 Orthopaedic signs in the diagnosis of disc protrusion. Lancet 1: 186-192Cleland J, Childs J, Palmer J, Eberhart S 2006 Slump stretching in the management of non-radicular low back pain:

a pilot clinical trial. Manual Therapy 11 (4): 279-286Coppieters M, Alshami A, Babri A, Souvlis T, Kippers V, Hodges P 2006 Strain and excursion of the sciatic, tibial,

and plantar nerves during a modified straight leg raising test. Journal Orthopaedic Research 24 (9): 1883-1889

Coppieters M, Alshami A, Hodges P 2006 An experimental pain model to investigate the specificity of the neurodynamic test for the median nerve in the differential diagnosis of hand symptoms. Archives of Physical Medicine and Rehabilitation 87(10):1412-1417

Coppieters MW, Alshami AM, Hodges P 2006 An experimental pain model to investigate the specificity of the neurodynamic test for the median nerve in the differential diagnosis of hand symptoms. Archives of Physical Medicine and Rehabilitation 87 (10):1412-1417

Coppieters M, Butler D 2008 Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application, Manual Therapy 13: 213–221

Coppieters M, Hough A, Dilley A 2009 Different Nerve-Gliding Exercises Induce Different Magnitudes of Median Nerve Longitudinal Excursion: An In Vivo Study Using Dynamic Ultrasound Imaging

Coppieters M, Kurz K, Mortenson T, Richards N, Skaret I, McLaughlin L, Hodges P 2005 The impact of neurodynamic testing on the perception of experimentally induced muscle pain. Manual Therapy 10 (1): 52-60

Coppieters M, Stappaerts K, Janssens K 2002 Reliability of detecting ‘onset of pain’ and ‘submaximal pain’ during neural provocation testing of the upper quadrant Physiotherapy Research International 7(3): 146–156

Coppieters M, Stappaerts K, Wouters L, Janssens K 2003 Aberrant protective force generation during neural provocation testing and the effect of treatment in patients with neurogenic cervicobrachial pain. Journal of Manipulative and Physiological Therapeutics 26 (2): 99-106

Coveney B, Trott P, Grimmer K, Bell A, Hall R, Shacklock M 1997 The upper limb tension test in a group of subjects with a clinical presentation of carpal tunnel syndrome. In: Proceedings of the Manipulative Physiotherapists’ Association of Australia, Melbourne: 31-33

Davis D, Anderson B, Carson M, Elkins C, Stuckey L 2008 Upper limb neural tension and seated slump tests: the false positive rate among healthy young adults without cervical or lumbar symptoms. Journal of Manual and Manipulative Therapy 16 (3): 136–141

Daniels T, Lau J, Hearn T 1998 The effects of foot position and load on tibial nerve tension. Foot and Ankle International 19 (2): 73-78

Dilley A, Lynn B, Pang S 2005 Pressure and stretch mechanosensitivity of peripheral nerve fibres following local inflammation of the nerve trunk. Pain 117 (3):462-472

Section 14 References 1


Eliav E, Benoliel R, Tal M 2001 Inflammation with no axonal damage of the rat saphenous nerve trunk induces ectopic discharge and mechanosensitivity in myelinated axons. Neuroscience Letters 311: 49-52

Ellis R, Hing W 2008 Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy. Journal of Manual and Manipulative Therapy 16(1): 8–22

Elvey 1979 Brachial plexus tension tests and the pathoanatomical origin of arm pain. In: Idczak R (ed.) Aspects of Manipulative Therapy. Lincoln Institute of Health Sciences, Melbourne: 105-110

Erel E, Dilley A, Greening J, Morris V, Cohen B, Lynn B 2003 Longitudinal sliding of the median nerve in patients with carpal tunnel syndrome. Journal of Hand Surgery 28B (5): 439-443

Greening J, Leary R 2007 Manual Therapy 2007 Jun 16 Letter to the Editor. Re: Improving application of neurodynamic (neural tension) and treatments: A message to researchers and clinicians M. Shacklock, 10 (3) (August 2005) 175-179

Farmer J, Wisneski R 1994 Cervical spine nerve root compression. An analysis of neuroforaminal pressures with varying head and arm positions. Spine 19(16): 1850-1855

Fazey PJ, Song S, Mønsås S, Johansson L, Haukalid T, Price RI, Singer KP 2006 An MRI investigation of intervertebral disc deformation in response to torsion. Clinical Biomechanics 21(5): 538-542

Flanagan M 1993 The normal response to the ulnar nerve bias upper limb tension. Master of Applied Science Thesis, University of South Australia

Gelberman R, Szabo R, Williamson R, Hargens A, Yaru N, Minteer-Convery M 1983 Tissue pressure threshold for peripheral nerve viability. Clinical Orthopaedics and Related Research 187: 285-291

Ginn K 1988 An investigation of tension development in upper limb soft tissues during the upper limb tension test. In: Proceedings of the International Federation of Orthopaedic Manual Therapists: 25-26

Greening J, Leary R 2007 Manual Therapy 2007 Jun 16 Letter to the Editor. Re: Improving application of neurodynamic (neural tension) and treatments: A message to researchers and clinicians M. Shacklock, 10 (3) (August 2005) 175-179

Greening J, Smart S, Leary R, Hall-Craggs M, O'Higgins P, Lynn B. Reduced movement of median nerve in carpal tunnel during wrist flexion in patients with non-specific arm pain. Lancet 1999; 354:217-218.

Grewal R, Varitimidis S, Vardakas D, Fu F, Sotereanos D 2000 Ulnar nerve elongation and excursion in the cubital tunnel after decompression and anterior transposition. Journal of Hand Surgery 25B (5): 457-460

Hall T, Zusman M, Elvey R 1998 Adverse mechanical tension in the nervous system? Analysis of the straight leg raise. Manual Therapy 3 (3): 140-146

Hough A, Moore A, Jones. M. Restricted excursion of the median nerve in carpal tunnel syndrome. Poster presentation, Manipulation Association of Chartered Physiotherapists conference, Edinburgh; 2005

Inufusa A, An HS, Lim TH, Hasegawa T, Haughton VM, Nowicki BH 1996 Anatomic changes of the spinal canal and intervertebral foramen associated with flexion-extension movement. Spine 21:2412-2420

Kenneally M, Rubenach H, Elvey R 1988 The upper limb tension test: the SLR of the arm. In: Grant R (ed), Physical Therapy of the Cervical and Thoracic Spine, Churchill Livingstone, New York

Kingery W, Park K, Wu P, Date E 1995 Electromyographic motor Tinel's sign in ulnar mononeuropathies at the elbow. American Journal of Physical Medicine and Rehabilitation 74 (6): 419-426

Kobayashi S, Shizu N, Suzuki Y, Asai T, Yoshizawa H 2003 Changes in nerve root motion and intraradicular blood flow during an intraoperative straight-leg-raising test. Spine. 28 (13):1427-34

Kornberg C, Lew P 1989 The effect of stretching neural structures on grade one hamstring injuries. Journal of Orthopaedic and Sports Physical Therapy 10 (12): 481-487

Laban M, MacKenzie J, Zemenick G 1989 Anatomic observations in carpal tunnel syndrome as they relate to the tethered median nerve stress test. Archives of Physical Medicine and Rehabilitation 70: 44-46

Lewis J, Ramot R, Green A 1998 Changes in mechanical tension in the median nerve: possible implications for the upper limb tension test. Physiotherapy 84 (6): 254-261

Levy L 1999 MR imaging of cerebrospinal fluid flow and spinal cord motion in neurologic disorders of the spine. Magnetic Resonance Imaging Clinics of North America 7 (3): 573-587

Lindquist B, Nilsson B, Skoglund C 1973 Observations on the mechanical sensitivity of sympathetic and other types of small-diameter nerve fibres. Brain Research 49: 432-435

Luchetti R, Schoenhuber R, Nathan P 1998 Correlation of segmental carpal tunnel pressures with changes in hand and wrist positions in patients with carpal tunnel syndrome and controls. Journal of Hand Surgery 23B (5): 598-602

Lundborg G, Rydevik B 1973 Effects of stretching the tibial nerve of the rabbit: a preliminary study of the intraneural circulation and barrier function of the perineurium. Journal of Bone and Joint Surgery 55B: 390-401



McLellan D, Swash M 1976 Longitudinal sliding of the median nerve during movements of the upper limb. Journal of Neurology, Neurosurgery and Psychiatry 39: 556-570

Maitland G 1986 Vertebral Manipulation, 5th edition. Butterworth Heinemann, LondonMarshall J Nerve stretching for the relief or cure of pain. British Medical Journal 1883; 1173-1179Mauhart D 1989 The effect of chronic ankle inversion sprain on the plantarflexion/inversion straight leg raise test.

Unpublished Graduate Diploma Thesis, University of South AustraliaMiller A 1986 The straight leg raise. Unpublished Graduate Diploma in Advanced Manipulative Therapy thesis,

University of South Australia.Morishita Y, Hida S, Naito M, Arimizu J, Matsushima U, Nakamura A 2006 Measurement of the local pressure of the

intervertebral foramen and the electrophysiologic values of the spinal nerve roots in the vertebral foramen. Spine 31 (26): 3076 –3080

Nakamichi K, Tachibana S 1995 Restricted motion of the median nerve in carpal tunnel syndrome. Journal of Hand Surgery 20B: 460-464

Neary D, Ochoa J, Gilliatt R 1975 Sub-clinical entrapment neuropathy in man. Journal of the Neurological Sciences 24: 283-298

Nee R, Yang C, Liang C-C, Tseng G-F, Coppieters M 2010 Impact of order of movement on nerve strain and longitudinal excursion: A biomechanical study with implications for neurodynamic test sequencing. Manual Therapy 15: 376-381

Olmarker K, Nordborg C, Larsson K, Rydevik B 1996 Ultrastructural changes in spinal nerve roots induced by autologous nucleus pulposus. Spine 21(4): 411-414

Olmarker K, Rydevik B, Nordborg C 1994 Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equina nerve roots. Spine 19 (20): 2369-2370

Pechan J, Julis I 1975 The pressure measurement in the ulnar nerve. A contribution to the pathophysiology of cubital tunnel syndrome. Journal of Biomechanics 8: 75-79

Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In Vivo MRI measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 2 - Comparison Between Unilateral and Bilateral Straight Leg Raise Tests.Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O. Spine Feb 5. [Epub ahead of print]PMID: 24503694 [PubMed - as supplied by publisher]

Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014 In vivo MRI Measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects: Part 1 - Straight Leg Raise Test. Spine Feb 5. [Epub ahead of print]PMID: 24503694 [PubMed - as supplied by publisher]

Read R 1991 Stress testing in nerve compression. Hand Clinics: Frontiers in hand rehabilitation. 7 (3): 521-526Rosenblueth A, Buylla A, Ramos G 1953 The responses of axons to mechanical stimuli. Acta Physiologica

Latinoamericana 3 (2): 204-215Rozmaryn L, Dovelle S, Rothman E, Gorman K, Olvey K, Bartko J 1998 Nerve and tendon gliding exercises and the

conservative management of carpal tunnel syndrome. Journal of Hand Therapy 11: 171-179 Rubenach H 1985 The upper limb tension test – the effect of the position and movement of the contralateral arm.

In: Proceedings of the 4th biennial conference of the Manipulative Therapists’ Association of Australia: 274-283

Rydevik B 1993 Neurophysiology of cauda equina compression. Acta Orthopaedica Scandinavica Supplement 251: 52-55

Saplys R, Mackinnon S, Dellon A 1987 The relationship between nerve entrapment versus neuroma. Complications and the misdiagnosis of de Quervain’s disease. Contemporary Orthopaedics 15: 51-57

Saranga, J, Green, A, Lewis, J, Worsfold, C 2003 Effect of a cervical lateral glide on the upper limb neurodynamic test 1: A blinded placebo-controlled investigation. Physiotherapy 89 (11): 678-684

Schmid A, Brunner F, Luomajoki H, Held U, Bachmann L, Künzer S, Coppieters M 2009 Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskeletal Disorders 10: 11 (http://www.biomedcentral.com/1471-2474/10/11)

Schuind F, Goldschmidt D, Bastin C, Burny F 1995 A biomechanical study of the ulnar nerve at the elbow. Journal of Hand Surgery 20B (5): 623-627

Selvaratnam P, Cook S, Matyas T 1997 Transmission of mechanical stimulation to the median nerve at the wrist during the upper limb tension test. In: Proceedings of the Manipulative Physiotherapists’ Association of Australia, Melbourne: 182-188



Selvaratnam P, Glasgow E, Matyas T 1988 Strain effects on the nerve roots of brachial plexus. Journal of Anatomy 161: 260-264

Shacklock M 1989 The plantarflexion inversion straight leg raise. Master of applied science thesis. University of South Australia, Adelaide

Shacklock M 1995a Neurodynamics. Physiotherapy 81: 9-16Shacklock M 1995b Clinical application of neurodynamics. In: Shacklock M (ed.) Moving in on Pain. Butterworth-

Heinemann, Sydney: 123-131Shacklock M 1996 Positive upper limb tension test is a case of surgically proven neuropathy: analysis and validity.

Manual Therapy 1: 154-161Shacklock M 1999a Central pain mechanisms; a new horizon in manual therapy. Australian Journal of

Physiotherapy 45: 83-92Shacklock M 1999b The clinical application of central pain mechanisms in manual therapy. Australian Journal of

Physiotherapy 45: 215-221Shacklock M 2005a Clinical Neurodynamics: a new system of musculoskeletal treatment. Elsevier, OxfordShacklock M 2005b Editorial: Improving application of neurodynamic (neural tension) testing and treatments: a

message to researchers and clinicians. Manual Therapy 10 (3): 175-179Shacklock M. Manual Therapy 2007 letter to the Editor, reply to Greening J, Leary R 2007Shacklock M, Wilkinson M 2000 Dynamics of the median nerve in the wrist and forearm with specific active and

passive movements of the upper limb and neck in the conscious human. Unpublished recordings, School of Medical Radiation, University of South Australia

Shacklock, M, Wilkinson M 2001 Can nerves be moved specifically? In: Proceedings of the 11th Biennial Conference of the Musculoskeletal Physiotherapists’ Association of Australia, Adelaide, Australia

Shacklock, M, Wilkinson M, Scutter S 2002 Dynamics of the median nerve at the elbow and posterior interosseous nerve during pronation and supination movements of the forearm. Unpublished recordings, School of Medical Radiation, University of South Australia

Shacklock M 2006 Van neuraler Spannung zu klinischer Neurodynamik - Neues System zur Anwendung neuraler Test - und Behandlungstechniken. Manuelle Therapie 10: 22-30

Slater H 1988 The effect of foot and ankle position on the ‘normal’ response to the SLR test, in young, asymptomatic subjects. Unpublished Master of Applied Science Thesis, University of South Australia

Takahashi K, Shima I, Porter R 1999 Nerve root pressure in lumbar disc herniation. Spine 24(19): 2003-2006Takahashi K, Kagechika K, Takino T, Matsui T, Miyazaki T, Shima I 1995 Changes in epidural pressure during walking

in patients with lumbar spinal stenosis. Spine 20 (24): 2746-2749Tsai Y-Y 1995 Tension change in the ulnar nerve by different order of upper limb tension test. Master of Science

Thesis, Northwestern University, ChicagoValls-Sollé J, Alvarez R, Nuñez M 1995 Limited longitudinal sliding of the median nerve in patients with carpal tunnel

syndrome. Muscle and Nerve 18: 761-767Wainner R, Fritz J, Irrgang J, Boninger M, Delitto A, Allison S 2003 Reliability and diagnostic accuracy of the clinical

examination and patient self-report measures for cervical radiculopathy. Spine 28 (1): 52–62 Werner C, Haeffner F, Rosén 1980 Direct recording of local pressure in the radial tunnel during passive stretch and

active contraction of the supinator muscle. Archives of Orthopaedic and Traumatic Surgery 96: 299-301Werner C, Ohlin P, Elmqvist D 1985 Pressures recorded in ulnar neuropathy. Acta Orthopaedica Scandinavica 56

(5): 404-406Wright T, Glowczewskie F, Wheeler D, Miller G, Cowin D. 1996 Excursion and strain of the median nerve. Journal of

Bone and Joint Surgery 78A (12): 1897-1903Yaxley G, Jull G 1991 A modified upper limb tension test: an investigation of responses in normal subjects.

Australian Journal of Physiotherapy 37 (3): 143-152Zochodne D, Allison J, Ho W, Ho L, Hargreaves K, Sharkey K 1995 Evidence for CGRP accumulation and activity in

experimental neuromas. American Journal of Physiology 268 (2/2): 584-90Zochodne D, Ho L 1991a Influence of perivascular peptides on endoneurial blood flow and microvascular resistance

in the sciatic nerve of the rat. Journal of Physiology 444: 615-630Zochodne D, Ho L 1991b Stimulation-induced peripheral nerve hyperemia: mediation by fibers innervating vasa

nervorum? Brain Research 12, 546 (1): 113-118Zochodne D, Ho L 1993 Vasa nervorum constriction from substance P and calcitonin gene-related peptide

antagonists: sensitivity to phentolamine and nimodipine. Regulatory Peptides 47 (3):285-90



Zochodne D, Huang Z, Ward K, Low P 1990 Guanethidine-induced adrenergic sympathectomy augments endoneurial perfusion and lowers endoneurial microvascular resistance. Brain Research 519 (1-2): 112-117

Zoech G, Reihsner R, Beer R, Millesi H 1991 Stress and strain in peripheral nerves. Neuro-Orthopaedics 10: 371-382

Zorn P, Shacklock M, Trott P, Hall R 1995 The effect of sequencing the movements of the upper limb tension test on the area of symptom production. Proceedings of the 9th biennial conference of the Manipulative Physiotherapists’ Association of Australia: 166-167



Section 11

Treatment MethodLecture

Working through a system of techniques

Treatment - working through a system of techniques

Note that the system of levels and types of examination applies to treatment in the same way that it does to examination.

SUMMARY OF TECHNIQUE SELECTION

General Principles

Observe symptoms at all times - before, during and after treatment

Reassess symptoms and physical signs - particularly neurodynamic status immediately after treatment, unless there is reason not to, such as to avoid provocation or undue focus on the problem. This includes neurological examination when appropriate.

Classify the dysfunction

Base treatment on the dysfunction category and level/type of examination

Avoid the words ‘stretch’ and ‘tension’ - I say ”this technique is designed to improve the function of the nerve”

Respect resistance - low, medium or high

Be extremely sensitive - because this forms the basis for close analysis between you and the patient so that treatment can be responsive and derived from the patient’s response.

Speed - slow and gentle

Amplitude - generally the movement should come back to the inner range each time so the mobilisations are usually medium to large in amplitude

Section 11 Treatment Method 2


Dosage/Repetitions - perform several movements then reassess symptoms at rest or some physical sign that is not irritated with reassessment. this may be performed up to several times in one treatment session, as long as there is some value in the technique.

Sometimes, at higher levels (2 and 3) treatment can evoke (or elicit) symptoms - but it should not provoke them. There is a difference. I use provoke to designate a more severe and long lasting response. Evoke suggests that symptoms have been triggered but more on an instantaneous basis rather than the response being long lasting.

Slider Techniques

Are particularly good for pain

Produce a lot of neural movement without producing much tension

Can be used reduce possibility of treatment soreness and settle symptoms down with advanced treatments

Section 11 Treatment Method 3


Section 12

TreatmentPractical/lab session

Neck and radicular pain

Brachialgia

Elbow pain

Neck and Radicular PainTreatment Progressions

Mechanical interface - reduced closing dysfunction

Level 1 (Limited) - Progression 1

Static opener

Indications:

• mainly distal symptoms• continuous distal symptoms• neurological changes• openers relieve the symptoms

Method

Place in open position - segmental localisation is preferable because it places less stress on neural and other structures than a generalised technique. Do not mobilise.

Degree of opening - depends on response to positioning

Section 12 Treatment - neck and radicular pain, brachialgia, elbow pain 2


Duration - 30-60 seconds at first. If better, repeat several times. If the same, still repeat once several and reassess at the next session. Can increase duration up to 15 mins as a home exercise after good effect is established, usually after a couple of sessions.

Lower cervical - more neck flexion, then contralateral lateral flexion and rotation

Upper cervical - less neck flexion, then contralateral lateral flexion

Range of motion and time are the key ingredients:

Level 1 - Progression 2

Dynamic opener

Monitor symptoms at rest and, if they improve, offer this position as a pain relief strategy.

Naturally, other treatments may be administered.

Dynamic opener for right side - contralateral lateral flexion



Level 2 - Standard

The main reason for the change in direction of the mobilisation (from opening to closing) is because the physiology in the nerve root has improved by now and we begin to treat the mechanical dysfunction (reduced closing). The nerve root should now be able to tolerate closing.

Dynamic closer

Is simply the reverse of the dynamic opener (closer for the ipsilateral side), except that the foramen is not specifically opened on the contralateral side.

Is gentle and monitored very closely. It is simply a similar technique as the opener but applied in the direction of ipsilateral lateral flexion.

Neural Tension Dysfunction

The IN and OUT are with respect to TENSION in the treated nerve root.

Contralateral and ipsilateral - which limb is used to produce the tension changes.

The following are pictures of the movement progressions but they are performed manually by the therapist



LEVEL 1

Progression 1 - Position OUT (ipsilateral)- Position OUT (contralateral)

Generic off-loader for the median nerve (applies to whole upper quarter)

Ipsilateral Contralateral

To reduce tension in the ipsilateral nerve root force must be applied to the contralateral.

Ipsilateral Limb:

‣ ipsilateral lateral flexion, if the closing will allow this‣ scapular elevation‣ shoulder adduction/internal rotation‣ elbow flexion, wrist and fingers comfortable

Contralateral Limb

‣ glenohumeral abduction/external rotation

‣ elbow extension

‣ wrist/finger extension if this is comfortable but these movements are often not necessary

‣ the contralateral test is performed as a TEST to ascertain if it will work. If so, proceed.

‣ hold for up to 10-15 seconds

‣ may need to do a neurological evaluation on the CONTRALATERAL side before and after performing the contralateral manoeuvre. This is to ensure that no neurological changes have developed in this limb.

‣ perform the test as a local sequence, ie. use the following sequence to focus the forces on the contralateral nerve root as opposed to the more distal part of the neural tract. This proximal sequence may be more likely to transmit forces to the ipsilateral nerve root

‣ contralateral scapular depression - gentle and small movement- glenohumeral abduction/external rotation



- elbow extension- wrist extension but this is often not necessary)

‣ may produce stretching in the contralateral limb but it should not produce pins and needles or other neurological symptoms

Progression 2 - Position OUT (ipsilateral)- Move OUT (contralateral)

Progression 3 - Position IN (ipsilateral) - Move OUT (contralateral)

Add some tension to the ipsilateral nerve root but move it out of tension. This effectively places the nerves in a slightly more loaded position before they are moved out of tension.

Ipsilateral abduction Contralateral movements

More ipsilateral abduction Contralateral elbow extension



Ipsilateral elbow extension Contralateral elbow extension

Add wrist extension Contralateral elbow extension

Progression 4 - Position OUT (contralateral) - move IN (ipsilateral)

Contralateral MNT1 Move ipsilateral MNT1

Add wrist extension



Progression 5 - Position IN (contralateral) - move IN (ipsilateral)

Move MNT1 Reduce protection - flex elbow

Add wrist extension

FINISH

LEVEL 2 - Standard Test

No assistance is provided by contralateral side now.

Ipsilateral side is moved INTO tension.



This is now level 2, standard testing

You now have a wide variety of techniques below level two that are not likely to

provoke symptoms.

LEVEL 3a - two-ended tensioner

Two-ended MNT1 tensioner - Contralateral lateral flexion, stabilize the scapula or depress it, elbow extension and wrist extension optional. Be sure to return the limb and neck to ipsilateral lateral flexion and elbow flexion between each mobilisation so as to reduce tension fully each time.



HERE IS THE PROCEDURE FOR SAFE TECHNIQUE

1. Test neurological function. If abnormal, this technique at level 3a is not recommended.

2. Position the patient comfortably.

3. Ask if the patient has any symptoms at rest. If “yes”, do NOT proceed. The problem may not be at level 3.

4. Explain that symptoms may occur and, if they do, they must only be mild at most. Generally reproduction of the patient’s clinical symptoms is to be avoided. Stretching sensations are common.

5.Perform a test movement to the first onset of symptoms.

5.1. make sure the patient moves slowly and carefully and that they learn to stop at the right place.

5.2. return to the starting position and check that any symptoms disappear instantly. If not, wait until they do. If they take more than a few seconds, it may be better to do something more gentle.

6. If this goes according to plan:

6.1. perform 3-5 movements the same way, making sure that the symptoms stop between movements.

6.2. return to the start position for at least a second or two each time a movement is performed.

7.Do NOT stay in the end range position for more than about one second.

8.Test the neurological status to be sure that it has not deteriorated. If a deterioration occurs, the technique is contraindicated.

Up to this point, the reduced closing dysfunction (interface) and neural tension dysfunction would have been treated separately, even though in the same session. Next, they can be combined (multistructural, level/type 3c).



Level/type 3b – Sensitised with Neurodynamic Sequencing (focused sequence)

Proximal-to-distal (local) sequence for the MNT1

Scapular stabilisation Contralateral lateral flexion

Abduction/external rotation - 90˚ Elbow extension/supination

Wrist and finger extension but t his is usually not necessary.



3c. Multistructural - Reduced Closing with Neural Tension Dysfunction

Localised closing at appropriate level

Add MNT1

Perform ILF and/or glide the neck contralaterally whilst performing a closing movement and the patient performs, elbow, wrist and finger extension.

A localised closing manoeuvre is (ILF) applied to the appropriate spinal segment and the MNT1 is executed by the patient.

Mechanical Interface - reduced opening dysfunction

General principles

The techniques for the reduced opening dysfunction actually are similar in some respects to the closing techniques. They start with dynamic openers, since static openers are likely to provoke symptoms. They commence early in the range and progress to the outer range. Generally, lateral flexion is the movement of choice but rotation can also be used.



Level 3c - Multistructural - Reduced Opening with Neural Tension Dysfunction

Emphasis can be placed on:

Neural Tension Dysfunction and Cervical Joints

The cervical joints are mobilized by using the contralateral hand whilst the scapula is stabilized by the other. The patient performs or holds the MNT1,. Here the force is directed through the contralateral spinal segment toward the correct level. This opens the ipsilateral segment.

Neural Tension Dysfunction and Neck Muscles HyperactivityUpper trapezius and levator scapulae

Here the scapula is stabilised and an upper trapezius stretch is performed whilst the patient maintains extension in the MNT1 position.

Levator scapulae

-flexion

- contralateral lateral flexion

- contralateral rotation

- contract/hold relax, then move nerve when muscle relaxes

Upper trapezius

- flexion

- contralateral lateral flexion

- ipsilateral rotation

- contract/hold relax, then move nerve when muscle relaxes

Sliders -for many types of problemsSliders can be used to relieve pain and improve dynamics in the nervous system at all levels of problem:

• reduce pain at level 1

• reduce treatment soreness between or after treatment at higher level (2, 3)

• do not produce much tension in the nervous system so they are particularly safe

Level 1 - Progression through the levels (continued) - sliders as an option

SlidersThere are two ways of performing the slider, with a. lateral flexion and b. lateral translation.

NEURAL SLIDERS WITH LATERAL TRANSLATION OF CERVICAL SPINE

Proximal- contralateral translation- elbow flexion- wrist flexion

Distal- ipsilateral translation- elbow extension- wrist extension

SLIDERS WITH LATERAL FLEXION

Proximal- contralateral lateral flexion- elbow flexion- wrist flexion

Distal- ipsilateral lateral flexion- elbow extension- wrist extension



Brachialgia/brachial plexusTreatment progressions


Classify the disorder in terms of opening or closing dysfunctions (reduced or excessive).

Level 1


Position – painful side up, scapular elevation/protraction to increase the distance between the clavicle and first rib.

Progression 2 - dynamic opener

As above as mobilisation

Small amplitude and within symptoms

Can emphasize different components - elevation or protraction

The patient can perform this as a home exercise.

Level 2 - dynamic closers

Position - as for opener

Mobilisation - scapular depression/retraction/posterior rotation.

Section 12 Brachialgia/brachial plexus 15


Opener (costoclavicular space) with Rib Mobilisation and Neural Slider

Breathing (opening and closing) is coordinated with neural sliders

Aim – to improve the dynamics and muscle control around the thoracic outlet in the presence of neurodynamic movements.

Starting position - caudad mobilisation for the first rib is performed with the patient performing components of the MNT1.

Opener + distal slider

Using MNT1 – exhale and depress first rib, elbow extension, ipsilateral lateral flexion.

NeuralLevel 1

Progression 1 - static off-loader

Position as for interface progression 1 and generic off-loader for the brachial plexus.



Progression 2 - two-ended slider

A) Median nerve

Position - 45° shoulder abduction, scapula stabilized,

Proximal Slider

- contralat. lat. flex./Elb. flex Distal slider – ipsilat. lat. flex./Elb. ext.

‣ perform as a wide amplitude without provocation‣ no scapular depression‣ short of symptoms or minimal symptoms

B) Ulnar nerve

As above except use:

Proximal slider – Elbow extension/contralateral lateral flexion

Distal slider - Elbow flexion/ipsilateral lateral flexion

Level 2

A. Median Nerve – two-ended tensioners

Progression 1

Position

• neck in neutral• arm in approx. 45° abduction or whatever is comfortable for the patient• elbow flexion 90˚• wrist in neutral

Movement

• Elb. ext./contralat. lat. flex.. Make the movement large in amplitude and return to the off-loaded position



Progression 2

Position‣ neck in neutral, stabilise scapula‣ 90° abduction or whatever is comfortable for the patient‣ elbow flexion 90˚‣ wrist in neutral

Movement – Elbow extension, contralateral lateral flexion.

Make the movement large in amplitude and return to the off-loaded position. Go into a reasonable range without provoking symptoms.

B) Ulnar Nerve – tensioners

Same as the MNT1 neurodynamic techniques except the elbow extension is swapped for elbow flexion.

Progression 1

Position‣ neck in neutral‣ arm in approx. 45° abduction or whatever is comfortable for the patient‣ elbow flexion 90˚, forearm comfortably pronated‣ wrist in neutral

Movement – Elb. flex/contralat. lat. flex. Make the movement large in amplitude and return to the off-loaded position

Progression 2

Position‣ neck in neutral‣ arm in approx. 90° abduction or whatever is comfortable for the patient‣ elbow flexion 90˚, forearm comfortably pronated‣ wrist in neutral

Movement – Elb. flex/contralat. lat. flex.. Make the movement large in amplitude and return to the off-loaded position

Level/type 3a - Neurodynamically Sensitised

A. Median Nerve

Position‣ neck in neutral‣ gentle scapular depression if so desired‣ 90° shoulder abduction‣ elbow extension 90˚ (with supination)‣ wrist and finger extension

Movement - Elb. ext./contralat. lat. flex.

B) Ulnar Nerve

Use elbow flexion, pronation and wrist and finger extension and contralateral lateral flexion



lateral elbow pain – supinator tunnel syndrome › @bin... · lateral elbow pain – supinator...

Documents