Scalene Hypertrophy

I recently evaluated yet another Major League baseball player with the “yips,” or what I like to call thoracic outlet syndrome.  I really don’t believe in the yips at all and feel that thoracic outlet syndrome is almost always to blame.  Telling a professional athlete it’s all in their head or some mysterious mechanical flaw is just insulting.

One of the major reasons that thoracic outlet syndrome occurs in baseball pitchers is from hypertrophy of the scalene muscles (and sternocleidomastoid).  Throwing a baseball causes many adaptations to the body, including this increase in scalene size.

Here is a video of the athlete inhaling with his head turned to each side.  Notice the significantly larger scalene and sternocleidomastoid on his right side.


scalene hypertrophy

I wish I had a magic trick to help in this situation.  I will perform manual therapy on the scalene muscles, surround musculature, 1st rib, and thoracic cage, however, it’s hard to combat the hypertrophy associated with throwing.

Understanding what to look for is the first step, though.  Scalene hypertrophy is a subtle finding to detect on examination.



Integrating Upper Cervical Flexion with Postural Exercises

chin nod with shoulder w exercise

Several weeks ago I published a quick video tip on a variation of the chin tuck exercise, the chin nod exercise.  I received a lot of nice feedback regarding the use of the nod and wanted to share the next phase of the progression, integrated the chin nod into exercises.

Just like any other aspect of our rehabilitation and corrective exercise programs, the ultimate goal should be to groove motor patterns with simple exercises and slowly integrate them into more complex functional movement patterns.  While the chin nod is a great choice to work on upper cervical flexion in those with postural adaptations and an upper body cross syndrome, it is really only a small part of the pattern.

We always talk about strengthening the lower trap and serratus and performing manual therapy on the pecs, subclavius, upper trap, and levator (just to name the big ones…).  The chin nod is also a simple way to set your posture prior to some of these activities.

As an example, I shot a quick clip on integrated the chin nod into the shoulder W exercise, which is fantastic for posterior cuff and lower trap strengthening, as well as opening up the anterior shoulder.  By adding the chin nod prior to performing the exercise, you essentially enhance the outcomes of the exercise by assuring proper alignment.

This isn’t rocket science, but by integrating the chin nod into exercises like this, it really helps groove the correct motor pattern better.  Incidentally, this is one of my favorite exercises for those with cervicogenic headaches and neck pain.  Have them sit up tall in the car at red lights and perform this exercise.  Great, even without Theraband.  I even use this integrated chin nod and shoulder W exercise as my breaks while sitting at the computer!


The Chin Tuck and Chin Nod Exercises

Chin Tuck Chin Nod ExerciseToday’s post is a quick and dirty video technique post on the chin tuck exercise technique.  The chin tuck is a pretty common exercises used for neck pain and postural adaptations.  The chin tuck exercise essentially works on upper cervical extension and lower cervical flexion.  I like using it as part of my reverse posturing series of exercises to get out of the forward head, rounded shoulder posture that we see so often, essentially Janda’s Upper Body Cross Syndrome.

While I do use the chin tuck exercise, I do sometimes find that it can be performed too aggressively by some, especially if you are having some acute neck pain.  You don’t want to jam you neck straight back and combine upper cervical flexion with a shear force.  My good friend and excellent therapist Todd Howatt turned me on to this over a decade ago.

Rather than aggressively shear your upper cervical spine, you may want to start with more of a chin nod rather than a chin tuck.  Perhaps this is just nomenclature, but the visual shouldn’t be “jam your head straight back” but rather to imagine a dowel going through your head between both ears.  You want to rotate your head around this dowel and essentially perform a nodding motion.  I tell my patients to focus on feeling a stretching sensation in their suboccipital region.

This movement can be performed both standing (or sitting in your car, wink, wink…) and lying on your back.  I usually start lying down to prevent the jamming back movement.  I will often instruct to use your hands on each side of your head to help with the rotational movement around the dowel concept.  You can use this as part of reverse posturing, repeated movements, or for deep neck flexor strengthening.  To focus on strengthening, gradually work up to slightly lifting your head off the table and holding for a duration of time.

Check out the video below for some visuals:

What do you think?  I am still pro using the chin tuck exercise at times, but also incorporate a chin nod exercise when the chin tuck is uncomfortable or with acute neck pain.


Exercise Considerations for Neck Pain

Today’s post is written by Rick Kaselj.  Rick is the creator of the Muscle Imbalances Revealed products that I have mentioned in the past.  I reviewed both the lower extremity and upper extremity editions of Muscle Imbalances Revealed in the past.  Rick has a nice presentation on the neck in the upper body edition and wanted to share this post on the topic.  Thanks Rick!

Exercises for Neck Pain

Often times our clients with neck pain will get all kinds of diagnostics tests, have all kinds of assessments, and have a stack of labels before they get to us.  With all that information, it is sometimes challenging to design a proper program.

The first exercise component that most of us go for is stretching the neck, but is this right?  Should you be stretching someone with neck pain?  After stretching, we start strengthening.  Now, do the good old 3 sets of 10 repetitions work for neck pain?  What kind of strengthening exercises do you do for the neck?  Should I be doing cable machine neck exercises?

These are all common questions that the research can help us answer.

Strengthening and Stretching Leads to Better Neck Pain Results

Lets start off with looking at headaches caused by neck pain and how exercise can help.  Looking at Ylinen 2010 where they had a 2 week clinical and home based exercise program that was done 5 days a week.  They had two groups in the study, one was a strength group and the other was an endurance group.

The endurance group lifted their heads up from a supine position for 3 sets of 20.

The strengthening group used a dynamic isometric hold with tubing in a sitting position for 1 set of 15 in 4 directions.

Both groups performed shoulder shrugs, shoulder presses, bicep curls, pec flys and pull overs with 2 kg dumbbells for 3 sets of 20.  The control group only performed shoulder and neck stretches.

What the researchers found was that the endurance group had the greatest decrease in headaches after 12 month follow up.  The authors suggest that stretching alone is not enough but an endurance or strengthening program along with stretches may be the best choice.

[EDITOR’S NOTE – My friend Phil Page has a really nice review of this article as well, be sure to check that out here.]

2 Minutes a Day of Exercise will Decrease Neck Pain

Anderson in 2011 performed a study with 174 women and 24 men who worked at least 30 hours a week and who reported frequent neck/shoulder pain.  They had one group that did 2 minutes of exercise and one group that did 12 minutes of exercise for 5 days a week.

After the 10 week program, they found both groups had a reduction of pain and tenderness.  The exercise that they performed was a resistive tubing, lateral raise in the scapular plane.  The 2 minute group performed the exercise for one set to failure while the 12 minute group performed 5 to 6 sets of 8 to 12 repetition.

Very cool.  Now a little more info on isometrics.

Isometric Strengthening is Not A Very Sexy Thing

Ylinen in 2006 reported that “the change in neck pain and disability indices correlated with the isometric neck strength.”  Has to make you wonder.  Keep stretching and get minimal results with neck pain or start doing isometrics and have happy clients and happy necks.

Are Home Programs that Good?

People that start a home program, do great at the start but things taper down as time passes.  We have experienced that in our clients and even in ourselves.  Häkkinen in 2006 noted that “progressive loading, supervision of training, and psychosocial support is needed in long-term rehabilitation programs to maintain patient motivation.”

I know many clinicians are good at this but encouraging your clients to come back and see you in order to review the exercises, provide support and motivation is a good idea to do.


There are a few key points to take away from this article regarding neck exercises:

  1. When strengthening, you are focusing on the neck being in neutral and the contraction is isometric.
  2. Even just 2 minutes of shoulder strengthening a day can help decrease neck/shoulder pain.
  3. Combine strengthening and stretching for better results.
  4. Jari Ylinen, is the man when it comes to exercise and neck pain.  He is Finish and if you do much research into how Scandinavian rehabilitate injuries, they go hard.
  5.  Improving isometric neck strength decreases neck pain.  It would be a good idea to add some to a neck pain program.
  6.  Encourage your clients to see you regularly in order to progress, review, support and motivate.

About the Author

Rick Kaselj, MS.  Rick is an exercise physiologist that has spent his 17 year professional career helping clients recover from injury and prevent injury through exercise. Rick has shared his tips, tricks and exercises when working with injuries to well over 5033 fitness professionals in Canada and the USA.  The foundation to Rick’s books, manuals, DVDs and presentations is his educational background which includes a Bachelors Degree in Kinesiology and a Masters of Science Degree in Exercise Science.  Rick helps clients in Surrey, BC, Canada and also writes a leading fitness education blog on exercises and injuries,

Be sure to check out his latest product Muscle Imbalances Revealed Upper Body.

Muscle Imbalances Revealed Upper Body Review


  • Andersen LL, Saervoll CA, Mortensen OS, Poulsen OM, Hannerz H, Zebis MK. (2011). Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: randomised controlled trial. Pain. 2011 Feb;152(2):440-6. Epub 2010 Dec 21.
  • Blangsted AK, Søgaard K, Hansen EA, Hannerz H, Sjøgaard G. (2008). One-year randomized controlled trial with different physical-activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers. Scand J Work Environ Health. 2008 Feb;34(1):55-65.
  • Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. (2001). A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain.Spine (Phila Pa 1976). 2001 Apr 1;26(7):788-97; discussion 798-9.
  • Häkkinen A, Kautiainen H, Hannonen P, Ylinen J.(2008).  Strength training and stretching versus stretching only in the treatment of patients with chronic neck pain: a randomized one-year follow-up study. Clin Rehabil. 2008 Jul;22(7):592-600.
  • Häkkinen A, Ylinen J, Kautiainen H, Tarvainen U, Kiviranta I. (2005). Effects of home strength training and stretching versus stretching alone after lumbar disk surgery: a randomized study with a 1-year follow-up. Arch Phys Med Rehabil. 2005 May;86(5):865-70.
  • Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976). 2002 Sep 1;27(17):1835-43; discussion 1843.
  • Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G; Cervical Overview Group. (2005). Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD004250.
  • Salo PK, Häkkinen AH, Kautiainen H, Ylinen JJ. (2010). Effect of neck strength training on health-related quality of life in females with chronic neck pain: a randomized controlled 1-year follow-up study. Health Qual Life Outcomes. 2010 May 14;8:48.
  • Taimela S, Takala EP, Asklöf T, Seppälä K, Parviainen S. (2000). Active treatment of chronic neck pain: a prospective randomized intervention. Spine (Phila Pa 1976). 2000 Apr 15;25(8):1021-7.
  • Ylinen J, Nikander R, Nykänen M, Kautiainen H, Häkkinen A. (2010). Effect of neck exercises on cervicogenic headache: a randomized controlled trial. J Rehabil Med. 2010 Apr;42(4):344-9.
  • Ylinen J. (2007). Physical exercises and functional rehabilitation for the management of chronic neck pain. Eura Medicophys. 2007 Mar;43(1):119-32.
  • Ylinen JJ, Häkkinen AH, Takala EP, Nykänen MJ, Kautiainen HJ, Mälkiä EA, Pohjolainen TH, Karppi SL, Airaksinen OV. (2006). Effects of neck muscle training in women with chronic neck pain: one-year follow-up study. J Strength Cond Res. 2006 Feb;20(1):6-13.
  • Ylinen JJ, Takala EP, Nykänen MJ, Kautiainen HJ, Häkkinen AH, Airaksinen OV.
  • (2006).Effects of twelve-month strength training subsequent to twelve-month stretching exercise in treatment of chronic neck pain. J Strength Cond Res. 2006 May;20(2):304-8.
  • Ylinen J, Takala EP, Nykänen M, Häkkinen A, Mälkiä E, Pohjolainen T, Karppi SL, Kautiainen H, Airaksinen O. (2003). Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. JAMA. 2003 May 21;289(19):2509-1

The McKenzie Method – Part 2 – Syndrome Classification and Treatment

In part 1 of this series, we discussed the misconceptions of the McKenzie Method.  Part 2 of the this guest post series by Christie Downing will review the three main mechanical syndromes and focus on treatment advice and some words of wisdom based on Christie’s experience.  Be sure to go back to Part 1 to learn about the basics of Mechanical Diagnosis and Therapy (MDT) if you haven’t read it already.

Syndrome Classification in MDT

There are three main syndromes in MDT – Derangement, dysfunction, and posture.  Each one will be discussed.

Derangement Syndrome

imageSimply put, this is a disruption in the normal articulation of a joint. There are several characteristics that make this syndrome unique including: it can be rapidly reversible, it can be acute or chronic, it can produce distal or local pain, there is loss of movement, it may display a “directional preference” and is the only syndrome to demonstrate “centralization” of symptoms…the hallmark of the disorder.

Possible mechanism: Tissue obstructing movement (i.e., disc protrusion)

Analogy for the patient: A pencil stuck in the door jam…it won’t open or close all the way until you wiggle the door around and get the pencil out of the way.

Dysfunction Syndrome

imageIt exists as both an articular or contractile tissue dysfunction. I will focus on articular because it is the easiest to understand. For those somewhat familiar with MDT, adherent nerve root is also a type of dysfunction, but I will not focus on this today. Basically, dysfunction is shorted and adapted tissues that when stretched or loaded, produce pain. There are several characteristics that can help one identify a dysfunction: it is always chronic, it only produces local pain (except adherent nerve root), it is consistent (the same activity always produces pain), there is loss of movement, it is not rapidly reversible and pain is always intermittent.

Possible Mechanism: restricted tissues that when stretched/loaded produce pain (i.e., a knee flexion contracture)

Analogy for the patient: someone who has been immobilized in a cast. The joint is stiff and each time it is stretched, it produces pain.

Posture Syndrome

imageIn this syndrome, it is faulty postures and positions that place undue mechanical strain on otherwise normal tissue. It’s actually somewhat rare to see this patient in the clinic. Often times, they figure out on their own what needs to be done, namely, posture correction. However, anecdotally, patients with this syndrome are typically teenagers who sit in a slumped position. Often times, a worried parent accompanies the patient to therapy, concerned that a more troublesome diagnosis exists. However, in these situations, the patient is pain free upon activity and only experiences the pain with prolonged sitting or standing with slouched posture. Movement is full and pain free. Education is very important, first, to reduce stress and ease worry; second, to educate about behavioral modification required.

Possible mechanism: deformation of mechanoreceptors with prolonged postures and/or temporary ischemia to joint capsules, ligaments and other soft tissues.

Analogy for the patient: Bend your finger backwards to demonstrate how prolonged stresses can cause pain, but that upon release of the prolonged position, the finger returns to full pain free range of motion.

Treating the derangement syndrome

There are a few pearls I have picked up over the years. Some I’ve learned as part of advanced clinical training and others on personal experience. I’m going to share a few with you that may help you understand how to proceed with the mechanical clinical reasoning.  Since the Derangement Syndrome is so common, we’ll use this syndrome as a model.

When it comes down to it, treatment of dysfunction and posture syndromes are really simple: increase tissue extensibility and educate (respectively for each).  Truth be told, the literature on these two syndromes in not as well versed, but as far as dysfunction syndrome, therapists can take their knowledge from sources outside MDT regarding connective tissue properties in order to effectively treat dysfunction.

Really Listen to Your Patient

Patients often tell me in their subjective history how to best treat them. They can give you clues not just about what syndrome they have, but how to best treat it.

  • Does your patient report that certain movements and positions sometimes hurt and other times do not? This is highly suggestive of derangement syndrome. Patient often need to be reassured that variability is common, as many think they are “crazy” because “one time I bend over and it hurts, and other times I can do it just fine.”
  • Do they tend to feel better with certain activities that suggest a directional preference? Is your patient typically better walking and lying prone and worse with sitting and bending? This highly suggests an extension bias. For the acutely injured patient or those with high fear avoidance belief questionnaires, avoiding repetitious motion testing into flexion, in this case, can result in getting to the answer faster while sparing the relationship with your patient.
  • Do they need a loaded or unloaded force? While we typically start motion testing in standing, for those who tell me that both standing and walking, but so does sitting while lying is quite comfortable, I may defer a lot of unnecessary testing in standing and go right to the supine or prone position after a general ROM baseline assessment.

Not only will you hopefully arise at a provisional diagnosis before the exam has even begun, but summarizing to the patient that you’ve really listened to them is a great way to establish a rapport: “Based on what you’ve told me, your body want to move in this way in order to help it heal…you were very clear about this in what you told me. The examination only confirmed what you told me…”

Use the “Traffic Light” Guide

Simply stated, this is a way to determine if you need to progress your force or consider an alternative.

  • Green light: The more a patient moves in a particular direction results in abolition of pain, lessening of pain, centralizing of peripheral symptoms and/or a rapid mechanical improvement (ie, more range of motion, lessening of neurogenic signs, etc). In this case, continue on with the current regimen. If it’s giving you the desired response, no need to change it.
  • Yellow light: Proceed with caution. This happens when one experiences an equivocal response. An example could be someone who is better during a movement, but does not remain so afterwards. It could also mean someone who is worse during a movement, but does not remain so afterwards. Yellow lights mean a force progression. This could mean more time and repetition, giving extra pressure to a movement (ie, mobilization)….or in some cases less pressure. The novice McKenzie practitioner often fails to recognize that force progression is a continuum of treatment in the same direction, but with variable levels of force. An example could be someone who needs to start with mid range extension in lying before proceeding to end range extension in lying.
  • Red lights: Stop! This one is obvious: motions that increase or produce symptoms that weren’t there before and/or result in peripheralizing symptoms that remain worse even after the maneuver. Red lights require a force alternative, usually a change in direction and/or loading strategy. This could be someone who is worse with repeated extension in lying who need to have a lateral component entered into the equation.

The traffic light guide is a very simple tool to not only guide clinical reasoning, but is also helpful for patients. I use it even in cases of non-mechanical pain. In treating those with a sensitized pain state, it gives them a guide to know how much to do, how much pain is allowable, what should happen afterwards and when they should “back off.” Giving patients permission to evaluate and respond to their own symptoms is highly empowering! It’s also a good chance to educate them about pain…pain does not always mean harm!

Watch for Mechanical Changes

Watch for mechanical changes when the symptomatic complaint does not seem to change. Novice McKenzie practitioners frequently forget this. For someone with painful and restricted motion, a rapid increase in range of motion in the face of an equivocal symptomatic response is still a green light. In my opinion, this is most easily observable in the cervical spine and extremities. Someone who has painful right rotation who, after doing repetitions of retraction and extension, still has painful right rotation that has improved from 20 degrees to 50 is still a green light. Keep going! Be patient!

I hope this series has helped to shed some light on the usefulness of the McKenzie Method and MDT principles.  Are you MDT trained?  What other advice would you offer? 

image_thumb[5]Christie Downing, PT, DPT, Dip. MDT, ICLM  Christie works at Alexian Brothers Rehabilitation Hospital in Elk Grove Village,  IL.  She specialize in musculoskeletal care as well as lymphedema management.  She is a MDT credentialed provider and student in the Diploma level of MDT, focusing primarily in MDT in both spine and extremity problems.

The McKenzie Method – Part 1 – Clearing Misconceptions about MDT

imageThis week features a 2-part guest post discussing the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) by Christie Downing.  Christie is a frequent contributor to this site.  I think this is a great series to “clear the air” about some of the misconceptions regarding MDT, and more importantly, to share some of Christie’s experience and pearls of wisdom.  If you are unfamiliar with MDT, take this as an opportunity to get to learn more about the method.  While Christie discusses that MDT is not all about extension exercises, it does fit into my reverse posturing theory to an extent.

The McKenzie Method – Clearing the Air

What is your gut reaction when you hear “McKenzie Method?” I predict you are either excited or just rolled your eyes. If it is the later, I hope you will give this post due diligence. For it is my observation that those who despise it have not been fully informed about it. It’s one of the most researched physical therapy approaches, yet is fraught with misconceptions. For those interested in the research, the McKenzie Institute International maintains a database of the most relevant research. However, rather than discuss the literature, my objective will be to clear up misconceptions of what the McKenzie method entails and to give some brief “Pearls of Wisdom.” This first post will entail a brief overview of the McKenzie Method, otherwise known as Mechanical Diagnosis and Therapy (or MDT).


Mechanical Diagnosis and Therapy – MDT

Due to long standing misconceptions, much has been inaccurately portrayed regarding MDT. When describing MDT to another practitioner, it is sometimes easier to first discuss what it is not. MDT is/does not:

  • A series of exercises
  • Only about derangement
  • Only extension
  • Only about the intervetebral disc
  • Only about repeated end range movements
  • Ignore biopsychosocial issues
  • Without the use of manual therapy
  • Only about spinal conditions

I will address each of these issues point by point to more accurately portray what MDT is:

MDT is not a series of exercises: Although some exercises are common, MDT is an assessment process and problem solving paradigm. One takes clues from the history about the effects of specific loading strategies on one’s symptoms. At the history, the therapist begins to formulate a differential diagnosis. First, is it a problem with a mechanical influence, a medical influence, a biopsychosocial influence or any combination of the above? Second, if mechanical, which of the syndromes are likely at play: derangement, dysfunction, posture or “other?” Then, the examination includes a series of loading strategies to confirm or refute the postulated diagnosis.

imageMDT is not only about derangement: Although found widely, derangement syndrome is not the holy grail of MDT. Muscular or articular restrictions (dysfunctions) and postural syndromes are part of the “main” three mechanical syndromes. However, stenosis, chronic pain state (i.e., centrally/periperhally sensitized pain), SIJ dysfunctions, s/p traumatic states, etc. are all recognized by MDT clinicians.

MDT is not just extension: Although a common treatment recommendation, all planes of movement can be considered in both the assessment and treatment recommendations.

MDT is not just about repeated end range movements: static positioning and mid range movements are all part of the spectrum of force progressions.

MDT is not just about the intervertebral disc: Although it serves as one model of joint derangement, other postulated mechanisms are frequently discussed including: joint inclusions, fat pads, loose bodies, capsular impingements, etc for both the spine and peripheral joints as applicable.

MDT does not ignore biopsychosocial influences: Although a positive mechanical response (such as centralization) can sometimes trump “yellow flag” indicators, fear avoidance behaviors and other biopsychosocial influences are always considered and dealt with by education and graded exposure to movement where necessary.

MDT does not exclude manual therapy: Although we take a “hands off” approach first, mobilization and manipulation are all part of the continuum of force progressions. We focus primarily on education and self directed treatments first in order to reduce dependency and empower the patient to control their symptoms; however, sometimes patients are not successful in reducing their own pain in the initial stages. It is at this time we consider the use of our hands. However, use our hands in order to foster greater success of the patient treating themselves. We put our hands on, only to take them off again.

MDT is not just about the spine: The concepts of assessment and classification can be applied to the peripheral joints as well.

As a brief summary, MDT is a classification system. It seeks to differentiate between mechanical and non-mechanical influences of pain and functional limitation by using mechanical loading strategies and assessing both the patient’s subjective response and any mechanical changes.

The main 3 mechanical syndromes are derangement, dysfunction and postural syndromes.

Although the intervertebral disc serves as one model for mechanical influences of spinal pain, other influences are recognized. MDT focuses on patient education and empowerment in order to promote self directed treatment, reduce fear, and promote function.  In part 2 of this series, we will describe the syndromes in more detail and offer “Pearls of Wisdom.”

imageThanks Christie, great post!  One thing that I wanted to also mention was a book that you can read for more information, Rapidly Reversible Low Back Pain.  The book has been discussed here in the past, is a quick read, and I think is pretty cheap (~$10) on Amazon.  I thought it did a good job talking about MDT, including it’s origin.  My favorite story was the discovery of extension exercises for low back pain, check it out if haven’t already.

Have you heard these misconceptions? Did this post surprise you? What other questions do you have about what MDT is?

imageChristie Downing, PT, DPT, Dip. MDT, ICLM  Christie works at Alexian Brothers Rehabilitation Hospital in Elk Grove Village,  IL.  She specialize in musculoskeletal care as well as lymphedema management.  She is a MDT credentialed provider and student in the Diploma level of MDT, focusing primarily in MDT in both spine and extremity problems.

Photo credit toyourhealth

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

Brian Mulligan’s NAGS, SNAGS, and Mobs with Motion

Several weeks ago, I had the amazing opportunity to host Brian Mulligan at his first baseball game and have him present a private workshop for my staff.  What an experience!  In addition to providing some excellent treatment techniques, he (and his colleague Brian Folk) also managed to help some of us with low back pain, hamstring tightness, and lateral epicondylitis!


For those that don’t know, Brian Mulligan is a world renowned physical therapist from New Zealand.  He is the originator of the NAGS, SNAGS, and MWMS concepts of manual therapy and has a very popular book on the topic (and a part of my essential reading list for physical therapists).

imageHis concepts are simple, yet highly effective, and an example of how we need to consider thinking outside the box at times and incorporate manual therapy techniques that work regardless of the evidence behind the rationale.  If you are familiar with the techniques then you know what I mean, there are some simple techniques that can have an immediate effect.  I am not kidding.  These are tools we should all have in our belt.  If you are not familiar than click below for more information on Brian Mulligan’s website.  You can also see some examples of the techniques in the videos below and in his book.