Medial elbow pain is a common complaint in throwing athletes (eg, baseball players) and is often treated conservatively with electrical modalities, therapeutic exercises, nonsteroidal anti-inflammatory drugs, and cortisone injections.1,2 Patients who present with medial elbow pain are often diagnosed as having medial epicondylitis, even when associated neurological symptoms are present.1,2 Elbow pain occurs in 1% to 2% of the population, but 80% of the time the condition results from chronic and reoccurring causes.2 In these cases, the use of neurodynamic nerve sliders may be indicated as an intervention.3 The current case review describes a collegiate baseball pitcher who reported medial elbow pain and was treated successfully with median and ulnar neurodynamic sliders.
A 22-year-old male collegiate baseball player presented with the primary complaint of right medial elbow pain. He rated his current pain a 6 of 10 on the Numeric Pain Rating Scale (NPRS), whereas he reported his best pain score a 3 of 10 and his worst pain score a 7 of 10.4 The initial observation revealed inflammation over the medial epicondyle and the flexor group at the medial elbow. The patient indicated he first experienced pain and tingling sensations after a normal pitching practice approximately 7 months earlier. His symptoms were intermittent and minor until the 2017 baseball season, during which the symptoms increased and became more consistent. The symptom increase occurred when the number of pitches in a single practice, and the number of innings he pitched, increased from the previous season. The patient also reported a tingling sensation on the ulnar side of his forearm down the fifth metacarpal that arose 5 minutes after his pitching session ended.
During the physical examination, the patient was tender to palpation on the involved right muscle belly and common flexor tendon of his medial forearm and elbow (ie, flexor carpi radialis, pronator teres, and flexor carpi ulnaris) and reported a 6 of 10 on the NPRS with palpation. The patient's active and passive range of motions were within normal limits and equal bilaterally through extension, flexion, pronation and supination of the elbow, wrist, and fingers. However, the patient reported experiencing pain and neurological symptoms with finger and wrist flexion. He rated both motions on the NPRS as a 5 of 10 actively and 7 of 10 passively. Valgus and varus stress tests at the elbow were negative for pain and laxity. Manual muscle testing results were within normal limits.
During the neurological examination, his dermatome assessment was normal; however, testing the C6 and C7 myotomes recreated the patient's reported tingling sensation and presented with weakness.5 In addition, the clinician performed an upper limb neurodynamic test of the median and ulnar nerves, and both tests reproduced his pain and tingling sensation. The “Golfer's Elbow” test also reproduced his radicular symptoms (8 of 10 on the NPRS). Based on the evaluation, the patient was diagnosed as having medial epicondylitis, with associated positive neural tension tests of the median and ulnar nerves.
The patient was prescribed a treatment protocol using neurodynamic sliding techniques for the median and ulnar nerves, without the use of anti-inflammatory medications. The patient was permitted to continue baseball activities as tolerated. The patient did continue to perform TheraBand (Theraband, Akron, OH) exercises that were part of his regular pitching routine, but the only intervention was the use of neurodynamic sliders. Before treatment, the Disablement in the Physically Active Scale (DPAS) and the Patient Specific Functional Scale (PSFS) were administered. The PSFS was administered daily and at discharge, whereas the DPAS was administered before treatment and at discharge.
The DPAS is an outcome measure to assess the disablement experienced by physically active patients with musculoskeletal injuries across four domains: impairments, functional limitations, disability, and quality of life.6 The questionnaire has 16 items that the patient rates from 1 (not a problem) to 5 (severe problem) and the total score ranges from 0 to 64.6 A score of 64 on the DPAS indicates severe disability, whereas 0 indicates no disability. The PSFS is a self-reported, patient-specific measure to assess specific activities on a 0 (unable to perform activity) to 10 (able to perform activity at the same level as before injury or problem) scale.7 The final score on the PSFS is produced by the sum of the activities divided by the number of activities.7 The patient rated the top three activities he had difficulty performing due to his condition, which included acceleration, deceleration, and release of the baseball. The patient's initial DPAS score was a 31 and the PSFS score was a 4.3.
The treatment protocol began with the patient completing two sets of 10 repetitions of median and ulnar sliders.8 The median slider was performed by the patient in a standing position with arm supination and slight elbow flexion, with slight external rotation of the wrist as if he was checking his watch (Figure 1).8 The patient was instructed to flex his neck toward his watch at a slow pace. The ulnar slider was performed in a standing position with the shoulder in abduction and external rotation. Then, the patient flexed his elbow and extended his wrist while rotating his neck toward the involved side (Figure 2).8 In addition to performing the sliders in the clinic, the patient also completed two sets (10 repetitions) once a day as part of a home program.
Example of median slider at (A) starting position and (B) finishing position.
Example of ulnar slider at (A) starting position and (B) finishing position.
After 6 consecutive days of treatment (clinic and home program) and participation in sport as tolerated, the patient reported a resolution of his primary pain complaint (pain was rated 0 of 10 on the NPRS for current, best, and worst). Physical examination revealed resolution of his reported tenderness to palpation, negative findings on all previously positive special tests, and normal findings on his neural tension test and myotomes. The patient also indicated recovery on the DPAS (6 of 64) and the PSFS (10 of 10) (Table 1). Based on the examination findings and patient-reported outcomes, the patient was discharged from care and continued to participate fully in athletic activities.
Results of Patient Outcomes During Treatment Sessions
The patient returned to the clinic for a follow-up examination at 1 week, 1 month, and 3 months after discharge. The follow-up physical examinations and patient-reported outcome findings (NPRS, DPAS, and PSFS) revealed continued maintenance of the patient's improvement. The patient decided to continue performing the neurodynamic slider treatment protocol as an injury prevention program and as part of his warm-up routine.
Currently, a “gold standard” treatment plan for medial epicondylitis with neurological symptoms does not exist. A systematic review was conducted that included several studies assessing different types of conservative treatments for epicondylitis and tendinopathy pain, including therapeutic exercises, therapeutic ultrasound, topical patches, and injection therapy.1 Therapeutic exercises produced an average of 25% to 60% improvement in patient symptoms using a twice-a-day regimen for 12 weeks.1 However, corticosteroid injection did result in a small, positive short-term effect, but the use of these drugs also included long-term negative effects, such as the potential for tendon rupture.1
Current research on the use of neurodynamic techniques for the upper extremity, specifically median and ulnar sliders, is primarily limited to carpal tunnel syndrome.9 In one case series, 18 patients were successfully discharged after 1 week of treatment and decreases in pain,9 but the patients did not remain symptom free at the 1-week follow up.9 The authors identified only one case study that used median, radial, and ulnar sliders for elbow tendinopathy.10 That patient was successfully discharged after five treatment sessions during a 6-week period and remained symptom free at the 3-month follow-up visit.10 Research on using neurodynamic techniques for the treatment of lower extremities is sparse. A case review on peroneal sliders indicated that neurodynamic techniques effectively treated pain in patients with medial tibial stress syndrome,11 whereas a case series on sciatic sliders indicated that neurodynamic techniques improved hamstring muscle group extensiblity.11,12
The relationship between the biomechanics and physiology of the nervous system is neurodynamic.13 Neural tension tests examine specific neurologic segments and indicate neurodynamic interventions.8 Neurodynamic techniques are used to treat neuromusculoskeletal pain and restore the function of the neural structures and non-neural structures (eg, muscle and fascia).11,13,14 The neurodynamic techniques are applied as passive or active movements and incorporate a sliding or tensioning component.14 Sliders and tensioners are a combination of movements that occur at both ends of the nerve. The tensioner technique will cause the nerve to move in opposite directions, and sliders will cause the nerve to move in the same direction.11,14 Sliders were recommended for the patient in the current study because they have the least chance of increasing symptoms. Application is intended to restore the ability of the nervous system to tolerate compression, friction, and tensile forces associated with daily and sport activities.13
The current case review is unique in that neurodynamic techniques have not been previously incorporated into the treatment of a baseball pitcher with medial elbow pain in the available literature. The case study also supports previous research for neurodynamic sliders successfully decreasing pain associated with elbow tendinopathy.10 Both the current case and previous research provide preliminary evidence that neurodynamic techniques can result in a rapid resolution of pain, range of motion impairment, and disablement. Furthermore, positive results can be lasting, with return to sport and/or activities of daily living.
Implications for Clinical Practice
Incorporating neurodynamic techniques may provide a less invasive and more efficient alternative treatment intervention for treating medial epicondylitis when indicated by clinical examination findings. Clinicians diagnosing patients as having medial epicondylitis should perform a neurological examination to identify possible neurological symptoms or tension supporting the inclusion of these techniques.
Patients diagnosed as having medial epicondylitis are often treated with several intervention strategies, with inconsistent or unsatisfactory results. Neurodynamic techniques have been found to successfully treat both upper and lower extremity musculoskeletal conditions. This case review supports using a neurodynamic examination and treatment for patients reporting with medial elbow pain with neurological symptoms who meet the criteria to be diagnosed as having medial epicondylitis. Future research should be conducted comparing neurodynamic techniques to other commonly used interventions in patients who present with complaints common in patients diagnosed as having medial epicondylitis.
- Ackermann PW, Renström P. Tendinopathy in sport. Sports Health. 2012;4:193–201. doi:10.1177/1941738112440957 [CrossRef]
- Ellenbecker TS, Nirschl R, Renstrom P. Current concepts in examination and treatment of elbow tendon injury. Sports Health. 2013;5:186–194. doi:10.1177/1941738112464761 [CrossRef]
- Shacklock M. Neurodynamics. Physio. 1995;81:9–15.
- Farrar JT, Pritchett YL, Robinson M, Prakash A, Chappell A. The clinical importance of changes in the 0 to 10 numeric rating scale for worst, least, and average pain intensity: analyses of data from clinical trials of Duloxetine in pain disorders. Pain. 2010;11:109–118. doi:10.1016/j.jpain.2009.06.007 [CrossRef]
- Prentice WE. Principles of Athletic Training: A Competency-Based Approach, 14th ed. New York: McGraw-Hill Higher Education; 2011.
- Vela LI, Denegar C. Transient disablement in the physically active with musculoskeletal injuries, part I: a descriptive model. J Athl Train. 2010;45:615–629. doi:10.4085/1062-6050-45.6.615 [CrossRef]
- Horn KK, Jennings S, Richardson G, Vliet DV, Hefford C, Abbott JH. The patient-specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther. 2012;42:30–42. doi:10.2519/jospt.2012.3727 [CrossRef]
- Butler D. The Neurodynamic Technique: A Definitive Guide from the Noigroup Team. South Australia: Noigroup Publication; 2008.
- De-la-Llave-Rincon AI, Ortega-Santiago R, Ambite-Quesada S, et al. Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome. J Man Physio Ther. 2012;35:420–427. doi:10.1016/j.jmpt.2012.06.002 [CrossRef]
- Matocha MA, Baker RT, Nasypany AM, Seegmiller JG. Effects of neuromobilization on tendinopathy: part II. Int J Athl Ther Train. 2015;20:41–47. doi:10.1123/ijatt.2014-0097 [CrossRef]
- Hansberger BL, Nasypany A, Baker RT, May J. Incorporating neurodynamics in the treatment of lower leg pain: a case review. Athletic Training & Sports Health Care. 2016;8:36–39. doi:10.3928/19425864-20151207-01 [CrossRef]
- Castellote-Caballero Y, Valenza MC, Puentedura EJ, Fernández-De-Las-Peñas C, Alburquerque-Sendín F. Immediate effects of neurodynamic sliding versus muscle stretching on hamstring flexibility in subjects with short hamstring syndrome. J Sports Med. 2014;1–8. doi:10.1155/2014/127471 [CrossRef]
- Nee RJ, Butler D. Management of peripheral neuropathic pain: integrating neurobiology, neurodynamics, and clinical evidence. Phys Ther Sport. 2006;7:36–49. doi:10.1016/j.ptsp.2005.10.002 [CrossRef]
- Coppieters MW, Butler DS. Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13:213–221. doi:10.1016/j.math.2006.12.008 [CrossRef]
Results of Patient Outcomes During Treatment Sessions
|Day 1 (initial evaluation)||7 of 10||4 of 10||4.3 of 10||31 of 64|
|Day 6 (discharge)||0||0||10||6|
|Week 1 follow-up||0||0||10||0|
|Month 1 follow-up||0||0||10||0|
|Month 3 follow-up||0||0||10||0|