A physiotherapy program will typically combine exercise and elbow manipulation (manual therapy). Various techniques may be used, including those described here.
Figures 1(a) and 1(b) below demonstrate a forearm muscle exercise for the wrist extensor muscles. The exercise involves the application of load while the muscle gradually contracts and moves the wrist from flexion to extension and back to flexion.
Starting and ending flexed position – do not go to end of range. Note elbow is flexed and forearm is supported. The other end of the elastic band is fixed by the patient’s foot or other hand.
Note elbow is flexed and forearm is supported. The other end of the elastic band is fixed by the patient’s foot or other hand.
Extended position mid-point of exercise – the target. Note elbow is flexed and forearm is supported on bench.
Note elbow is flexed and forearm is supported on bench.
To perform the exercise: start with the wrist in a flexed position, then move through the range of extension over 4 seconds and then return to a flexed position over 4 seconds. Load is applied using a resistance band or small weight.
The exercise should be supervised f or the first 6–8 weeks to ensure the right load is used and the correct movement/form is performed, and that the load and degree of difficulty is progressed.
Exercise should not provoke pain beyond 2 out of 10 on a scale where 10 is the worst pain imaginable and 0 is no pain. Where moving the wrist through flexion and extension provokes pain, the patient can start with a static (or isometric) wrist extensor exercise demonstrated in Figure 2. Here, without bending the wrist, the patient resists downward pressure applied (by the other hand, physiotherapist or GP).
Patient performing isometric exercise by using the other hand. Make sure to have the wrist in some extension.
Make sure to have the wrist in some extension.
Duration, frequency and progression
In the first 2 weeks, the patient should exercise twice daily, doing 12–15 repetitions. From 2 to 6 weeks, the patient should perform the exercise once daily, doing three sets of 8–12 repetitions on both arms. From 6 weeks onward, the load can be progressed and the patient performs three sets of 6–8 repetitions every other day (if the patient’s strength is nearing 80% of the unaffected side).
If the patient has time, other exercises can be used such as gripping exercise putty, or supination and pronation exercises as shown in Figure 3 and Figure 4. Patients who perform repetitive tasks in their day-to-day work should be specifically assessed for individualised exercises for those tasks once their strength improves (to approximately 90% of the unaffected side).
Resisted supination start position, moving to supination and then back to this neutral position.
A progression can be to start in a more pronated position.
Resisted supination exercise (at mid-position of supination), with forearm supported on bench.
Resisted pronation: starting in supination the patient pronates the forearm, holding onto the elastic band with the other hand. Forearm is supported on bench.
Elbow manipulation (manual therapy)
Two techniques used are the ulnar-humeral lateral glide (Figure 5) and radial head posteroanterior glide (Figure 6).
Ulnar-humeral lateral glide: this involves lateral elbow mobilisation with movement.
If significant improvement in pain-free grip is observed, repeat the technique for a total 6 to 10 repetitions. A belt may be used to assist with the glide.
Radial head posteroanterior glide: while the patient performs (and relaxes) their painful action (e.g. gripping), a posterior to anterior glide over the radial head is applied and sustained.
If significant improvement in pain-free grip is observed, repeat the technique 6 to 10 times.
See Training for additional instructions.