Dr. E here with another asynchronous episode of Untold Physio Stories, featuring the great Dr. Wells!

We're diving deep into the trenches of chronic elbow tendinopathies, specifically lateral epicondylalgia, and the surprising speed of response in a couple of recent patient cases.

What We Cover in This Episode:

The Power of Length and Load: We revisit the concept of using isometric contractions in a lengthened position (70-80% MVC) for superior tendon loading, inspired by Dr Michaud's excellent tendinopathy article.

Dr. E shares a recent article on LinkedIn by Dr. Malliaras showing that this position creates significantly higher tensile force in the tendon compared to concentric/eccentric exercises, making it ideal for remodeling and managing inflammation.

Case 1: The WFH Warrior (Lateral Epicondylalgia): A work-from-home patient with bilateral elbow pain from excessive arm raises found complete symptom resolution in just two weeks using the lengthened isometric contraction technique (wrist flexion, pronation, resisting extension). We discuss why this response was so much faster than typically expected for tendinopathy. Was it pain modulation, a true strength issue, or something else?

Case 2: The Chronic Tennis Coach: A long-term case of lateral epicondylalgia that didn't respond to the initial lengthened isometric program or even repeated cervical retractions. We explore the eventual success with a Mulligan Mobilization with Movement (MWM) technique (lateral ulnar glide with gripping/wrist extension), highlighting the sometimes-necessary shift from exercise to pain-modulating manual therapy before resuming loading.

The Big Question: Dr. Wells and Dr. E debate the varying patient responses, the balance between mid-range vs. lengthened loading, and why these tendinopathy cases can be so unpredictable. Dr. Wells also shares a cautionary tale about an athlete who didn't respond to conservative care, ultimately revealing a significant tear.

🔑 Key Takeaways for Rehab Pros:

Don't underestimate the loading capacity of isometrics in a lengthened position for tendinopathy—it's backed by science to create high tensile force!

Always rule out or treat the cervical and thoracic spine, but recognize when a tendon needs direct, aggressive loading or a different form of pain modulation (like the Mulligan MWM).

Be ready for the "Mulligan Miracle" and keep those MWMs in your toolbox for instant pain relief that allows for better, deeper loading later.

The path to resolution is rarely linear—different athletes and presentations require different starting points.

Listen to the full episode on your favorite podcast platform and let us know your experiences with lengthened isometrics and Mulligan MWMs for those tricky elbow cases!

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