Epicondylitis and Cervical Radiculopathy

Have you ever had a patient or client with unrelenting medial or lateral epicondylitis?  Someone that has had symptoms off and on for months, maybe even years?  I think we all have.  I learned a long time ago after I was frustrated with my first few epicondylitis patients that many times epicondylitis is actually being caused by cervical radiculopathy.

A new study published in the journal Sports Health sought to estimate the actual prevalence of medial epicondylitis among patients with cervical radiculopathy.  The authors evaluated 102 patients with documented cervical radiculopathy and found that more than half (55 to be exact) also had medial epicondylitis.  None of these patients had a documented cause of the epicondylitis.  The vast majority (80%) of these patients had C6 and C7 radiculopathy, the remaining 20% had C6 radiculopathy.

These findings make a good argument for radiculopathy being a potential cause of epicondylitis and I think that the results can be extrapolated for lateral epicondylitis.  If muscle weakness or imbalance occurs to the wrist extensors and flexors, which are innervated by C6 and C7, overuse and eventual tendonopathy are likely to occur.  This could be a very large reason why epicondylitis has traditionally been such a challenging pathology to treat.  We can treat the symptoms but will not make any lasting gains without treating the source – the neck.

Based on this, I would suggest that we all make it standard practice to clear the cervical spine when we are evaluating patients with epicondylitis.

The results of the study are very interesting and make sense clinically.  There is a limitation of the study that should be mentioned.  The authors evaluated the percentage of patients with cervical radiculopathy that also had medial epicondylitis.  I am actually more interested in the reverse, the percentage of medial epicondylitis patients that have cervical radiculopathy.  But, a good study nonetheless.

What do you think?  Have you noticed a correlation between epicondylitis and cervical radiculopathy?

 

 

Photo credit

22 replies
  1. Stacey
    Stacey says:

    I had tennis elbow and had 2 tears in my tendon. Had surgery June 1, 2017. Woke up in recovery in agonizing pain. It wasn’t the normal amount of pain it should have been. I relate it to a trauma. Since then I have had horrible shoulder pain. Went to nerve specialists. Says c4-5 moderate spondylitis foraminal stenosis. Had ZERO neck or shoulder pain prior to surgery. Thoughts ? Seeing a spine specialist soon.

  2. Pamela Jackson
    Pamela Jackson says:

    I am fused from the brainstem through the C8 nerve. 3 weeks ago I feel a weird sensation goe down my arm. Then it started the most incredible unbearable pain i have ever had.i have a central disc 3mm bone spur sitting on the C8 nerve. They did an emergemcy epidural on the C8 nerve helped temporarily now the pain is back with a vengeance. I saw a Neurosurgeon that said i had rediculopathy and epicondylitis . He stated i go back in my neck collar , stay on my meds. Do traction twice a day. The pain is still unbearable. Can’t get away from it. I am also to see an Ortho to get steroid injections for relief
    Don’t know how much more pain I can stand any suggestions ?

  3. Sandra
    Sandra says:

    I found this after looking for information regarding my severe right elbow pain. Without going into my entire life story of chronic osteoarthritis, I will give you my most recent problem. I am 44 yo female. I had a Cervical ACDF at C6/C7 in 2008. In 2010, my C5/C6 started acting up (as was expected). Over the last 3 years I have had every treatment available to me to quiet the pain in my neck, everything except Rhizotomy which was denied by my insurance. Now, beginning in November 2013 just after a facet injection (bilateral), my right arm began screaming with pain. It begins just below my bicep, down through my elbow into the thumb and index finger. One more facet injection, no help. MRI on 12/30 – herniated C5/C6 abudding C6 nerve root. I am unable to barely lift a cup of coffee and is painful to answer my office phone. I am waiting for insurance pre-auth for EMG which my Pain Mgmt. Dr. says will definitively tell me if the pain is from my neck or if this pain is Tennis Elbow (which I don’t believe it is). I would think, that after all I’ve been through surgery would be next in my future. I am have been trying all means to avoid another surgery, but I think I am running out of options. I am on 5mg oxy / 4 times a day and muscle relaxers. Last week Friday, they prescribed a compression brace, and Lidocaine patches for my arm, which are barely touching it. I think we are on the right track and interestingly I found this article – sounds like me to a “T”. Thank you.

  4. Bernie
    Bernie says:

    I had a accident where my C5/6 and C 3/4 was damaged with disc herniation .After more than one year , I have left (Seatbelt ) thoracic outlet syndrome and now on the right the tennis elbow .I don’t play tennis , and I am left hand ). The problem is , that it change the pain from today to tomorrow from the elbow to the neck .So I think the Tennis elbow is miss diagnostic and my neck is the problem.

  5. KenpStack
    KenpStack says:

    The longer I practice physical therapy the more I appreciate a proximal cause if not outright pain generator. Have always viewed screening the spine a necessity for many extremity complaints.

  6. S Conrad DC
    S Conrad DC says:

    I have treated upper extremity issues along with cervical spine for years with great success. Review text book “Disorders of the Cervical Spine” by John H. Bland MD pages 210-211. This text book is from 1987.

  7. Anonymous
    Anonymous says:

    Look for research on "double crush syndrome". The concept of proximal nerve irritation (even if subclinical) cause cause a distal nerve to be more excitable (ie. painful). Cool stuff.

  8. Kelly R. Hutson, D.C.
    Kelly R. Hutson, D.C. says:

    " many of the "traditional" therapists particularly DCs who rely upon the subluxation model to treat certain areas without a strong or supportable rationale."

    As a practicing chiropractor, I couldn't agree with you more. Then again, any DC who wasn't interested in learning more and getting better at what we do wouldn't be found on this forum.

  9. Dr. Seth
    Dr. Seth says:

    Theoretically, the relationship is highly agreeable. NOW, how to properly mobilize/stabilize is much more challenging. Do you start changing alignment in the pelvis? The feet? Let's just take C6-7 as an example. It's a transition zone, so particularly prone to dysfunction. MET to correct T-spine? MFR to the ground substance? Manips? (too bad I live in WA).

    I personally look at the pelvis first w/ almost all of my spine/referred pain patients. The whole foundation is important to me. What do you guys think?

  10. Carson Boddicker
    Carson Boddicker says:

    Harrison,

    I agree largely with your assertions regarding the chiropractic and PT communities. I have gone beyond the letters, and if you do good work and can support your rationale with some solid thinking and a little bit of evidence, I don't really care how you get it done. The issue I've seen, however, is that many of the "traditional" therapists particularly DCs who rely upon the subluxation model to treat certain areas without a strong or supportable rationale.

    The c-spine is an incredibly vital piece of the good movement equation.

    Regards,
    Carson Boddicker

  11. Harrison Vaughan, PT, DPT, Cert. SMT
    Harrison Vaughan, PT, DPT, Cert. SMT says:

    To add to my prior response, I do think it is the clinician's responsibility to open up the differential diagnosis to consider entrapments proximal to the current site. It may not be purely neurogenic at times, but we should keep in mind the 'double crush' syndrome. We typically do not see the patient in time anyway until multiple regions are affected making this more reasonable.

    Based on the anonymity response concerning chiropractors and physical therapists' background in origin of symptoms, I do think we (most of us are PTs) should respect that DCs have been around for awhile and are typically "chosen" before us for musculoskeletal care (back and neck pain mainly). So, maybe they are on the right track with their treatments…
    …however, I do not think they are always on the right track with diagnosis concerning subluxations, adjustments, things out of place, etc. This may actually open up a whole different discussion (sorry if it does Mike!)

  12. Jess
    Jess says:

    Mike-
    I definitely see this trend and also usually treat both entrapments, especially with my golfers. Many of my patients have chronic facet and possibly disk issues in addition to repetitive "elbow" itis.

    I have had a lot of success after treating C/T junction. I see significant grip test gains and reduction in elbow symptoms. This is with most of my patients presenting with both symptoms (often undiagnosed radic symptoms fitting the radic cluster that were referred for elbow tendonopathy).

    Of course following this with improving thoracic mobility and scap / cervical stab is essential for "elbow" patients. Thanks for the great post!

  13. Mike Reinold
    Mike Reinold says:

    Hard to create a lot of dialogue with so many “anonymous” posters…

    @Anony2 – Traction would be helpful and is one of the few treatments with some efficacy for radiculopathy. How soon would depend on the extent and severity, could vary.

    @Anony3 – Can he stand at work?? Kidding… Posture education, if no resolution with tx – back to doc, thay may want to start steroid dose pack or give injection.

    @Christie Downing – I still think this is medial epicondylitis, but secondary to the neck. The epi is real and likely from overuse of weakened muscles. You need to treat the elbow, but if you don’t treat the neck too, the elbow wont get better. Similar to secondary impingement of the shoulder, you still treat the impingement but need to work on the cause of results wont last.

    @Nicolas – agree with your references

  14. Nicolás Sepúlveda
    Nicolás Sepúlveda says:

    Humbly, i would suggest reading Mulligan's Manual Therapy and the masterclass by Prof. Bill Vicenzino "Lateral epicondilalgia: a musculoskeletal physiotherapy perspective" Man. Ther. 2003;8(2):66-79. In both of those documents they explain the techniques and the rationale behind the movilizations of the cervical spine or the elbow. I've had really good results with this approach plus eccentric exercise!

  15. Christie Downing, PT, DPT, Dip. MDT
    Christie Downing, PT, DPT, Dip. MDT says:

    So Mike…

    Do you think these are "true" cases of medial epicondylitis…or simply misdiagnosis? I would argue that the latter is more common…

  16. Anonymous
    Anonymous says:

    Interesting you bring up this issue, i currently have a patient with a diagnosis of medial epicondylitis. He did not respond to PT/OT for 4 months, MRI of the elbow later confirmed the above dx. After discussing this dx with the referring MD, i suggested that he get an EMG to rule-out C-spine involvement. Sure enough he had a C6-C7 radiculopathy on that side and some mild atrophy in the hyperthenar eminence. I started some nerve glides and STM to UT/Levator/Scalenes and manual traction. FYI, he only gets his pain/paresthesias while sitting at PC at work. Any other ideas?

  17. Anonymous
    Anonymous says:

    I find it interesting that if a PT says "clear the cervical spine" for an elbow condition – it is generally well perceived. If a chiropractor does this…well that's just the dogma based on the claim that all disease emanates from the spine. Unfortunately this issue of cultural authority is a boundary for far too many people, specifically patients.

    ALL peripheral entrapment presentations should be evaluated this way…it only makes sense to check the entire path of the involved nerve.

    Rarely will there be any somatic dysfunction without some component of soft tissue dysfunction. While SMT can have anti-spastic effects, as well as modulation of the afferent input – without some muscle therapy there is a considerable chance the issue will return to some degree.

  18. Harrison Vaughan, PT, DPT, Cert. SMT
    Harrison Vaughan, PT, DPT, Cert. SMT says:

    You're right Mike. I do think the cervical spine is highly involved in not only elbow pain but carpal tunnel and more often than not co-exists with shoulder pain. This is also true for the low back and knee pain, etc.

    Cause and effect treatment (work on the neck and bam, no symptoms…its the neck!) works well with these type of "uncertain" diagnoses to determine the origin of symptoms. It clears the clinician's mind that he/she covered all bases and the patient usually feels more comfortable too.

  19. Anonymous
    Anonymous says:

    So would you prefer to add manual or mech. txn if it is true rad. pain from the cx spine? How soon would you expect to see benefit from removing the stressor – that visit, or next visit? I assume if it's really chronic it will take a little while to calm the inflamm. tissue down.

  20. Anonymous
    Anonymous says:

    I think you miss a huge piece of the puzzle if you are not screening the spine with peripheral, overuse injuries. Whether its epicondylitis of the elbow or a patellofemoral disorder, you should always clear the spine.

Comments are closed.