In this research summary we will be sharing a simple practical test that helps show the cause, or at least a major contributing factor, for lateral epicondylitis (tennis elbow). We also share a simple procedure that can be a huge help to resolve these problems. The basic principles of this test and treatment can be used for many other similar syndromes.
This was written in response to reading a sports practitioners forum. For tennis elbow one practitioner used dry needling and various therapies while another stated that these would just make the inflamed epicondyle angry. A third recommended a journal article (see below) that contained further contradictory advice. Too often we see this in the treatment of musculoskeletal conditions.
- The treatment/management of such conditions fails when basic principles are ignored.
- Management too often focuses on symptoms and effects rather than underlying causes.
In this article we attempt to give a rationale that is consistent with basic principles, and focuses on causes rather than symptoms. Comments are most welcome.
Epicondylitis in a nut shell
What is tennis elbow
One of the basic principles of exercise is that repeated or over usage causes microscopic damage to muscles and connective tissues. Body builders use this principle by exercising to deliberately cause this damage, then follow this by recovery where the body is stimulated to repair and rebuild stronger. In the case of tennis elbow this injury occurs at the area of high stress at the lateral epicondyle of the elbow where most of the forearm extensor muscles attach. However, unlike what occurs with body builders it is repeated without allowing recovery. The body's ability to repair is overwhelmed. Over time this continual injury and attempted repair causes the pathophysiology known as epicondylitis.
The condition becomes chronic
As with most musculoskeletal conditions, if allowed to continue it becomes chronic and more complex. For example, the condition of the tissues at the epicondyle will deteriorate. The continual bombardment of the central nervous system by pain impulses can cause sensitization similar to that which occurs in fibromyalgia. Furthermore, the continuous pain, disability, and possibly failed attempts at therapy can cause psycho-social problems.
The involvement of muscular issues
In addition to the affect at the epicondyle, repeated/over usage usage of muscles usually causes the development of myofascial trigger points. (trigger points). As discussed elsewhere these are focal sections of muscle that chronically spasm causing the whole muscle to become constantly tightened.
- In the case of the forearm extensor muscles a tightening puts a constant stress on the attachment at the condyle. This tension will serve to exacerbate the injury and prevent healing. Because if this the management of tennis elbow should always consider the elimination of these trigger points to remove the abnormal tension on the epicondyle.
- A further consideration is that trigger points cause referred pain which may add to the symptom pattern and possibly confuse the diagnosis.
The simple tests that helps make tennis elbow easy
The following simple tests will demonstrate this principle, showing the patient you have identified the cause of his or her problem and providing a clear rationale and direction for treatment.
Trigger point pain reproduction
Palate the forearm muscles for trigger points. Does pressing on these reproduce symptoms?
The Tension Relief Test
- Deeply palpate the epicondyle, noting it’s tenderness. It is usually worth having the patient do this his or herself to help understand the problem first hand without any thought of the practitioner using differing pressure in subsequent tests.
- Palpate the extensor muscles for trigger points.
- Thoroughly treat all the trigger points in the forearm extensors, allowing these muscles to relax to normal tension. This author does this by demonstrating to the patient how to apply the DrGraeme massager for approximately 30 seconds to each trigger point, then observing while they complete the treatment themselves. A post check is needed to ensure all have been treated. It must be stressed that they are not to put the massager on the condyle (sore spot), just the trigger points in the muscles.
- After the trigger points are treated re-palpate (and have the patient re-palpate) the condyle. All things going well the condyle will be far less tender to palpate, demonstrating that the tension in the muscles was aggravating the condition.
Explanation to the patients
Tennis elbow is caused by repeated or over usage straining where the muscles attach. The trigger points cause the muscles to become tight, putting strain on the attachment., and not allowing it to heal. Treatment of the trigger points allowed the muscle to relax, taking the tension off. That is why the attachment became less tender. The management strategy is to remove the continuing stress and allow the injury to heal. Consistent with this as a goal, management could also include
- modification or restriction of aggravating activities
- stretching of the forearm muscles
- the possible temporary use of some sort of brace.
As the forum respondent said, if one pokes, prods or stick needles into the injured part it will just make it angry, so we leave the body to heal it.
As discussed in another research summary, a trial of 12 weekly extensive treatment sessions on shoulder trigger points produced considerable symptomatic relief, but examination showed that over half the trigger points still remained. From this it can be concluded that the complete elimination of the forearm trigger points may require well in excess of 12 applications of therapy, plus probably ongoing “maintenance”. The cost and time taken to have this done by a professional alone would likely be prohibitive. This is why we recommend supplementary home massage, and is why we have the patient apply the initial treatment themselves with a DrGraeme massager.
Tissue changes, sensitisation of the nervous system and psycho-social aspects
If the condition has not progressed too far the body should be perfectly capable of recovering. However, when any of these are present some assistance may be needed. Many of the possibilities discussed in the forum and journal article may need to be considered.
- These basic principles can applied to evaluating and treating many other musculoskeletal pain syndromes.
- Myofascial trigger points have been at least a complicating factor in every case of tennis elbow seen by this author in over 25 years of practice. In spite of this the journal article does not even mention them as a cause, aggravating factor or as a differential diagnosis.
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.