Regional Interdependence In Treatment Of The Elbow

Regional Interdependence

  • Treatment directed at one area of the body to elicit changes in another
  • In addition to treatment directed at the elbow, patients with elbow pain may benefit from treatment directed at the cervical or thoracic spines, and/or wrist.


  • Differential diagnosis for Lateral Epicondylalgia can be done through Elbow Examination
  • Prior to performing interventions directed at the spine, appropriate examination and safety screens should be performed.

               -Cervical Examination and screen for Red Flags

               -Vertebral Artery Test

               -Transverse Ligament Stress Test

               -Tests for Cervical Instability

               -Thoracic Examination

Interventions for the Following Diagnoses  

                -Cervical Manipulation

                -Cervico-Thoracic Mobilization

                -Thoracic Manipulation

                -Wrist Manipulation

                -Carpal Manipulation


                -Median and Radial Nerve mobilization

Cervical Thrust Manipulation [1][2]

  • One randomized pilot study and one randomized clinical trial have shown that the following cervical manipulation is beneficial in those with lateral epicondylalgia
  • Patient supine with neck in nuetral
  • Physical therapist positions neck into rotation and contralateral flexion
  • High velocity low amplitude (HVLA) thrust manipulation directed superior and medial towards contralateral eye

Cervical Thrust Manip Video

Cervico-Thoracic Mobilization [3]

  • One pilot clinical trial has shown that the following cervico-thoracic mobilization is beneficial in those with lateral epicondylalgia
  • Non-thrust grade III and IV PPIVM and PAIVM directed at impaired segment

Done in combination with the following:  

  • Stretching of wrist extensors, strengthening of wrist and forearm, and mobilizations of elbow/wrist

CT Manip Video

Thoracic Manipulation [2]

  • One randomized clinical trial has shown the following thoracic manipulation is beneficial in those with lateral epicondylalgia
  • Patient supine with arms crossed over chest
  • Physical therapist localizes thoracic segment using “pistol grip”
  • Physical therapist flexes thoracic spine and stabilizes neck and head
  • Physical therapist performs high-velocity, low amplitude manipulation in a cephalad direction.

Wrist Manipulation [4]

  • One randomized pilot study has shown the following wrist manipulation is beneficial in those with lateral epicondylalgia
  • Therapist grips patient's scaphoid between thumb and index finger
  • Place other hand over same landmarks for stabilization
  • Extend patient's wrist while manipulating scaphoid ventrally

Carpal Mobilization [5]

  • One case study has shown the following carpal mobilization is beneficial in those with cubital tunnel syndrome
  • Patient seated
  • Physical therapist stabilizes patient's hamate palmarly
  • Dorsally, physical therapist palpates triquetrum with thumbs stacked on one another
  • Patient instructed to lean back to provide traction on carpals
  • Wrist flexion maintained and HVLA thrust to triquetrum palmarly

Nerve Mobilization  [6]

  • One case report has shown the following nerve mobilizations are beneficial in those with radial or median nerve entrapment
  • Patient supine, placed in ULTT positions for radial or median nerve
  • Flex/Extend patients elbow while in test positions
  • Extend elbow about 2 seconds into range
  • Tension felt/ no pain
  • Flex elbow to point of no tension
  • Repeat 6-7 times



Decreased Pain

Increased Pain Free Grip Strength

Increased Pressure Pain Threshold Decreased Disability (DASH) Perception of Change Global Improvement Increased Max Grip Force Improved Carpal Mobility Improved Elbow Flexion Test
Cervical [1] [2] X X
CT [3] X X X X
Thoracic [2] X


Carpal Mobilization [5] X X X X
Median/Radial Nerve Mob [6]  X X


Clinical Bottom Line

• Incorporating manual therapy directed at the cervical spine, thoracic spine, cervico-thoracic junction, wrist, and carpals appear to provide benefits for patients with lateral epicondylalgia, cubital tunnel syndrome, and nerve entrapment. Clinicians may consider these interventions in addition to treatment directed only at the elbow. More specific information can be found in the references below.


  1. 1.0 1.1 Fernández-Carnero J, Fernández-de-las-Peñas C, Cleland J. Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. Journal Of Manipulative and Physiological Therapeutics. November 2008;31(9):675-681.
  2. 2.0 2.1 2.2 2.3 Fernández-Carnero J, Cleland J, Touche. Examination of Motor and Hypoalgesic Effects of Cervical vs Thoracic Spine Manipulation in Patients With Lateral Epicondylalgia: A Clinical Trial. Journal Of Manipulative and Physiological Therapeutics. September 2011;34(7):432-440.
  3. 3.0 3.1 Cleland J, Flynn T, Palmer J. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. Journal Of Manual and Manipulative Therapy (Journal Of Manual and Manipulative Therapy). September 2005;13(3):143-151.
  4. 4.0 4.1 Struijs P, Damen P, Bakker E, Blankevoort L, Assendelft W, van Dijk C. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Physical Therapy. July 2003;83(7):608-616.
  5. 5.0 5.1 Kearns G. Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals. Journal Of Manual and Manipulative Therapy (Maney Publishing). December 2010;18(4):228.
  6. 6.0 6.1 Ekstrom R, Holden K. Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Physical Therapy [serial online]. November 2002;82(11):1077-1086.