Saturday 2nd March 2019

Why “tennis elbows” tend to not get better, and what you can do about it.


Tennis elbow is described as an “overuse injury”.  However, unlike injuries such cuts, bruises and broken bones  which heal, they tend to not heal, defy treatment and go on for ever?  Why does a such a small injury doom people to a life of restricted ability and pain medication?    In this article we present the commonly overlooked thing that helps cause tennis elbow then stops it healing.  We will provide a simple test your practitioner can use to test for this, plus a strategy to help diagnose and manage this condition.

What is tennis elbow

The basics

Tennis elbow is pain at the highly stressed point  at the side of the elbow where the bulk of the forearm muscles attach.  It begins with heavy or repetitive use of  muscles causing microscopic injury.   Body builders use this microscopic damage principle to build muscles and strengthen tissues.  They first exercise to cause this damage, then give the body sufficient time to heal and re-build stronger.  In the case of tennis elbow though the overuse is repeated before the body has time to repair.  It does not have time to heal. The body’s repair mechanisms are overwhelmed, and try to patch things up as best as it can.

Complications with time

As with most musculoskeletal conditions, if allowed to remain it becomes more complex.  The continuing attempts at repair can cause an accumulation of scar type tissue.  The continuing pain can sensitise the nervous system as occurs in fibromyalgia, where pain is felt greater than it actually is. .  Further, pain, disability and frustration can cause psychological, social and economic issues.

Common treatment

The common treatment is to remove the continual stress by restricting usage and possibly using a brace.  Pain medications are often given for the purpose of making a patient more comfortable while they heal.  When this fails (as it often does) there are therapies designed to assist healing and address the buildup of scar tissue.  Examples include dry needling and other physical therapies.

Why do these often fail?

As discussed, much more serious injuries heal, so why does this “overuse injury” persist when one stops over using it?  The primary reason is trigger points, which are those tender lumps that masseurs lover to find.  They are actually sections of muscle that have gone into spasm and will not release.  This causes the muscles to become tight, creating tension at the injured area.  This tension causes pain and stops healing.  Further, if one googles “trigger point chart” one will find that trigger points in the forearm muscles  produce more pain in the same areas, adding to the symptoms.

Common, yet overlooked

The same heavy or over use that causes injury also causes trigger points to develop.  Because of this when you get overuse injuries you practically always get trigger points.  Despite practically always being present and causing complications trigger points usually do not get mentioned in medical research or guidelines, and hence often not considered.  As an example, the reference below the medical journal article on the management of tennis elbow.  It makes no mention of  trigger points what so ever.  Lets look simply what  happens because of this omission.  A person with tennis elbow is commonly advised to rest and given medication.  However, because of the tension on the muscles the injury will not heal, and the trigger points themselves cause more pain adding to the symptoms.  When the pain persists it’s out with the braces, stronger medication, dry needling and so forth.  With a key cause remaining  it still won’t heal, and as previously mentioned, the longer such issues remain the more complications occur.  There is a build up of scar tissue.  The nervous system becomes sensitized so pain is felt much more strongly, and the strong pain and disability has a terrible psycho social affect.

How to fix the problem

In this section we provide two simple tests that show if trigger points are involved, plus how they are treated.  This is not specific advice, and we are not recommending you diagnose and treat yourself.  Rather it is to allow for informed discussion with your qualified practitioner.  Discussion of tests and management will be kept simple, with more detail provided in the practitioner version of this article.  As previously discussed if a condition has existed for some time it becomes more complex.   Trigger point therapy plus all the previously mentioned strategies and treatments can have merit if appropriate, however this needs to be determined by a professional.

Two simple tests

Tension release test

The first test shows whether muscle tension caused by trigger points is aggravating the injury.  The area of injury is found by pressing in near the outside of the elbow where the muscles join.  The amount of tenderness is noted.  Next, any trigger points in the forearm muscles are treated, allowing the tightened muscles to relax.  There are several ways to treat trigger points.  We recommend the use of a DrGraeme massager.  These are quick, easy to use, highly affective, and can be used at home.  Once the trigger points are treated the injured spot is pressed upon again.  If it is less tender this confirms that the tension due to trigger points is causing aggravation.

Pain reproduction test

Each trigger point in the forearm is pressed upon.  If it reproduces some or all of the pain this confirms that trigger points are actually causing some or all of the pain.

The management trigger points

We have more in depth discussion on the treatment of trigger points elsewhere.  There are many effective methods.  However, research has shown that they can be extremely stubborn requiring a great number of treatments.  As an example, one trial used 12 treatment sessions.  At each session patients were given multiple therapies, which is much more than they would get at a typical professional consultation.  In spite of this huge amount of treatment patients felt better but over half the trigger points remained.  This means  it would be prohibitively expensive to get the large number of treatments needed done by a professional alone.
Because of this that the only practical way to deal with the trigger points associated with a tennis elbow  for most people is by using supplementary home massage.  The DrGraeme hand held massagers were built for this purpose.  They are highly effective and easy to use.  You will need a professional to show you how to identify trigger points and treat them effectively, but you will be able to have practically unlimited treatments.  He or she will also be able to evaluate your condition to determine any other aspects of manage that may be needed.


Coombes, Brooke K., Leanne Bisset, and Bill Vicenzino. "Management of lateral elbow tendinopathy: one size does not fit all." journal of orthopaedic & sports physical therapy 45.11 (2015): 938-949.



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About Dr Graeme

Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and ... read more